Volume 3, Supplement 1 - October 2004 - World Psychiatric ...

PAWorld PsychiatryOFFICIAL JOURNAL OF THE WORLD PSYCHIATRIC ASSOCIATION (WPA)Volume 3, Supplement 1 October 2004WORLD PSYCHIATRIC ASSOCIATIONINTERNATIONAL CONGRESS“TREATMENTS IN PSYCHIATRY: AN UPDATE”November 10-13, 2004Florence, ItalyABSTRACTS

The World Psychiatric Association (WPA)Avenue, Suite 4M-3, New York, NY 10029-7404, USA.Phone: +12124237001; E-mail: wpasecretariat@wpanet.org.The WPA is an association of psychiatric societies aimed toincrease knowledge and skills necessary for work in the fieldof mental health and the care for the mentally ill. Its membersocieties are presently 128, spanning 111 different countriesand representing more than 150,000 psychiatrists. The WPAorganizes the World Congress of Psychiatry every three years.It also organizes international and regional congresses andmeetings, and thematic conferences. It has 60 scientific sections,aimed to disseminate information and promote collaborativework in specific domains of psychiatry. It has producedrecently several educational programmes and series ofbooks. It has developed ethical guidelines for psychiatricpractice, including the Madrid Declaration (1996). Furtherinformation on the WPA can be found in the websitewww.wpanet.org.WPA Executive CommitteePresident – A. Okasha (Egypt)President-Elect – J.E. Mezzich (USA)Secretary General – J. Cox (UK)Secretary for Finances – S. Tyano (Israel)Secretary for Meetings – P. Ruiz (USA)Secretary for Education – R. Montenegro (Argentina)Secretary for Publications – M. Maj (Italy)Secretary for Sections – G. Christodoulou (Greece)WPA SecretariatDepartment of Psychiatry and Behavioral Sciences, MetropolitanHospital Center, New York Medical College, 1901 First

WORLD PSYCHIATRIC ASSOCIATIONINTERNATIONAL CONGRESS“TREATMENTS IN PSYCHIATRY:AN UPDATE”November 10-13, 2004Florence, ItalyPRESIDENT OF THE CONGRESSAhmed OkashaHONORARY PRESIDENTCarlo Lorenzo CazzulloORGANIZING COMMITTEEChairmanMario MajCo-ChairmenPedro RuizGiorgio RacagniSCIENTIFIC COMMITTEEChairmanJuan E. MezzichCo-ChairmanMario Maj

CONTENTSUPDATE LECTURESUL1. The context of treatment in psychiatry 1UL2. Empathy, meaning, and the therapeuticalliance in psychiatric practice 1UL3. The comprehensive managementof schizophrenia 1UL4. Early psychosis: detection and interventions 1UL5. The comprehensive managementof recurrent major depression 2UL6. Comprehensive long-term managementof bipolar disorder 2UL7. Understanding and managingthe consequences of violence and trauma 2UL8. Integrating pharmacotherapyand psychotherapy in the managementof anxiety disorders 3UL9. Evidence based management of dementia 3UL10. The multimodal treatmentof eating disorders 3UL11. The principles and practiceof cognitive-behavioural psychotherapy 4UL12. Psychodynamic psychotherapies:evidence-based and clinical wisdom 4UL13. Integration of services in communitymental health care 4UL14. The challenge of primary preventionin psychiatry 5SPECIAL LECTURESSL1.SL2.Current treatment in psychoses:did it change the outcome? 5Comprehensive diagnosis as a basis forintegrated treatment and health promotion 5INTERACTIVE SYMPOSIAIS1. The future of psychotherapies 6IS2. The contribution of neuroimaging researchto clinical psychiatry 7IS3. The future of pharmacotherapy for moodand anxiety disorders 8IS4. Cultural issues in mental health care 9IS5. The current management of personalitydisorders 10IS6. The management of somatoform disordersand medically unexplained physicalsymptoms 11IS7. New strategies in the managementof sexual disorders 12IS8. Partnerships in mental health care 13IS9. Current approaches to autism 14IS10. Current approaches to sleep disorders 15IS11. The present and futureof consultation-liaison psychiatry 17IS12. Combining medications in psychiatry:advantages and risks 18IS13. The evaluation of psychiatric treatments 19IS14. Advances in the diagnosis and treatmentof bipolar disorder 20IS15. Recent advances in pharmacogenomics 21IS16. The present and future of rehabilitationin psychiatry 22IS17. Management of alcohol-related problems 23IS18. Non-pharmacological somatic therapiesin psychiatry 24IS19. Ethical and legal aspects of treatmentsin psychiatry 26IS20. Diagnosis and treatmentof attention-deficit/hyperactivitydisorder (ADHD) 27IS21. The current managementof obsessive-compulsive disorder 28IS22. Understanding and managing“comorbidity” in psychiatry 29IS23. Economic aspects of mental health care 30IS24. Assessment and managementof social anxiety disorder 31IS25. The future of pharmacotherapyfor schizophrenia 32IS26. Family interventions for mental disorders 33IS27. Molecular genetics and genomicsof psychiatric disorders: identificationof novel drug targets 34IS28. Prevention and managementof substance abuse 35IS29. Psychotropic drugs and cognitive functions 37IS30. “Difficult” children and adolescents:underdiagnosis and overdiagnosis of mentaldisorder and relevant treatment issues 38IS31. Gender-related issues in psychiatrictreatments 39IS32. New strategies for the careof the mentally retarded 40IS33. Epidemiology and prevention of suicide 41IS34. Management of mental disorders in old age 42IS35. The current management of panic disorderand generalized anxiety disorder 43IS36. The management of non-schizophrenicpsychotic disorders 44I

SPECIAL WHO/WPA SYMPOSIASPS1. From advances in neuroscience of substanceuse disorders to new treatment approaches 45SPS2. Nosological validity and diagnostic validity 46SECTION SYMPOSIASS1. Current questions in the treatmentof bipolar disorders 48SS2. Diagnosing personality disorders:does it matter for treatment? 50SS3. The educational challenge of improvingthe quality of psychiatric treatment 51SS4. Spirituality, treatment and health 52SS5. Art and therapeutic communication 53SS6. Developing and implementing trainingin old age psychiatry 54SS7. Hormones as treatments of affectivedisorders 55SS8. The effect of disability pension policyon outcome from mental illness 56SS9. Management of first episode schizophrenia 57SS10. Stress, depression and cardiac events 59SS11. Sexual health educational programme:an update 59SS12. Conceptual and ethical issues in earlydiagnosis and treatment 59SS13. Family functioning and family interventionsin axis I and axis III disorders 61SS14. Predictors of response to therapiesfor eating disorders 62SS15. Psychiatric issues in psycho-oncology:a challenge for the new millennium 64SS16. Treatment of eating disordersin psychoanalytically informed psychiatry 65SS17. Biological correlates of disturbed sleep 66SS18. Treatment research on eating disorders 67SS19. Psychopathology and treatment 68SS20. Childhood sexual abuse, paraphiliasand sex offence: are they related? 69SS21. Labour, law and disability 70SS22. European psychiatry from 1800 to 2004:institutions, concepts and policies 71SS23. Psychiatry, law and ethics 72SS24. Interventions in disasters 73SS25. The role of the psychiatristin the HIV/AIDS epidemic 74SS26. Psychophysiological characterizationof mental disorders:therapeutic implications 74SS27. Access to care impediments: African,American and European experiences 76SS28. Military psychiatry 77SS29. Quality improvement: practice guidelinesand suicide prevention 78SS30. New perspectives on neuroimagingin schizophrenia 79SS31. Well-being and quality of lifein the 21st century 80SS32. Ecological changes and mental distress:therapeutic perspectives 81SS33. Topics of prevention: evidence and research 82SS34. Updating suicidology 83SS35. Psychoimmunology: evidenceand perspectives 84SS36. Evolutionary psychopathology:toward empirical and epigeneticexplanations 85SS37. Intervention strategies for mentalretardation: an integrative approach 86SS38. The use of psychoanalysis in today’surban mental health settings 87SS39. Violence against women across cultures 88SS40. Genetics and psychopathologyof suicidal behaviours 89SS41. The MIND clinical imaging consortium:a multimodality collaborativestudy of schizophrenia 90SS42. Rehabilitation of torture victimsand the problems of these victimsfrom the psychiatrist’s viewpoint 92SS43. Depression associated with medicalconditions in primary care andother settings 93SS44. Transcultural psychiatry in Europe:something is going on 94SS45. Positive and negative impactof new technologies in psychiatric sciences 95SS46. The hidden burden of mental retardation 96SS47. Psychosis: meaning, mechanismand interpersonal consequences 97SS48. The relevance of neuropsychophysiologicalresearch to psychiatric treatment 97SS49. Attention-deficit/hyperactivity disorderin primary care 98SS50. Violence: a man made disaster 99SS51. Substance abuse and the family 100SS52. Settings and techniques of interventionin emergency psychiatry: a comparisonof different models 101SS53. Common mental disordersin private practice 102ZONAL SYMPOSIAZS1.Interdisciplinary approaches to treatmentof mental disorders: the experienceof Eastern Europe 104II World Psychiatry 3:S1 - October 2004

ZS2. Partnership in mental health care in Africa 105ZS3. Mental health and psychiatryin Latin America 106ZS4. Developing the identity of the contemporaryEuropean psychiatrist 106ZS5. Administration of health servicesand educational programs in Latin America 107ZS6. Perspectives on psychotherapy from the US 108ZS7. Mental health services in North Africa 109ZS8. Psychiatry in Central European countrieswithin the process of affiliationto the European Union 110ZS9. Mental health and primary care servicesworking together: the Canadian experience 112ZS10. Modern and traditional treatmentsin the context of a developing country 113ZS11. Community psychiatry in theMediterranean region and the roleof psychiatric associations 113WORKSHOPSWO1. Disasters, terrorism and trauma 115WO2. Training in psychiatric treatmentin different European countries 116WO3. Diagnosis and treatment of catatonia 117WO4. HIV/AIDS and psychiatric disorders 118WO5. Methodological challenges in non-industrysponsoredmulticenter clinical trials 118WO6. Diagnosing and treating social phobia 120WO7. Comparing mental health and risk factorsacross European Union countries 121WO8. International perspectives on coercivetreatment in psychiatry 123WO9. Recent advances in brain imagingof drug abuse 124WO10. Successful implementationof evidence-based family treatmentfor mental disorders 125WO11. Suicide prevention in major psychoses:risk factors and role of long-term treatment 126WO12. The GABA neuron and schizophreniamorbidity: treatment implications 127WO13. International perspectives on mentalhealth services for youth in prison 129WO14. European guidelines on privacyand confidentiality in healthcare 130WO15. Court-ordered psychiatric treatmentin New York City 130WO16. The prevalence of mental disordersin Europe and Italy: results of the EuropeanStudy of Epidemiology of Mental Disorders(ESEMeD) 131WO17. Psychiatric therapies in movies 132WO18. The atypical psychoses:from psychopathology to neurobiology 133WO19. Epidemiology, clinical pictureand treatment of childhood depression 134WO20. How to organize a scientific congress 134WO21. Treatments in psychiatry: youngpsychiatrists’ knowledge and attitudesin various countries 136WO22. Strategies for psychotropic drugsof the future 137WO23. Current approaches to severepersonality disorders 139WO24. Targeted combination of drugsor polypharmacy? Evidence forand against combined drug treatment 140WO25. Perspectives in psychiatric training:implications for treatment 141WO26. Psychotherapy for childhood depression:a cross-national European study 142WO27. Treatment of limits, limits of treatment 143WO28. Involving patients and familiesin integrated psychiatric treatments 144WO29. Mental health issues in HIV/AIDS 145WO30. Implementation of psychoeducationalinterventions for schizophreniain routine clinical settings 145WO31. The evolution of community psychiatryin Italy 147WO32. Predicting response to antipsychotics andantidepressants by functional imaging 148WO33. Treatment of personality disorders:new perspectives 149WO34. Biological correlates and treatmentof pathological gambling 150WO35. Psychiatry in the countriesof Eastern Europe and the Balkans:similarities and differences 151WO36. Autism in schizophrenia, today 152WO37. Clinical research on impulsivity:new developments and directionsfor possible treatments 153WO38. Teaching and learning core competenciesof basic consultation/liaison psychiatry 154WO39. The current role of psychotherapyin graduate psychiatric training 155WO40. Innovative approaches to outcomeassessment of psychosocial interventionsin severe mental disorders 157WO41. How to improve adherenceto psychiatric treatments 157WO42. Obsessive-compulsive disorder:from serotonin to other monoaminesand back again 158WO43. Guideline development and implementationin psychiatry 159III

WO44. The current management of Alzheimer’sdisease 160WO45. Coming-out and health care for younghomosexuals 161WO46. Cognitive dysfunction in schizophrenia:from evaluation to treatment 162WO47. Early psychosis: new strategiesfor prevention and rehabilitation 163WO48. Therapeutic factors in the differentpsychotherapeutic methods 164WO49. Update on research in psychiatric treatmentissues for lesbian, gay, bisexualand transgender patients 165WO50. Psychiatry in forensic settings 165WO51. Pharmacological and non-pharmacologicaltreatment issues concerning schizophreniain Korea 166WO52. Inpatient treatment of personalitydisorders 167WO53. An integrated research-basedapproach to treating first episode psychosis 168NEW RESEARCH SESSIONSNRS1. Psychotic disorders (I) 169NRS2. Primary care and liaison psychiatry 171NRS3. Community psychiatry (I) 173NRS4. Biological research 174NRS5. Mood disorders (I) 176NRS6. Improving psychiatric practice 178NRS7. Personality disorders and aggressivebehaviour 180NRS8. Psychotic disorders (II) 182NRS9. Mood disorders (II) 183NRS10. Psychotic disorders (III) 185NRS11. Child and adolescent psychiatry (I) 186NRS12. Psychotic disorders (IV) 188NRS13. Child and adolescent psychiatry (II) 190NRS14. Cultural and preventive psychiatry 191NRS15. New and traditional approachesin mental health care in developingcountries 193POSTER SESSIONSPO1. Psychotic disorders 194PO2. Mood, anxiety and eating disorders;child psychiatry; substance abuse 245PO3. Old age, consultation-liaison and forensicpsychiatry; psychiatric services;psychotherapies 309SPONSORED SYMPOSIASAS1. Free your patients from depression:treating the spectrum of symptoms 350SAS2. Escitalopram: innovation through evolution 350SAS3. Controversies and consensusin the management of bipolar depression 352SAS4. Novel ways to understand depression 353SAS5. The psychiatric patient: new treatmentperspectives across the lifespan 354SAS6. Beyond depression and anxiety:understanding treatment myths and facts 356SAS7. Integrating science and medicine: strategiesfor the management of bipolar disorder 357SAS8. Clinical strategies in managingschizophrenia and bipolar disorder 358SAS9. The many phases of bipolar disorders:epidemiology and management 359SAS10. Attention-deficit/hyperactivity disorder(ADHD), a life-long impairing disorder:an international perspective 360SAS11. Role of antipsychotics in the treatmentof bipolar disorder: from acute symptomcontrol to long-term management 361SAS12. The boundaries of anxiety 362SAS13. Maintaining global patient healthin the treatment of psychiatric disorders 363SAS14. Raising the bar in the treatmentof patients with mood and anxiety disorders 364INDEX OF AUTHORS 367IV World Psychiatry 3:S1 - October 2004

UPDATE LECTURESUL1.THE CONTEXT OF TREATMENT IN PSYCHIATRYN. SartoriusUniversity of Geneva, SwitzerlandThe ingredients of the treatment process are the treatment methods,the patients and their illnesses, the persons applying the therapy andthe environment in which the treatment is taking place. This lecturewill address the latter. It will describe the social and economic factorscharacterizing the context of treatment of mental disorders in differentparts of the world, the impact of culture on the perception of themental disorder and its treatment, the technical and human resourcesavailable for the treatment of people with mental illness and thetrends and developments in society (and in science) likely to affectthe treatment of mental illness in the future.UL2.EMPATHY, MEANING, AND THE THERAPEUTICALLIANCE IN PSYCHIATRIC PRACTICEA. TasmanDepartment of Psychiatry and Behavioral Sciences,University of Louisville School of Medicine, Louisville, KY, USAScientific advances in psychiatry in the last several decades have beendramatic, but there has been a concomitant de-emphasis on a biopsychosocialapproach to understanding and intervention for psychiatricdisorders. For example, the DSM diagnostic changes emphasizesymptom checklist approaches to psychiatric diagnosis; neuroscienceand psychopharmacology gains emphasize somatic interventions;delivery system changes, and inadequate availability of psychiatrists,diminish attention to the psychological aspects of the patient’s presentationand treatment. This lecture will argue for the benefits ofa re-emphasis on a comprehensive biopsychosocial approach, whichwill encompass a number of positive patient care results. Clearly,compliance with treatment is enhanced when the treatment occurswithin the context of a trusting therapeutic alliance with a skilled,psychologically minded, and empathic clinician. Attention to psychologicalfactors and developmental stresses allows for a more thoroughunderstanding of psychopathology. In addition, research studies havebegun to demonstrate the superiority of combined psychotherapeuticand psychopharmacologic treatment over one-dimensional interventions,especially for seriously ill patients. A key task for psychiatry willbe the integration of the best of our humanistic traditions with the latestscientific advances. Clinical vignettes from the author’s practicewill be used to illustrate the issues being discussed.UL3.THE COMPREHENSIVE MANAGEMENTOF SCHIZOPHRENIAN. SchoolerGeorgetown University School of Medicine, Washington, DC, USAClinical management of schizophrenia represents an ongoing challengein today’s complicated clinical environment. In virtually allcountries hospitalization is reserved for the most severely ill patientsand is only long enough to accomplish the most limited goals of crisisresolution. Therefore, long-term psychosocial and pharmacologicaltreatments are provided in community settings and implementationof most treatment changes takes place in these settings as well. Thispresentation will review current information regarding both medicationsand psychosocial treatments. Over the last decade newantipsychotic medications have become available that have greatlychanged the expectations both for clinical response and for sideeffects. Most recently, a long-acting version of a new antipsychotichas been developed. Data regarding long-term efficacy of these medicationsin comparison to classic antipsychotics will be presented aswill information regarding differential side effect profiles. The complexquestion of switching from one medication to another will beaddressed focusing on when and how to implement changes. Thedevelopment of novel psychosocial treatments has been almost as fastpaced as the changes in the pharmacological environment. Cognitiveremediation, cognitive behavior therapy, social skills training andenvironmental modifications to address cognitive deficits have nowbeen added to family based psychoeducation as treatments withdemonstrated long-term efficacy. The presentation will review evidenceregarding these treatments and suggest strategies for integratingspecific psychosocial interventions in a comprehensive treatmentplan for long-term community management. Ultimately, treatment ofschizophrenia requires a long-term commitment on the part of a teamthat integrates patients and family members with professional clinicians.We do not have cures for schizophrenia but the outlook hasnever been brighter.UL4.EARLY PSYCHOSIS: DETECTIONAND INTERVENTIONSP. McGorryDepartment of Psychiatry, University of Melbourne, AustraliaEarly intervention in serious medical illnesses - such as cancer,ischaemic heart disease, stroke, and diabetes - has long been accepted.In recent years this paradigm has been belatedly introduced intothe landscape of psychiatric treatment, focusing on psychotic disordersinitially, particularly schizophrenia. Transcending the therapeuticnihilism that has plagued the schizophrenia field, this paradigmhas been enthusiastically taken up around the world by a large networkof clinical researchers and major academic centres, and bymany clinicians as well. As a reform process, it is arguably the moststrongly evidence-based to date. Naturally critics and sceptics coexistand usefully challenge the process, helping to balance and guidethis evidence-based reform. As early intervention shades fromclearcut secondary prevention into intervention in subthreshold (prodromal)cases and ultimately further back to asymptomatic but highrisk individuals, then the ethical scenario changes significantly. Theonus to avoid harm and to demonstrate real benefit and cost-effectivenessbecomes much stronger. As David Sackett has trenchantlyobserved, preventive medicine can be intrinsically arrogant and itsproponents must take care. Yet, for most (usually young) people withemerging psychosis, these concerns are far from the reality of theirexperience. The timing and quality of their initial care remains seriouslyflawed even in the most affluent societies, despite the currentavailability of highly effective and better tolerated medicines, a newgeneration of psychosocial interventions and evolved models of carefirmly embedded in the general community. This situation mandates apractical reform process merely to improve the quality of care,whether or not the long-term course of illness ends up being changedfor the better. In addition, a focus on the early phases of illnessalready has the demonstrated benefit of clarifying the neurobiological1

of evidence based specialised/differentiated care: specialised outpatient/ambulatoryclinics, specialised community mental healthteams, assertive community treatment teams, early interventionsteams, alternatives to acute in-patient care, alternative types of longtermcommunity residential care, and alternative forms of occupationand vocational rehabilitation.UL14.THE CHALLENGE OF PRIMARY PREVENTIONIN PSYCHIATRYS. SaxenaWorld Health Organization, Geneva, SwitzerlandMental and behavioural disorders cause an enormous burden on individuals,families and societies. According to the latest figures availablefrom the World Health Organization (WHO), 12.9% of all disabilityadjusted life years (DALYs) lost are accounted for by these disorders.In addition, these disorders decrease quality of life and cause a massiveeconomic burden. Existing methods for treatment, though effective,have serious limitations. If the burden caused by mental andbehavioural disorders has to be decreased, it is essential that primarypreventive strategies are utilised more effectively and more widely.Some of the main barriers to using preventive interventions are lack ofconceptual clarity around the aims, boundaries and overlap betweenprevention, promotion and treatment interventions, lack of awarenessof evidence for their effectiveness and lack of consensus on roles andresponsibilities of mental health professionals for prevention. TheWHO has recently completed an international review of effectivenessof preventive strategies. While this review has clarified conceptualissues and provided much needed evidence, it has also revealed theextreme paucity of research from low and middle income countriesand almost a complete lack of cost-effectiveness information. Effortsto fill these lacunae need to be made urgently, but the available evidenceclearly substantiates the effectiveness of a variety of interventions.These range from macro-level strategies, like improving nutrition,housing, education and economic stability, to more specificmeso- and micro-level strategies like home-based or school-based programmesfor children, work-place interventions and those targeted atvulnerable populations. While the effectiveness of these strategies isestablished (at least in some cultures), a major challenge is to findfinancial and professional resources to implement these widely. Thisinvolves convincing the policy makers and competing for resourcesagainst more immediate demands. Traditional medical thinking hasplaced more emphasis on treatment and the entire health care systemis organized around care rather than prevention. There are also seriousissues around financing of prevention activities. How can preventionsucceed? The key to implementing prevention programmes is to establishstrong links across sectors and to utilize synergies of efforts. Preventionmessages need to be delivered to colleagues from sectors asdiverse as education, social security, employment, justice, housing,community development, poverty reduction, sports and many more.The role of mental health professionals is to inform, advise, guide,support and lead these sectors into adopting policies and implementingactions that facilitate prevention of mental disorders. Our successwill depend on how effectively we fulfil these roles.SPECIAL LECTURESSL1.CURRENT TREATMENT IN PSYCHOSES:DID IT CHANGE THE OUTCOME?A. OkashaPresident, World Psychiatric AssociationThis lecture will discuss whether there have been any actual changesin the outcome of psychotic illnesses after the introduction of secondgenerationantipsychotics. There is some confusion in the literatureconcerning the terms prognosis, course and outcome. Prognosis actuallyincludes course and outcome, while outcome is only one aspectof the course, “the end point of the course in a defined period oftime”. We shall focus on schizophrenia, bipolar disorder and psychoticdepression. An evaluation of outcome from the beginning ofthe 20th century (i.e. before the introduction of neuroleptics) up tonow will be attempted, taking into consideration both symptomaticand functional outcome. Psychotic disorders are long lasting and usuallylife long disorders. Affective disorders have a better long-termoutcome than schizophrenic and schizoaffective disorders. It is stilluncertain whether modern treatment has substantially changed thecourse and outcome of psychotic disorders. Manifest changes in theoutcome, if any, will be reflected not on a symptomatic or syndromallevel but probably on functional, occupational and interpersonal levels,where psychotic patients are not so dislocated from society asbefore. Reviewing the literature, outcome studies scarcely differentiatebetween symptomatic (syndromal) and functional outcome,which may lead to biased results. It is unfortunate that recent outcomestudies deal only with intermediate and short-term outcome,influenced by research of the industry, to assess the value of novelantipsychotics. The lecture will review the state of the art in the currentliterature, in developed and developing countries, regarding theshort, intermediate and long-term outcome of psychotic disorders.SL2.COMPREHENSIVE DIAGNOSIS AS A BASISFOR INTEGRATED TREATMENT AND HEALTHPROMOTIONJ.E. MezzichPresident Elect, World Psychiatric AssociationDiagnosis is recognized as the basis for responsible and effectiveplanning of care. In order to fulfill this objective, a number of sotermed comprehensive diagnostic models are emerging which dealwith diagnosis as both a formulation and a process. As a formulation,comprehensive diagnosis, first, covers a range of domains pertinent tohealth care, from illnesses to positive aspects of health (e.g., functioning,strengths, supports, and quality of life). The appraisal and measurementof these domains may be approached through standardizedtypologies (classical and prototypical), dimensional and configuralscales, and narratives. The evaluators involved include clinicians, thepatient, his/her family, and other relevant community members. As aprocess, comprehensive diagnostic models recognize the importanceof the collaborative and dynamic interaction among all participantsin the clinical encounter, unfolding longitudinally. Among illustrativecomprehensive diagnostic models one can list, first, the WPA InternationalGuidelines for Diagnostic Assessment (IGDA), whichinclude a multiaxial standardized component (I. Illnesses, II. Functioning,III. Contextual Factors, and IV. Quality of Life) and an idio-5

graphic personalized component (covering contextualized clinicalproblems, patient’s positive factors and assets relevant to clinical care,and expectations for health restoration and promotion). Another isthe World Health Organization (WHO) International Family of Classifications,which includes presently as main elements the InternationalClassification of Diseases and the International Classificationof Functioning and Health. Comprehensive diagnostic models, bothby furnishing a wide and differentiated informational statement andby stimulating an interactive and longitudinal process among clinicians,patients and their families, can contribute to a systematic articulationof planning of care (treatment of illness and health promotion)and to the optimization of its outcome.INTERACTIVE SYMPOSIAIS1. THE FUTURE OF PSYCHOTHERAPIESIS1.1.THE FUTURE OF PSYCHOTHERAPIES:COGNITIVE-BEHAVIOURAL THERAPY, PROBABLYP. SalkovskisDepartment of Psychology, Institute of Psychiatry,de Crespigny Park, Denmark Hill, London, UKThe future of psychotherapies is a complex matter, but some clarity isemerging in terms of prominent themes. These are: a) the developmentof empirically grounded clinical interventions; b) the application ofclinical science to the understanding and treatment of psychologicalproblems; c) the need for formulation-based (rather than diagnosisbased) assessment and intervention strategies; d) the development ofeffective dissemination of effective therapies; e) the importance ofovercoming conservatism and inertia in professionals engaged indelivering psychological treatment; f) the application of stepped caremodels in clinical practice and the related problem of humanresources and g) the development of shared decision making and evidence-basedpatient choice as part of the process of empowering serviceusers. Although all of these concepts are potentially trans-theoretical,only cognitive-behavioural therapy (CBT) is currently seeking tomeet the full range of these challenging ideas. The way each of thesethemes may affect the future of psychotherapy is considered, althoughthe results so far are patchy. It is concluded that CBT is currently theapproach best suited to fully meeting these challenges. To more fullymeet it, some integration with other theoretical orientations may behelpful, but not on an indiscriminate basis. It is also suggested that amajor re-adjustment of priorities and resources in psychological treatmentis now inevitable if psychological treatment is to remain viable inthe face of developments in physical treatment methods.IS1.2.THE FUTURE OF PSYCHOTHERAPIES:PSYCHODYNAMICJ. HolmesUniversity of Exeter, UKA sceptic might ask: does psychodynamic psychotherapy have afuture? The allegiance effect ensures that for this author the answermust be – most definitely. I start by defining psychodynamic psychotherapyas the therapeutic practice of developmental, interpersonalpsychology. I shall approach the subject from three angles: a) developmentalpsychopathology (here I shall look at accumulating evidencefrom neurobiology, mother-infant interaction studies, and attachmentresearch that is consistent with and extends fundamental tenets ofdynamic psychotherapy); b) outcome studies of dynamic psychotherapy(here I shall argue that there is a modest but gradually accumulatingbody of evidence supportive of the efficacy and effectiveness of psychodynamicpsychotherapy in treating a range of psychiatric disorders,especially borderline personality disorder); c) applications of dynamicpsychotherapy in the psychiatric workplace (using examples drawnfrom the North Devon Personality Disorder Service, I will illustrate theways in which, in the context of a multi-modal, multi-disciplinary psychotherapyservice, psychodynamic thinking can help mental healthworkers manage their own feelings and those of their most complexand difficult patients). I shall end by some speculations about an agendafor future developments within the psychodynamic tradition.IS1.3.THE FUTURE OF INTERPERSONALPSYCHOTHERAPYJ.C. MarkowitzNew York State Psychiatric Institute, New York, NY, USAInterpersonal psychotherapy (IPT) is a time-limited, diagnosisfocused,relatively simple, here-and-now treatment. Its basic assumptionsinclude diagnosing major depression as a treatable mental illnessthat is not the patient’s fault, and linking mood shifts to the patient’scoping with life events. IPT has been shown to build social skills whilerelieving depressive symptoms. This talk discusses the potential futureof IPT in research, training, and clinical use. IPT is among the bestresearched of psychotherapies. Its efficacy has been demonstrated forpatients with major depression, and ongoing research shows promisefor a growing list of mood and non-mood diagnostic indications. Partof the research future of IPT will be a continuing series of outcome trialsfor Axis I and Axis II diagnoses, defining efficacy and comparingIPT to other efficacious psychotherapies. Other trials will examine thesequencing and combination of IPT with pharmacotherapy for specificdisorders. Still other studies will explore the neglected area of IPTprocess research, seeking to determine the mechanisms of this eclectictreatment. In contrast to the slew of careful research studies to whichit has been subjected, IPT has received little clinical use. Disseminationto clinicians began only recently. Part of the future of IPT is its furtherdissemination. Whereas research standards for competence andadherence exist, clinical standards are as yet under development. TheInternational Society for Interpersonal Psychotherapy may help tocoordinate clinical training around the world, so that IPT does notlose definition and coherence as it spreads in practice.IS1.4.THE FUTURE OF FAMILY THERAPYS. BlochDepartment of Psychiatry and Centre for the Study of Health andSociety, University of Melbourne, AustraliaThe term “family therapy”, when used in the adult psychiatric setting,covers a variety of approaches. At one extreme, it is a methoddrawn from one or more of a range of theoretically-based schoolswhich seeks to help an individual patient who presents with a clinicalsyndrome. At the other extreme, family therapy is a way ofthinking about psychotherapy in general; the intervention mayinvolve the individual alone, the nuclear family or an extended network,but the focus is the relationships between people. Accordingto this view, psychopathology reflects recurring, problematic inter-6 World Psychiatry 3:S1 - October 2004

actional patterns among family members and between the familyand, possibly, other social institutions, which may include doctorsand helping agencies. Midway between these two positions is onethat views the family as acting potentially as a resource or as a liabilityfor an identified patient; different interventions are thus neededto enhance the positive effects of family relationships as comparedwith those which seek to minimize or negate their noxiouseffects. As I shall elaborate in this presentation, such a range ofinterventions makes it tricky to define and research family therapy,let alone anticipate its future. Notwithstanding, I shall take up thechallenge and outline the sort of future I think family should have.This could perhaps be summed up in the following way: guruismout, scientific rigor in, but let us not forget that family therapy, likeall the psychotherapies, if it is to be practised effectively, relies onboth science and art. Indeed, a complementarity between scienceand art is the ideal. And, let us not forget the ethical dimension,since working with families throws up a whole series of intricatequandaries for the therapist.IS2.THE CONTRIBUTION OF NEUROIMAGINGRESEARCH TO CLINICAL PSYCHIATRYIS2.1.THEORY OF MIND: THE INTERFACE OF EMOTIONAND LANGUAGE IN SCHIZOPHRENIAN.C. Andreasen, C. Calarge, D.S. O’LearyDepartment of Psychiatry, University of Iowa, Iowa City, IA, USAThe concept of “theory of mind” (TOM) refers to the ability to inferand attribute mental states to one’s self and to others and to recognizethat behaviors are guided by these mental states. Examples of mentalstates include beliefs, wishes, thoughts, goals, and knowledge. Thisability is also referred to as “mentalizing”. TOM or “mentalizing”requires the understanding that those mental states reflect a subjectivereality rather than the real world. This capacity, which is relatedto the capacity to put oneself in another’s place, or to have empathy,is an important component of social interactions. It appears to beimpaired in many individuals with schizophrenia. Because of itsphilosophical and clinical importance, we undertook a study of TOMin a group of healthy volunteers and patients with schizophrenia,using positron emission tomography (PET) to identify the neural circuitsused during a language task that required subjects to attribute amental state to another person. Specifically, they were asked to“imagine that you sat next to a woman on an park bench and yourealized she was crying. Make up a story about what led up to her crying”.(The gender of the person was changed to female if the subjectwas a male.) The comparison task consisted of reading a neutral storyaloud, in order to control for the speech component of the task. Innormal individuals the former task activated a distributed group ofnodes that included anterior cingulate and paracingulate regions, leftanterior frontal regions, left anterior temporal lobe, and cerebellum.Many of these regions are implicated in the identification of goals andassociative memories. The large cerebellar activations add further evidenceto the importance of the cerebellum in many types of mentalactivity. The patients with schizophrenia had decreased flow in multipleregions (lateral cerebellum and vermis, visual association cortex,and thalamus) and increases in others (right inferior frontal, rightdorsolateral frontal, right parietal, and right putamen). The areas ofdecreased flow are consistent with many previous studies indicatingproblems in recruiting cortical-cerebellar circuits in schizophrenia.The areas of increase may reflect a need to draw on right hemisphereregions to perform the task, in order to compensate for deficits in leftfrontal and cingulate regions.IS2.2.POSITRON EMISSION TOMOGRAPHY STUDIESON THE DOPAMINE SYSTEMS IN SCHIZOPHRENIAL. FardeKarolinska Institutet, Stockholm, SwedenThe original dopamine (DA) hypothesis of schizophrenia was basedon pharmacological evidences and suggested hyperactivity of centralDA neurotransmission. It has been supported by findings in vitro thatall antipsychotic drugs are D2-DA-antagonists. Positron emissiontomography (PET) studies have later confirmed high occupancy ofD2-DA-receptors during clinical treatment. It has, however, been difficultto obtain consistent evidence for generally increased activity ofDA systems in patients with schizophrenia. Though effective for thetreatment of positive symptoms, hitherto developed antipsychoticshave poor efficacy or may even worsen negative symptoms. Interestingly,the psychostimulant D-amphetamine may, in some cases,improve negative symptoms. These observations are a basis for theDA dysregulation hypothesis in schizophrenia. The hypothesis hasreceived additional support from a series of experimental neurophysiologicalstudies. PET studies on D1- and D2-DA-receptors havedemonstrated up- as well as down-regulation of these DA markers.Strong support for DA hyperactivity has been given by studies indicatingincreased DA release following challenges with amphetamine.The finding has, due to methodological limitations, only been reportedfor the striatum, and more sparsely innervated extrastriatal regionshave not yet been examined using this PET approach. Another limitationis that most PET measurements have been performed withantagonists having equal affinity for receptors in the high and lowaffinity state. Agonists, like nor-propyl-apomorphine (NPA) or (R)-2-OCH 3-N-n-propylnorpomorphine (MNPA), bind preferentially to thehigh affinity state and have been suggested to provide a more validmeasure of the functional state of the DA system. Agonist radioligands,such as [11C]MNPA, may thus provide new tools for examinationof the DA dysregulation hypothesis in schizophrenia.IS2.3.PSYCHOPHARMACOLOGY AND FUNCTIONALNEUROIMAGING: NEW INSIGHTS INTO DRUGMODELS OF SCHIZOPHRENIAP.C. FletcherUniversity of Cambridge, UKA drug model of a psychiatric disorder is validated by consistentobservations that behaviour under the influence of the drug is redolentof that observed in association with that disorder. This leads us toask which behavioural measures most sensitively reflect the drug’seffects since these are clearly the measures that may most fruitfully becompared with the disordered state. In the main, behavioural measuressuch as reaction time and performance levels on various tasksmay lie some distance downstream of the cognitive processes thatgenerate them and it is possible that, in certain cognitive tasks, standardbehavioural measures provide only a vague representation ofdrug-induced cognitive change. I will present data suggesting thatfunctional magnetic resonance imaging (fMRI) provides a highlysensitive outcome variable: one that may prove complementary toexisting behavioural measures and subjective reports in delineatingthe effects of ketamine – a non-competitive N-methyl-D-aspartate7

(NMDA) antagonist that is drawing increasing attention as a modelfor the schizophrenic state. The effects of ketamine may be seen tohave an impact upon task-related changes in regional brain activity.Crucially, under certain circumstances, these changes may beobserved even when the subject is unaware of whether he is receivingdrug or placebo and when there is no measurable deficit in his abilityto perform the task. The key frontal, thalamic and parietal regionsthat appear to be sensitive to the drug are those that have also beenimplicated in schizophrenia. I suggest that the functional neuroimagingtechniques may, in this respect, provide a new and complementaryway of looking at the effects of drugs and, by extrapolation, of evaluatingthose drugs as models of psychiatric disease.IS2.4.FUNCTIONAL BRAIN STUDIES OF EMOTIONALAND SPIRITUAL BEHAVIOR IN HUMANS:TOWARD A BIOCHEMISTRY OF THE SOUL?P. PietriniLaboratory of Clinical Biochemistry and Molecular Biology,University of Pisa, ItalyWith the appearance of non-invasive methodologies for the in vivofunctional exploration of the brain, including positron emissiontomography (PET) and functional magnetic resonance imaging(fMRI), scientists have been provided with the unprecedented opportunityto examine the biochemical aspects of the human brain inaction, as well as the effects of disease and therapeutic interventions.Over the last thirty years, experimental paradigms, which initiallywere restricted to relatively elementary sensory stimulation or motortasks, have ventured into the investigation of more elusive aspects ofmental function, such as emotional behavior, moral discernment andspirituality. Exposure to physically or morally hurtful events elicitsbehavioral responses finalized to overcome the painful condition.Forgiveness occurs when a person, hurt by another person resultingin resentment, excuses the offender. We hypothesized that forgivingenables an individual to overcome more effectively a situation thatwould otherwise represent a major bio-psychological stress. Adaptinga previously validated experimental set-up, we designed an fMRIstudy to examine emotional and behavioral responses and brainactivity associated with the imaginal process of giving or withholdingforgiving in relation to the experience of hurtful events in healthyyoung individuals with no psychiatric morbidity. Overall activationswere observed in extrastriate and striate visual cortex, intraparietalsulci, motor cortex, superior and middle temporal gyri, anterior cingulate,limbic areas, ventromedial prefrontal cortex, and orbitofrontalcortex. Specifically, the hurtful conditions showed increases in anteriormiddle frontal and ventral temporal cortices compared to thebaseline control condition. The enactment of forgiving versus unforgivingwas associated with different neural activity in the right medial,middle and superior frontal cortices, right amygdala, bilateral striatum,left anterior cingulate, bilateral posterior parietal cortices andcerebellum. Thus, imaginal evocation of emotionally relevant hurtfulevents followed by forgiving or not forgiving was associated withmodulation of brain areas implicated in visual/semantic representationand imagery, and more anterior areas, such as frontal cortex,amygdala, anterior cingulate and striatum, that regulate emotionalresponse, moral judgment, perception of physical and moral pain,mood and decision making processes.Supported by Grant CFR-5103, John Templeton FoundationIS3.THE FUTURE OF PHARMACOTHERAPYFOR MOOD AND ANXIETY DISORDERSIS3.1.THE FUTURE OF PHARMACOTHERAPY FORDEPRESSION: AN AMERICAN PERSPECTIVED.J. KupferDepartment of Psychiatry, University of Pittsburgh, PA, USAWhile considerable advances in the treatment, and particularly thepharmacological treatment, for mood disorders have been made inthe last two decades, a number of gaps and obstacles remain. Thislecture will discuss the American perspective on the future status ofpharmacotherapy in depression. Since the Food and Drug Administration(FDA) has emphasized acute trials for efficacy “approval”,one major gap in the treatment of depression is the relative paucity ofdata on long-term treatment. The convergence of FDA regulations,the needs of the pharmaceutical industry and National Institute ofHealth (NIH) priorities has decreased the likelihood of increasingour knowledge base on long-term treatment of this disorder. On theother hand, there is considerable promise of developing a new generationof “antidepressants” based on molecular targets and theapplication of clinical and basic neuroscience tools. Medicationscurrently under testing programs include dual reuptake inhibitors,novel dopamine reuptake inhibitors, drugs combining serotonin (5-HT) reuptake inhibition with 5HT 2/5HT 3antagonism; corticotropinreleasingfactor (CRF) receptor antagonists; substance P (neurokinin)receptor antagonists and compounds modulating glutamatergicneurotransmission. Other novel treatment strategies arealso in the pipeline. Most recently, attention has moved from intrasynapticchanges in neurotransmitter levels to focusing on intracellularsignaling pathways. Our recent discoveries in genetics and functionalimaging, combined with more precise behavioral phenotypes,could lead to better subgrouping of depressive disorders. Furthermore,advances in pharmacogenomics can assist us in such investigations.In short, the future is bright, although there are clearlybumps in the road.IS3.2.THE FUTURE OF PHARMACOTHERAPY FORDEPRESSION: A EUROPEAN PERSPECTIVED.S. BaldwinUniversity of Southampton, UKThere are many treatments for depression, but overall care ofdepressed patients is usually far from optimal. This presentationexamines how future care might be improved by alternativeapproaches, including enhanced use of existing treatments, modificationsto existing antidepressants, and new targets for antidepressantpharmacotherapy. Clinical outcomes might be enhanced simply bybetter use of existing treatments, for example by prescribing antidepressantsaccording to evidence-based guidelines, with or withoutsupplementary algorithms; or through judicious combinations withstructured psychotherapies. Outcomes might also be improved bymodifications to some already available antidepressants, such as theproduction of single enantiomers, when the ‘parent’ compound is aracemic mixture; changes to the mode of delivery or pharmacokineticproperties; and combination of two psychotropic drugs within asingle tablet, the components being in novel formulations. Potentialnew antidepressants include corticotropin-releasing factor receptorantagonists; glucocorticoid receptor antagonists; vasopressin recep-8 World Psychiatry 3:S1 - October 2004

tor antagonists; melatonin receptor agonists; and antagonists at thesubstance P (NK-1) receptor. There are many approaches towardsdevelopment of potential new antidepressant treatments, but the likelyimpact of new health technologies is hard to predict. The developmentof treatments that are more efficacious or earlier to act remainsa goal of drug discovery, but if new treatments are complex for doctorsto prescribe, hard for patients to tolerate, or too expensive forhealthcare providers to offer, they will have limited impact. Groundbreakingtreatments can only alter the burden of depression whenthey are adopted widely by clinicians, and accepted readily bypatients.IS3.3.THE FUTURE OF PHARMACOTHERAPYFOR BIPOLAR DISORDERE. VietaBipolar Disorders Program, Hospital Clinic,University of Barcelona, SpainLong-term treatment and compliance are crucial issues in the outcomeof bipolar disorder, a long-lasting condition with highly recurrentepisodes which is associated to high levels of suffering, occupationaldysfunction, and impairment of social life and relationships.The length of remission, when the individual is well, is reduced inmany cases both with age and the number of previous episodes.Although our current armamentarium for the treatment of mania isquite broad and successful, bipolar depression, mixed states, andprophylaxis are still huge challenges, and we are still far fromaddressing the true clinically meaningful target, which is interepisodefunctioning. For many years lithium has been considered the firstlinetreatment of bipolar disorder, and to some extent it remains so.However, a number of drugs coming from research in schizophreniaand epilepsy have become available for the treatment of bipolar illness.During coming years, a broader use of atypical antipsychoticsand third-generation anticonvulsants is expected, but only thosewhich may be able to prove their efficacy beyond the short-termtreatment and in different clinical situations may succeed. Newresearch is now focusing on the intimate mechanism of action oflithium, and this may lead to new drugs discovery, not necessarilycoming from other indications. Challenges for the future are to succeedto discriminate between true therapeutic progress and marketingissues, to learn how to use novel compounds, and not to forgethow to use those that are still important, regardless of their patentstatus. Combination treatment may become very widespread, andagain clinicians will need tools to deal with potential interactions,compliance issues, and cost-effectiveness decisions.IS3.4.THE FUTURE OF PHARMACOTHERAPY FORANXIETY DISORDERSD.J. SteinUniversity of Stellenbosch, Cape Town, South Africa;University of Florida, Gainesville, FL, USAAdvances in psychiatric nosology and the introduction of modernantidepressant agents have led to significant advances in the treatmentof anxiety disorders. Nevertheless, these agents are not withoutdisadvantages, and a significant proportion of patients with anxietyconditions fail to respond to first-line agents. Furthermore, theseagents act on the same limited number of neurotransmitter pathwaysas did the early antidepressants. Developments in the cognitive-affectiveneuroscience of anxiety indicate, however, that the future will seethe introduction of agents with novel mechanisms of action and perhapsparticularly useful clinical niches. In this talk, we discuss someof these developments, and new molecular targets for the treatment ofanxiety disorders, including corticotropin-releasing factor, glutamate,and neurotrophic factors.IS4.CULTURAL ISSUES IN MENTAL HEALTH CAREIS4.1.THE PLACE OF CULTURE IN MENTAL HEALTHCARE: A CROSS-NATIONAL COMPARATIVEPERSPECTIVEL.J. KirmayerDivision of Social and Transcultural Psychiatry,McGill University, Montreal, CanadaCultural psychiatry has moved from exoticizing the other throughattention to ‘culture-bound syndromes’ to the recognition that psychiatrictheory itself is a cultural product. This shift reflects fundamentalchanges in our understanding of the nature of culture in aglobalizing world. Culture is now understood as a biological construct,both cause and consequence of the social brain. Local culturalworlds emerge from interactions between individual agency andglobal systems. This presentation will consider the implications ofthese new notions of culture for mental health care. The cross-nationalcomparative study of models of mental health care reveals some ofthe cultural assumptions of psychiatric practice. Models of servicedelivery developed in different countries reflect the demographics ofthe population and the history of dominant approaches in psychiatryand medicine. However, models of service are also strongly influencedby health policy, which in turn reflects ideologies of citizenship,response to migration, and the politics of national and ethnoculturalidentity. These social factors in turn influence psychiatricmodes of interpreting individual suffering. International psychiatrypresents itself as a “value-free” system of rational medical science andevidence-based “best practices”. However, there is ample evidence forthe social, political and economic shaping of psychiatric theory andpractice. The call for evidence-based psychiatry makes attention toculture essential to clarify the context and generalizability of psychiatrictheory and practice.IS4.2.CULTURAL INFLUENCES ON HELP SEEKING ANDMODES OF ADMISSION: IMPLICATIONS FOR THEORGANIZATION OF MENTAL HEALTH SERVICESJ. LeffTAPS Research Unit, London, UKCultural factors exert an influence on many aspects of mental healthcare, from the initial seeking of professional help, through the proceduresof diagnosis and treatment, to aftercare and social reintegration,including the organisation of mental health services. The firstresource that individuals and their families utilise in the case of psychiatricdisorders is often the informal network of relatives andfriends. If that fails, then the next stage on the pathway to caredepends on cultural factors, particularly beliefs about the causes andtreatments of mental disorders. In developing countries, traditionalbeliefs usually lead to consultation with a healer before biomedicalservices are sought. The scarcity of such services also dictates thiscourse of action. Ethnic minority groups in a developed country also9

consult healers in their own community first, at least until somedegree of acculturation is achieved. It has been claimed that psychiatricprofessionals faced with a person from an unfamiliar culture areprone to make incorrect diagnoses, mistaking culturally acceptableideas and behaviour as indicative of psychopathology. While there islittle evidence for these claims, they create an atmosphere of suspicionin ethnic minority communities which inhibits contacting theservices. Racial prejudice has also been claimed as the cause of differentialtreatment experiences of majority and minority ethnic patients.The engagement of patients in follow-up care after treatment of anacute episode is often fraught with difficulties. Beliefs concerningcure as opposed to maintenance are culturally influenced. Furthermore,patients from ethnic minority groups who feel they have beendiscriminated against during their acute care are less likely to complywith aftercare. Full reintegration into the community depends cruciallyon the attitudes of the public towards psychiatric illness, andthese vary markedly between cultures. A contentious issue in a multiculturalsociety is whether dedicated services should be provided forpatients from minority ethnic groups. There are strong arguments forsegregated services, including culturally sensitive staff and ease ofcommunication with patients and relatives. However, there is thecontrary argument that such services perpetuate difference and fosterdiscrimination. All the above issues are difficult to resolve but opendiscussion between professionals, clients and family members holdsout hope of developing acceptable solutions.IS4.3.CULTURAL ISSUES IN MENTAL HEALTH CARE:INTERACTION BETWEEN LEGISLATION ANDMENTAL HEALTHM. KastrupCentre for Transcultural Psychiatry, Rigshospitalet, Copenhagen,DenmarkRefugees seeking asylum have a high frequency of traumatic experiences.Such events include pre-flight experiences such as persecution,internment or torture as well as post-flight experiences such aslanguage barriers, discrimination, alienation, or social problems.Mental health professionals meeting refugees should be aware of thisand the possible negative consequences on their mental health. Thereis increasing recognition on how important the conditions in countryof exile are for the mental health and quality of life of the refugee populationand its integration in the new environment. In many Westerncountries we are presently experiencing changes in the legislationinvolving immigrants. Such alterations may relate to family reunionsamong refugees, social benefits in the host country, conditions forgranting asylum, length of permission to stay in the country. Thesechanges and the implied uncertainties for the refugee population mayresult in an exacerbation of an already fragile mental health situation.The paper will provide an overview of issues of concern regardingrefugee mental health and the relationship between altered immigrationpolicy and the mental health status of those involved.IS4.4.CULTURAL ISSUES IN MENTAL HEALTH CARE:A VIEW FROM DEVELOPING COUNTRIESR. Srinivasa MurthyEastern Mediterranean Regional Office, World HealthOrganization, Cairo, EgyptAll over the world there is a major shift in the organisation of mentalhealth care. In developed countries, the shift is from institutional careto community care. In developed countries, the organisation of mentalhealth care in a systematic manner is less than three decades old.Most of the countries have only in the recent times initiated measuresto develop mental health programmes to cover the total populations.The challenges in developing countries are the lack of mental healthinfrastructures and trained professionals, public ignorance and lackof supportive policies, funding and legislation. There are a number ofareas where cultural issues play an important role in the organisationof mental health care. There are both positive and negative aspects ofculture that influence mental health care. On the negative side, theexisting beliefs about the supernatural causation lead to seeking initiallyhelp from traditional healers or not considering the illness asrequiring medical care. The differential roles of men and women getsreflected in the differing ways ill men and women are brought to care.The trend of the population to express their psychological distress insomatic terms leads to people seeking help mainly from primaryhealth care and being treated for physical problems rather than thepsychological problems. The strong belief of heredity as a cause ofmental disorders presents problems in marriage and breakdown ofmarriage among the ill persons. On the positive side, the high tolerancein the community to deviant behaviour in general and mental illnessesin particular limits “exclusion” of the mentally ill from communitylife. Ill persons continue to live in families and communities,especially in the rural areas. There is also less resistance to setting upof community care facilities like half-way homes, day care centres andhostels in the residential areas. The family as a readily available andabiding source of support is an advantage in planning of care programmes.Studies in Sri Lanka in the 1970s, Nigeria, Colombia andIndia as part of the World Health Organization’s International PilotStudy on Schizophrenia and from a number of countries in the lastdecade have pointed to the value of this type of support towardsrecovery. Some countries in Africa and Pakistan have developed linkageswith traditional healers to reach ill persons to the advantage ofthe patients and to develop services in a culturally acceptable manner.The “external” orientation to understanding the causation in someways decreases the stigma and blaming of the ill persons. The availabilityof cultural practices relating to grief and child rearing, andtherapeutic measures like yoga and meditation are valuable for preventionof mental health and promotion of mental health. The mentalhealth professionals in developing countries have to recognise thatculture can function as a friend and foe. The challenge is to harnessthe positive aspects and minimise/eliminate the negative aspects ofcultural practices, to meet the modern needs of mental health care.IS5.THE CURRENT MANAGEMENT OF PERSONALITYDISORDERSIS5.1.THE MANAGEMENT OF CLUSTER C PERSONALITYDISORDERSP. TyrerDivision of Neuroscience and Psychological Medicine,Imperial College, London, UKBoth pharmacological and psychological treatments have been usedfor the treatment of cluster C personality disorders - dependent andavoidant (anxious). However, the management of these disorders maybe confused with the treatment of anxiety, depression, drug misuseand somatoform disorders, which often exist in conjunction with thepersonality disorder. Antidepressant drugs have been evaluated10 World Psychiatry 3:S1 - October 2004

specifically for the treatment of cluster C personality disorders, andthe evidence to date suggests that selective serotonin reuptakeinhibitors are effective independent of their antidepressive effects.Psychological treatments for anxiety and depression are hindered bythe presence of a cluster C personality disorder, but this is not surprisingif the personality abnormality is ignored in treatment, as itusually is. In management of cluster C personality disorders, regulartreatment with clear boundaries and constant monitoring of psychologicaldependence are desirable. In many instances, this can beachieved optimally in a day hospital setting.IS5.2.THE MANAGEMENT OF CLUSTER A PERSONALITYDISORDERSM. Isohanni, J. Miettunen, H. KoponenDepartment of Psychiatry, University of Oulu, FinlandThe basic epidemiology and state of care of cluster A personality disordersis relatively unknown. Cases are rarely detected and enteredinto clinical, register or population based databanks. After the 31-yearfollow-up of 11,017 persons in the register-based Northern Finland1966 Birth Cohort, we have only four hospital-treated cases. Studysamples are usually non-epidemiological and consequently the resultsof different studies show considerable variation. Cluster A disordersare usually harmful and complicated by common comorbid conditions(both psychiatric and somatic). The most profound core psychopathologyincludes the cognitive-perceptual dimension, whichmay relate to disturbances in the dopamine system. This is in line withthe current data that low doses of conventional and second-generationantipsychotics are useful medications for these patients. Benzodiazepinesmay alleviate anxiety and serotonin-selective antidepressantsmake the patients less sensitive to rejection. Usually pharmacotherapyis short term, although in some cases long-term treatment may bepromising. Pharmacotherapy must always combine with supportivetherapeutic interaction. Psycho- and sociotherapeutic correction ofsome traits is theoretically possible. In practice, it is hard to find a psychotherapeuticmethod that has not been tried for personality disorders.However, empirical data on the psychotherapy for cluster A disordersis minimal. This reflects difficulties in understanding and minimalresponse of these disorders. Summarising, moderately effectivetreatments exist to alleviate symptoms and reduce symptomatic behavioursthat characterize cluster A personality disorders.IS5.3.THE CURRENT MANAGEMENT OF BORDERLINEPERSONALITY DISORDERC. MaffeiClinical Psychology and Psychotherapy Unit, Vita-Salute SanRaffaele University, Milan, ItalyBorderline personality disorder (BPD) includes a heterogeneousgroup of subjects with different clinical characteristics and differentlevels of severity. Each subject can also present with different problemsin time. Consequently, psychiatrists have to take into considerationaspects that vary depending on each clinical case and they haveto do it very carefully. However, aspects of management common toall the subjects diagnosed as borderline represent a general indispensableframework. Safety is the first issue: borderline subjects are atrisk of suicidal attempts and various aspects of self-destructivenessrepresent a common problem. The evaluation of safety issues determinesthe treatment setting, that has to be agreed by the patient.Establishing agreement with the patient about the treatment goals isone of the basic principles of management. Psychiatrists should provideclinical management throughout the course of treatment.According to the American Psychiatric Association, important componentsof this process are: a) responding to crises and monitoringthe patient’s safety; b) establishing and maintaining a therapeuticframework and alliance; c) coordinating treatment provided by multipleclinicians; d) reassessing the effectiveness of the treatment plan.In this framework, psychiatrists can decide what kind of therapeuticinstruments to use. Different psychotherapeutic approaches and differentpsychotropic medications are available. The choice of specifictherapeutic instruments should also take into consideration the presenceof comorbid Axis I and Axis II disorders.IS5.4.ANTISOCIAL PERSONALITY DISORDER:A THERAPEUTIC PERSPECTIVEC. DugganEast Midlands Centre for Forensic Mental Health, Cordelia Close,Leicester, UKWhen mental health professionals advocate a therapeutic perspectivefor those with antisocial personality disorder (ASPD), they are facedwith questions that appear to go beyond the narrow confines of theirdiscipline. For instance: a) as there is a substantial overlap betweenASPD and criminality, does this imply that therapeutic programmesought to be offered to prisoners? b) Should the focus of such programmesbe a reduction in re-offending or a change in personalitystructure? c) Is it ethical for mental health professionals to collude withthe state in protecting the public by legitimizing preventative detentionfor a small subgroup of those with ASPD? d) If it is the case that interventionsfor a subgroup of those with ASPD (i.e. those with high psychopathyscores) lead to their deterioration rather than improvement,should we therefore withhold interventions even though this may prolongtheir detention? As these questions cover important moral andethical issues, they will continue to be debated for the foreseeablefuture. Psychiatry, however, could make an important contribution if itwere to clarify the nosology of ASPD so that antisocial traits are moreclearly separated from antisocial (i.e. criminal) behaviour. In order todo so, I believe that we need to identify the mechanism linking the disorderwith the behaviour by investigating the underlying neurobiologyof ASPD. If this approach were to be implemented successfully, itwould provide an explicit rationale for limited psychiatric interventionin a subgroup with ASPD, and thereby encourage practitioners tobecome more involved with this disadvantaged group.IS6.THE MANAGEMENT OF SOMATOFORM DISORDERSAND MEDICALLY UNEXPLAINED PHYSICALSYMPTOMSIS6.1.MEDICALLY UNEXPLAINED SYMPTOMSAND SOMATOFORM DISORDERS:TIME FOR A NEW APPROACHM. SharpeSchool of Molecular and Clinical Medicine,University of Edinburgh, UKSymptoms considered disproportionate to identifiable disease pathologyare referred to as ‘medically unexplained’, ‘functional’ or ‘somatoform’.They represent a major burden to medicine. Psychiatrists are11

often called on to assist in the management of these patients. Thispresentation will consider the current conceptualization of suchsymptoms as manifestations of ‘somatization’ and the current psychiatricclassification. A new approach to conceptualization and classificationbased on the concept of functional bodily disturbance will bedescribed. Research data will be presented to support this newapproach. The practical implications for patient management will beoutlined and illustrated with clinical examples.IS6.2.SOMATOFORM DISORDERS AND MEDICALLYUNEXPLAINED SYMPTOMS:FACTORS INFLUENCING OUTCOMEF. CreedUniversity of Manchester, UKImproved management of patients with somatoform disorders andmedically unexplained symptoms requires a clear model of the influenceson outcome. Outcome, as measured by Short Form-36 (SF-36)physical component score (how much the disorder affects the person’sdaily life) is influenced by depression, anxiety, current socialstress, childhood adversity, health anxiety and the individual’s perceptionof his symptoms. A model of these components in relationto functional gastro-intestinal complaints will be presented usingdata from several studies of patients seen in medical clinics in secondarycare. Psychotherapy and antidepressants may lead toimprovement through different mechanisms – the former is particularlyhelpful to those with reported prior abuse whereas antidepressantshelp through reduction of depression and improvement in pain.The importance of changing illness beliefs as well as treating anxiety,depression and psychosocial difficulties will be stressed. The ways inwhich these may be delivered in primary and secondary care settingswill be presented.IS6.3.COGNITIVE BEHAVIOR THERAPY FORSOMATIZATIONJ. Escobar, M. Gara, L. Allen, A. Díaz-Martínez, A. Interian,M. WarmanDepartment of Psychiatry, UMDNJ-Robert Word Johnson MedicalSchool, Piscataway, NJ, USAPatients presenting with high levels of medically unexplained symptomsare a frequent, frustrating and costly reality in primary care.While these patients may have underlying psychopathologies, thesomatic symptom assumes a dominating role and patients reject psychologicallabels and referral. Recognition and management of thesepatients at the primary care site is essential and development of treatmentsthat can be adapted to the primary care environment may havesignificant practical value. This presentation reports on a controlledNational Institute of Mental Health (NIMH)–funded study of cognitive-behaviortherapy (CBT) on a large, multiethnic sample ofpatients visiting a primary care clinic in New Jersey. 150 patients haveentered the study thus far. About one half of the patients were randomlyassigned to a CBT treatment group, and the other half to a“consultation letter” control group. The treatment group received 10sessions of a manualized CBT designed for patients with somatoformdisorders. Blind raters assessed change in somatic, mood and anxietysymptoms at baseline and frequent intervals with several instrumentalmeasures. Interim analyses of the first 53 patients completing thestudy show a significant effect of CBT on somatic symptom severityand functional outcomes compared to the control group. For example,in the Clinical Global Impressions anchored for somatic symptoms,over 70% of CBT-treated patients were rated as “much/verymuch improved” compared to only 30% of patients in the controlgroup. This effect seems to be independent of any effect CBT mayhave on mood or anxiety symptoms.IS6.4.SOMATOFORM DISORDERS AND MEDICALLYUNEXPLAINED PHYSICAL SYMPTOMS:AN ARAB PERSPECTIVET. OkashaInstitute of Psychiatry, Ain Shams University, Kasr El Nil, Cairo,EgyptAs our societies become more diverse and the world evolves into aglobal village, the need to integrate culture into medicine and psychiatrybecomes more critically important. In the Arab culture, thehumanitarian interaction with a doctor is valued as much, if notmore, than his or her technical ability or scientific knowledge. Thehumanitarian nature of this interaction depends on the way the doctordeals with the patient and his or her family and the extent towhich the doctor expresses respect for, and acceptance of local culturalnorms. The society is more family than individual centered andthere is interdependence rather than autonomy. There is no doubtthat culture has a marked influence on the presentation of psychiatricsymptoms, the understanding of these symptoms and the therapeuticmethods adapted. Due to understaffed mental health facilities, it isessential that the general practitioner help in the diagnosis and managementof psychiatric disorders under the title of unexplainedsomatic symptoms, which is an essential part of the undergraduatepsychiatric training. In this presentation the main differencesbetween traditional and western societies will be reviewed, with specialemphasis on the diagnosis of somatoform disorders in the Arabculture.IS7.NEW STRATEGIES IN THE MANAGEMENTOF SEXUAL DISORDERSIS7.1.EVIDENCE BASED APPROACH AND DRUGTREATMENT OF PREMATURE EJACULATIONM.D. WaldingerLeyenburg Hospital, The Hague, The NetherlandsPremature ejaculation (ejaculatio praecox) is probably the most commonmale ejaculatory complaint. In recent years, well-controlled neuropharmacologicalstudies have shown the efficacy of serotonergicdrugs to delay ejaculation. A recent meta-analysis demonstrated thatparoxetine has the most prominent ejaculation delaying effect comparedto the other selective serotonin reuptake inhibitors (SSRIs) andclomipramine. We believe that lifelong premature ejaculation is notan acquired disorder due to learned behaviour, as has been suggestedby Masters and Johnson. On the contrary, we postulated that therapidity is part of the biological variability of the intravaginal ejaculationlatency time (IELT) in men who have a possible familialgenetic vulnerability. Male rat studies have demonstrated that serotonin(5-HT) and various 5-HT receptors are involved in the ejaculatoryprocess. Activation of 5-HT 2Creceptors delays ejaculation,whereas activation of 5-HT 1Areceptors results in shorter ejaculationlatency. Based on such animal studies, we have postulated that life-12 World Psychiatry 3:S1 - October 2004

long premature ejaculation is a neurobiological phenomenon relatedto decreased central serotonergic neurotransmission, 5-HT 2Creceptorhyposensitivity and/or 5-HT 1Areceptor hypersensitivity. Treatmentshould therefore consist of 5-HT 2Creceptor stimulation and/or 5-HT 1Areceptor inhibition.IS7.2.NEW DRUGS FOR ERECTILE DYSFUNCTIONK.R. WyliePorterbrook Clinic and Royal Hallamshire Hospital, Sheffield, UKErectile dysfunction (ED), otherwise known as impotence, is defined as“the persistent inability to attain and maintain an erection adequate topermit satisfactory sexual performance”. This indicates that the erectionis either too short lived, or not firm enough for the man to penetratehis partner. In extreme cases there may be no erectile response atall, this is termed ‘severe’ or ‘complete’ ED. Psychiatrists see patientswith conditions where sexual problems and ED are common, includingdepression, psychoses and substance misuse, as well as prescribingmedications that can affect erectile function, e.g. selective serotoninreuptake inhibitors and neuroleptics. Oral agents used to treat ED arereliable, have minimal side effects, and are simple to use. The oral therapiescurrently licensed for ED are the phosphodiesterase 5 inhibitors(PDE5 inhibitors) sildenafil, tadalafil and vardenafil, which all have aperipheral mechanism of action, and apomorphine, which acts centrally.All of these agents require sexual stimulation to initiate the neuronalactivation required to start the haemodynamic erectile response. This isin contrast to the PGE mediated response initiated by intracavernosaland intraurethral alprostadil administration, that ‘forces’ an erection.The role of psychotherapy to augment response to pharmacologicaltherapies should not be underestimated. Several new formulations arebeing developed, such as topical alprostadil and intranasal apomorphine.New agents are being developed, such as selective PDE3/4/5inhibitors including sildenafil nitrate, non-selective inhibitors of postsynaptic alpha-adrenoceptors within the corpus cavernosum, phentolamine,melanocortin receptor agonists such as melatonan II and the5HT1 agonist VML670. In addition, herbal remedies have been scrutinisedfor potential benefit. These will all be reviewed and discussed asrelevant to the practicing clinician.IS7.3.WHY DRUGS MAY NOT BE EFFECTIVE IN TREATINGWOMEN’S SEXUAL PROBLEMSE. LaanDepartment of Clinical Psychology, University of Amsterdam,The NetherlandsThe majority of studies investigating the effect of drugs that may helpimprove sexual function in women have generated inconsistentresults. Earlier this year, Pfizer officially announced that it would giveup testing Viagra on women, even though their male program with thisdrug has been overwhelmingly successful. This paper addresses possiblereasons of why drugs may not be effective in treating women’s sexualproblems. Among these may be: disregard of the importance of sexualstimulation; inadequate outcome measures; inadequate conceptualizationof women’s sexual problems. Modern motivation theoriespredict that sexual response is the result of an interaction between thesensitivity of the sexual response system and stimuli that are present inthe environment. There is increasing evidence that, in somaticallyhealthy women, sexual problems are unrelated to insensitivity of thesexual response system. Lack of adequate sexual stimulation –whether that is the result of absence of sexual stimulation or of lack ofknowledge, bad technique, a lack of attention for, or negative emotionsto sexual stimuli – and relationship issues seem to better explainthe absence of sexual feelings and genital response in women.IS7.4.WHAT IS LOVE ANYWAY?S.B. LevineCase University School of Medicine, Beachwood, OH, USASexology now has a better understanding of the context-sensitivenature of women’s sexual function, the successes and limitations ofmedical treatments for male dysfunctions, and the failure to find prosexualdrugs for women. While laymen assume that love is the ultimatecontext for understanding sex and its psychogenic problems,love is rarely mentioned in professional literature. This may bebecause clinicians are not sure what it is and how to assess it. Thispresentation will review the love paradigms of Lewis, Lee, and Sternbergwhile presenting a new paradigm of seven distinct interlockingmeanings of love. These meanings will clarify what “I love you” and“I love my partner but I am not in love with him (her)” means. Thedefinitions are: Love is not a simple feeling; it is an emotion. It consistsof pleasure, interest, and only sometimes sexual desire. Thisemotion is always further complicated by the diverse and sometimesdeceitful motives for telling another “I love you”. Love is a grand, culturallysupported ambition with definable goals. Love is a moral commitment.Love is the mental struggle to live the commitment. Love isa force in nature that provides the framework for life processes. Loveis a deal - an arrangement - that enables new attitudes and behaviorstoward the partner. Love is a stop sign preventing inquiry about itsprivate mental aspects. The significance of this paradigm for cultureand psychotherapy will be discussed along with its role in illuminatingotherwise mysterious sexual avoidance patterns.IS8.PARTNERSHIPS IN MENTAL HEALTH CAREIS8.1.PARTNERSHIPS IN MENTAL HEALTH CARE:THE WHO CONTRIBUTIONB. SaracenoDepartment of Mental Health and Substance Abuse,World Health Organization, Geneva, SwitzerlandThe time has come to create partnerships for mental health care. TheWorld Health Organization (WHO), in its capacity as the intergovernmentalUnited Nations (UN) agency for health, will bring its leadingauthority to create a global body which should reflect the need oflocal partnerships in care. This global body will act as a forum formental health. Its main goal will be to support the WHO in carryingout its global mandate that seeks to improve mental health andreduce substance abuse problems worldwide. The partnership willhave as its general objectives: a) To bring together diverse constituencieswith a real interest in better promoting mental health, preventingand treating mental disorders. Based on their different perspectivesand bringing specific points of view from their own environments,these diverse constituencies will contribute to a common vision of theproblem in order not only to enhance the opportunities for effectiveand coordinated action, but also to advance their common and specificaims: from diverse perspectives to a common vision of the problem.b) To stimulate and lend support to action aimed at raisingawareness in countries around the world of the burden of mental and13

substance abuse problems, the interventions available to reducethem, and the pervasive effects of stigma and discrimination thataffect persons with mental disorders and their families. c) To promotethe implementation of the Ten Recommendations of the WorldHealth Report 2001 in all regions, and the adoption of the strategiesput forth by the Mental Health Global Action Programme.IS8.2.PARTNERSHIPS IN MENTAL HEALTH CARE:THE EXPERIENCE OF EUFAMIB. AriñoEuropean Federation of Associations of Families of Mentally IllPeople (EUFAMI)The main barriers to user involvement and partnerships in mentalhealth care are lack of confidence and discrimination/stigma. EUFA-MI is working directly, by means of programs such as Prospect, totrain family members to work with other family members in order toimprove their coping skills, and to train those with self-experience towork with others with self-experience in order to give them the confidenceto take control of their own lives. The key strengths users andcarers can deploy to get stronger voice are: a) working together withprofessionals in an alliance (this has been shown recently in somecountries where the mental health alliance forced the delay in proposedmental health legislation); b) doing their own research (so thatthey talk with authority from facts, not from individual stories); c) lifeexperience (they speak from the basis of their knowledge living dayto-daywith the problem). Carers are pleased to be working withorganisations such as the World Health Organization (WHO) and theWorld Psychiatric Association and for families and users to be given aplatform in major conferences to speak of mental health policy asexperts on the same level as professionals. Governments must make itpractically possible for users and carers to be involved. Professionalsdo it as part of the work and are employed, trained and paid expensesto be involved. Families and those with self-experience are expectedto do this in their own time, to spend their own money and generallyare not trained to be involved in the process. Governments mustdemonstrate that they are listening by changing proposals. Often carerssee no results from being involved or have been ignored. Thismakes it less likely that users and carers will want to be involved infuture. Professionals should enable user/carer involvement as equalpartners in any mental health policy planning. If we all join forces asthe WHO is recommending, the future of many thousands of peopleis bound to improve.IS8.3.PARTNERSHIPS: THE PERSONAL, THE POLITICAL,THE PRACTICALS. CarasPeople Who, Santa Cruz, CA, USAThemes of collaboration, partnership and coalition are prominenttoday. This presentation will set a personal and political context anddescribe some global and local instances of partnerships. Suggestionsabout what makes good partnerships work will be offered, using JeanBaker Miller’s relational criteria as a frame. A brief history of the consumermovement will provide background for examples of partnerships:how the World Health Organization (WHO) is soliciting inputfor their Mental Health Policy work; California’s Village, an IntegratedService Agency; and last year’s Information Society Global DisabilityForum. Pointers will be provided to resources about rights andinformation, the work of the Ad Hoc Committee on the UnitedNations Comprehensive and Integral International Convention toPromote and Protect the Rights and Dignity of Persons with Disabilities,integrating mental health and general health, a social model ofdisability, the role of consumers in mental health care, embeddingrecovery into service provision, how respectful language impacts dignity,and paying attention to abuse and trauma-induced disorders.Suggestions will be made for practical steps toward partnership thatpsychiatrists might consider, including a strengths-based focusexpecting recovery and wellness and attention to basic needs, housing,and meaningful activity.IS8.4.PARTNERSHIP:A CHALLENGE IN MENTAL HEALTH CAREG. GombosEuropean Network of (ex-)Users and Survivors of PsychiatryPartnership in mental health care has become slogan. Publicly denyingthe need for a partnership approach qualifies politically incorrect.Still, old-fashioned paternalistic, hierarchical relationships have beensurviving. Coercion versus collaboration has remained an unresolveddilemma for the care providers. During the last decades we witnesseda controversial process: on the one hand the involvement of users andformer users of services resulted in a more democratic care system inseveral places; on the other hand the temptation to reduce mental,emotional and psychosocial problems to brain biochemistry led tothe view that mental health service users are passive objects to befixed. A pre-requisite for partnership is equality. But how can equalityexist when some of the ’actors’ (the professionals) are authorized tocare for the other ’actors’ (users, clients, patients, etc.), under certainconditions even against their will? Does this inherent asymmetry notprevent equality and thus partnership as well? In my contribution Ishall argue that equality and partnership can be maintained only ifservice users are viewed in a holistic way. Without practical implementationof the rights to dignity, to self-determination there is nopartnership between the user and the professional. The challengehere is how to exercise self-determination under difficult mental conditions.Partnership also has an important aspect that goes far beyondthe personal level. The ”expertise by experience” of users, formerusers and survivors of services is hitherto not used sufficiently. Partnershipneeds to actively seek for the utilization of this expertise.IS9.CURRENT APPROACHES TO AUTISMIS9.1.UNDERSTANDING THE SOCIAL NATURE OF AUTISMF. VolkmarYale University School of Medicine, New Haven, CT, USAAutism is a neurodevelopmental disorder of early onset marked by aprofound social disability affecting a person’s capacity for understandingother people, intuiting their feelings, and establishing reciprocalrelationships. The core social disorder both defines the conditionand significantly contributes to the derailment of development inthese other areas and yet remains poorly understood. This presentationwill summarize current knowledge regarding the neurobiologicalfoundations of social dysfunction in autism spectrum disorders. Workfrom our group has also shown that although higher functioning individualswith autism can perform adequately on a facial recognitiontask from a behavioral standpoint, neurofunctionally they exhibit14 World Psychiatry 3:S1 - October 2004

decreased fusiform and increased inferior temporal gyrus activationwhen performing such tasks. Ambiguous stimuli studies suggest that,unlike typically developing children, individuals with autism spectrumdisorders are much less able to attribute social meaning toambiguous situations. Another line of work has shown that, whileviewing social scenes, cognitively able individuals with autism exhibitmarkedly different patterns of looking from typical individuals. Animportant goal of this research is the refinement of our views of thesocial phenotype in autism, but also of unraveling central aspects ofthe pathogenesis of this and related conditions.IS9.2.A DEVELOPMENTAL APPROACH TO EARLYDIAGNOSIS OF AUTISM: PREDICTING OUTCOMEAND DEVELOPMENTAL TRAJECTORIEST. CharmanInstitute of Child Health, University College of London, UKProgress has recently been made in the earlier identification of childrenwith autism. Whilst being welcome, this presents new challengesto clinical practice, including the utility of standardised assessmentinstruments with young pre-schoolers, the accuracy and stability ofearly diagnosis, and the ability to indicate prognosis. We followed asample of children diagnosed with autism at age 2 years to ages 3 and7 years. Standard assessments at age 2 did not predict outcome at age7 but the same assessments conducted at age 3 did. In contrast, ameasure of non-verbal communication at age 2 was significantly associatedwith language, communication and social outcomes at age 7.On all measures group variability in scores increased with age. Thetrajectory of autism symptoms over time differed in different domains,suggesting that they may be, at least in part, separable. Understandingthe ‘natural history’ of development in different domains in childrenwith autism has important implications for assessment and for thedesign of treatment studies.IS9.3.NEURAL MECHANISMS OF AUTISMN.J. MinshewUniversity of Pittsburgh, PA, USAAutism is widely accepted as being a developmental neurobiologicdisorder of polygenetic origin. Although multiple etiologies are suspected,a common pathophysiology of structural and functional brainabnormalities is hypothesized as the underlying cause of the behavioralsyndrome. Exciting new findings about brain structure include anabnormal acceleration in brain growth that coincides with the onset ofsymptoms. This growth of the brain appears to involve primarily theouter radiate white matter zone that affects intrahemispheric and corticocorticalconnections that mature postnatally. A second majorstructural brain anatomic finding has been the report of abnormalitiesof the minicolumns of the cerebral cortex. These abnormalities havebeen bilaterally symmetric and involved anterior and posteriorregions. Functional magnetic resonance imaging (fMRI) studies of thebrain in autism have revealed that autistic individuals often rely onlower brain regions and more basic cognitive skills to accomplishtasks and that their brains are characterized by functional under connectivity.These fMRI studies suggest that there is reduced integrativecircuitry and that this results in a deficit in the integration of informationat both the neural and cognitive levels. At the cognitive level,studies suggest that there is a generalized problem with complex informationprocessing and that autistic individuals rely on basic skills tofunction and lack higher order abilities in order to process informationand function. A critical issue for intervention in the future is whethernovel interventions can trigger the growth of intrahemispheric andcorticocortical connections and integrative circuitry.IS9.4.GENETICS OF AUTISM: FROM EXPERIMENTALDATA TO INTERPRETATIVE MODELING OF DISEASEE. Caffo 1 , F. Macciardi 21 Department of Psychiatry and Mental Health,University of Modena and Reggio Emilia, Italy;2 Advanced Center for Theoretical and Computational Genetics,University of Toronto, Canada; Department of Biologyand Genetics, University of Milan, ItalyThe advancements of our current knowledge of the human genomeand the development of the technology that makes such knowledgepossible are progressing at an unprecedented rate. As a consequence,we deem to be closer than ever to the understanding of the biologicalbases of even complex traits like psychiatric disorders. We review herethe state-of-the-art about the genetic bases of autism and autism spectrumdisorders (ASD) and present possible etiopathogenetic pathwaysof this severe disease. Integrating the already known findings relativeto the genetic bases of ASDs with our experimental results, it is possibleto begin shaping possible etiologic models of disease. To rebuildthe biological pathways representing hypothetical etiological mechanismsand to understand how they correlate to the clinical dimensionsof the phenotype, we applied current biostatistic-bioinformatic strategiesthat collectively are included under the broad definition of supervisedlearning. More than one etiopathogenetic model of autism andASDs is possible with a high degree of reliability. The autism-relatedgenes identified so far allow us to hypothesize various possible pathways:this diversity fits with our current awareness of the clinical andgenetic heterogeneity of the disease, at the same time reflecting ourincomplete knowledge of the central nervous system and of the functionalsystems underlying cognition and behavior. While we are moreand more able to identify the various components of the biologicalbases of autism, despite still being at an initial stage, our abilities totranslate these findings into a coherent understanding of the disease,and consequently improve also our therapeutic practices, are both limited.This present restraint is surely in part due to the far from completeknowledge of the genetics and biology of autism, but in another consistentpart is also due to our conception of the disease. We speculatethat only considering the overall complexity of autism – both geneticbiologicaland not – into a unified framework, we will eventually beable to make a substantial breakthrough, giving rise to feasible treatmentsand proper management of the disease.IS10.CURRENT APPROACHES TO SLEEP DISORDERSIS10.1.THE INTEGRATIVE APPROACH TO THE TREATMENTOF INSOMNIAC.R. SoldatosDepartment of Psychiatry, University of Athens, GreeceInsomnia is a highly prevalent disorder affecting approximately 20%of the general population. Although insomnia is usually a secondarycondition, when chronic and severe it may become the focus of thepatient’s attention and is perceived as a disorder in its own right.Insomnia should be understood as a complex, multifaceted disorder15

that requires a multidimensional approach to its treatment. From theoutset, whenever insomnia is not secondary to another underlyingcondition, the clinician should overcome the patient’s usual denial ofthe frequently underlying psychological problems and the consequentresistance to a systematic therapeutic approach. The plan shouldcomprise non-pharmacological interventions and pharmacotherapyas an adjunct. Non-pharmacological management includes sleephygiene education, relaxation techniques, stimulus control therapy,sleep restriction, chronotherapy, and a variety of cognitive/behavioraland educational strategies. The primary targets of such interventionsare cognitive/physiologic arousal, maladaptive sleep habits and faultybeliefs and attitudes about sleep. To help patients with insomnia mastertheir fear of sleeplessness and the consequent psychophysiologicalarousal, which feeds the vicious cycle of insomnia, hypnotic drugsshould generally be administered early in treatment. All modern hypnoticsare initially effective. However, the slowly eliminated benzodiazepinehypnotics have been associated with carryover sedativeeffects, and the rapidly eliminated ones have been associated withearly development of tolerance and rebound insomnia upon discontinuation.The introduction of newer benzodiazepine-like hypnotics,such as zolpidem and zaleplon, has been advantageous because oftheir lower propensity for the development of tolerance and reboundinsomnia and their safe ‘as needed’ administration.IS10.2.PSYCHIATRIC ASPECTS OF HYPERSOMNIA:CURRENT TREATMENTSM. BilliardSchool of Medicine, Gui de Chauliac Hospital, Montpellier, FranceExcessive daytime sleepiness (EDS) is a neglected symptom, both bypatients and primary care physicians, although it can be at the root ofsevere socio-professional difficulties. There are several causes ofEDS, including insufficient sleep; intake of hypnotics and alcohol;sleep induced respiratory impairment; narcolepsy; the Kleine-Levinsyndrome; neurologic, psychiatric, infectious, endocrinologic, andmetabolic disorders; disorders of the circadian rhythm of sleep. Allthese disorders are of potential interest to the psychiatrist. Sleepinsufficiency may be responsible for irritability, fatigue, nervousnessand sometimes depression. Intake of hypnotics and alcohol is oftenassociated with symptoms of tension, anxiety or depression. Sleepinduced respiratory impairment is a cause of aggressiveness, irritability,anxiety or depression. The Kleine-Levin syndrome is remarkablefor prolonged episodes of sleep, associated with abnormal behavioraland cognitive features. Hypersomnia associated with mental disordersoccurs mainly in subjects with mild bipolar depression or dysthymia,and less frequently in subjects with schizoaffective disorders,personality disorders and somatoform disorders. Delayed sleep phasesyndrome is associated with psychiatric features in up to 80% ofcases. The management of these conditions relies on various pharmacologicor non-pharmacologic procedures. Subjects with the insufficientsleep syndrome are advised to increase sleep time of one ormore hours. Chronic use of hypnotics benefits from a supervised,structured, and time-limited withdrawal program, with or withoutcognitive-behavioural treatment. Sleep induced respiratory impairmentis best treated by continuous positive airway pressure. Narcolepsytreatment relies on stimulants or drugs with awakening properties.There is no satisfactory treatment of the episodes of the Kleine-Levin syndrome; on the other hand mood stabilizers may have prophylacticvalue. Hypersomnia associated with mental disorders oftenresponds to stimulants or drugs with an awakening property betterthan to antidepressants. Chronotherapy and light therapy are thetreatments of choice for the sleep delayed phase syndrome, but areusually ineffective on the associated psychiatric symptoms. In conclusion,mental disorders may sometimes be a consequence of differenttypes of hypersomnia and only respond to the treatment of thesesleep disorders. The degree of alertness of a subject with mental disordershould always be considered.IS10.3.CURRENT DIAGNOSIS AND MANAGEMENTOF PARASOMNIASW. SzelenbergerDepartment of Psychiatry, Medical University of Warsaw, PolandParasomnias are not abnormalities of the process of sleep itself, butundesirable phenomena that occur during sleep. In this presentation,only parasomnias enumerated in the ICD-10 classification (somnambulism,night terrors, and nightmares) are discussed. Many parasomniasrun in families, so genetic factors have been suggested. Geneenvironmentinteractions are most probable. Benign forms of parasomniasoccur frequently in childhood, but attenuate in the teenyears. Co-occurrence of parasomnias is common. Somnambulismand sleep terrors are considered arousal disorders. They are morelikely to manifest during the first episode of slow wave sleep, but mayalso appear any time during non-rapid eye movement (NREM) sleep.Sleep terrors are the least frequent parasomnias in adults; however,co-occurrence with somnambulism is particularly dangerous. Nightmaresare frightening vivid dreams, arising almost exclusively duringrapid eye movement (REM) sleep, so they are more likely to occur inthe second half of the night when REM episodes prevail. Nightmaresin adults are frequently symptoms of post-traumatic stress disorder.Nightmares may also be associated with depression, anxiety disorders,schizophrenia-spectrum pathology or schizotypy. Emergingdata indicates that the frequency of nightmares is directly associatedwith suicide risk. The diagnosis of parasomnias is based upon clinicalhistory, but videopolysomnography is required for differential diagnosis.Treatment of arousal disorders is symptomatic, with strongemphasis on sleep hygiene. Recently, some new pharmacologic andnon-pharmacologic treatments of nightmares have been proposed.IS10.4.SLEEP APNEA SYNDROME:AN UPDATE ON A PREVALENT SLEEP DISORDERP. Lavie, L. LavieTechnion-Israel Institute of Technology, Haifa, IsraelSleep apnea syndrome is characterized by repeated apneic eventsduring sleep which result in intermittent hypoxia and severe sleepfragmentation. It is a prevalent syndrome affecting 4% of men and2% of women. Patients suffering from sleep apnea syndrome mostlycomplain of habitual snoring, excessive daytime sleepiness, chronicfatigue and neuro-cognitive deterioration. It is well established thatthe syndrome is closely associated with cardiovascular morbidity,particularly with hypertension, and with cardiovascular mortality, aswell as with increased rates of work and car related accidents. Inrecent years our laboratory has focused on investigating the mechanismunderlying cardiovascular morbidity in sleep apnea, on mortalityof sleep apnea patients and on daytime consequences of the syndrome.The following are highlights of our recent findings. We foundthat oxidative stress plays a major role in cardiovascular morbidity insleep apnea syndrome by initiating atherogenic processes. Sleepapnea patients, free of any overt cardiovascular disease, suffer fromendothelial dysfunction, which is a sub-clinical state of atherosclero-16 World Psychiatry 3:S1 - October 2004

sis. Comparing mortality rates of sleep apnea patients to that of thegeneral population revealed that only patients

confirmed this connection. Stress, whether acute, chronic, or episodicsuch as affective disorder, is associated with cardiovascularchanges, increased rates of myocardial disease and elevated mortalityrates in those individuals following myocardial infarction. Stress isdifficult to measure, but a variety of surveys demonstrate that bothlower socioeconomic strata and social support correlate with cardiovasculardisease even when other confounding risk factors are controlled.Epidemiological data reveal that both depressed mood andsyndromic depression are risk factors for cardiovascular disease incommunity surveys, at risk populations in medical settings, and thosewith documented disease states. The positive association with cardiacdisease remains even if confounds such as male gender, history ofhypertension, tobacco use, family history and diabetic status are controlled.Such data will be reviewed and new findings discussed.Recent data from Montreal suggest that depression will foster a threefold increase in death following uncomplicated myocardial infarction.This risk is equivalent to significant left ventricular failure. Theinnate mechanisms for such an association may be reduced heart ratevariability, dysfunctional platelet function, or impaired macrophagefunction. The presentation will conclude with a review of possibleinterventions for the depressed patient following a myocardial infarctionor cerebrovascular accident. Are antidepressants preferred overpsychotherapy? What is the mechanism of antidepressant use in themyocardial infarction survivor? A review of the Enhancing Recoveryin Coronary Heart Disease (ENRICH-D) study and the SertralineAntidepressant Heart Attack Randomized Trial (SADHART) willhelp to answer these questions.IS12.COMBINING MEDICATIONS IN PSYCHIATRY:ADVANTAGES AND RISKSIS12.1. COMBINATION THERAPIES IN THETREATMENT OF SCHIZOPHRENIAH.-J. MöllerPsychiatric Department, University of Munich, GermanyMost textbooks of psychiatry and pharmacopsychiatry traditionallysuggest a mono-therapeutic regimen. This is of course theoreticallymeaningful for different reasons and is seen as an indicator of rationalpsychopharmacotherapy. However, it is well known that clinicalpractice in psychiatry does not follow this principle. Even in academicinstitutions, drug combinations seem to be the rule and monotherapymore or less the exception. In the treatment of schizophrenicinpatients, polypharmacy with two, and often three or even moredrugs is very common. Combined drug therapy in schizophrenia andother psychiatric disorders is often criticised, especially by psychopharmacologistsnot working in a hospital. Even if the criticism isnot so severe, the potential risks of a combined psychopharmacotherapyin comparison to monotherapy are stressed. However,from a clinical perspective, positive aspects and even a meaningfultheoretical justification of combination therapy in schizophrenia, andof course also other psychiatric disorders, can be underlined, withoutdenying that there are also risks with such an approach, for example,pharmacokinetic risks or the risk of potentiation of serious sideeffects. Of course the potential benefits and risks have to be consideredand well balanced in each individual case. A careful approach,for example with measurement of drug levels, can reduce many risks.Examples of a meaningful combination of drugs in the treatment ofschizophrenia are as follows: the combination of an antipsychoticand a benzodiazepine to induce better tranquilisation in agitated psychoticpatients; the combination, for the same purpose, of a lowpotency traditional antipsychotic such as levopromazine with a highpotency/non-sedating antipsychotic; in the case of drug resistance toa treatment with a low D2-binder, the add-on therapy with a highpotency D2-blocker; in the case of schizoaffective psychoses, thecombination of an antipsychotic with a mood stabiliser. In the case ofnegative symptoms refractory to neuroleptic treatment as amonotherapy, the combination of selective serotonin reuptakeinhibitors is indicated. Similarly, in depressed schizophrenic patients,a combination with antidepressants might be helpful. There are severalgood theoretical reasons and a large amount of good clinical evidenceindicating that these combination therapies are meaningful.IS12.2.COMBINING MEDICATIONS IN MOOD SPECTRUMDISORDERS: ADVANTAGES AND DRAWBACKSG.B. CassanoDepartment of Psychiatry, Neurobiology, Pharmacologyand Biotechnology, University of Pisa, ItalyClinical evidence suggests that monotherapy is often inadequate andcombination drug regimens have become the norm for the treatmentof bipolar disorder. This is mostly due to the fact that, so far, no availablemood stabilizer has equivalent efficacy in both phases of bipolardisorder, nor is fully effective for the prophylaxis of recurrences.Moreover, comorbid psychiatric disorders such as substance abuse oranxiety disorders should also be considered in designing a treatmentregimen. In this regard, a combination therapy is supposed to addressmore effectively the wide area of phenomenology that characterizespatients with bipolar disorder. However, randomized controlled studiesin bipolar populations are needed to further characterize optimalmatching of patient and medication. Furthermore, when selecting themost appropriate mood stabilizer for a patient - particularly whenpolypharmacy is required - the clinician should keep potential sideeffects and drug interactions in mind. The author argues for a newgeneration of adequately powered investigations of efficacy, whichare necessary before the issue of cost-effectiveness of combinationtherapies can be properly addressed.IS12.3.CO-MEDICATION AND AUGMENTATIONSTRATEGIES IN UNIPOLAR DEPRESSIONS. KasperDepartment of General Psychiatry, Medical University of Vienna,AustriaResponse to antidepressants can be achieved in approximately 70%of patients and thereafter the question arises how to combine or augmentpharmacological as well as non-pharmacological strategies.Adding a second antidepressant to the ongoing treatment is likely toproduce a different response than either medication alone. Ideally acombination should take advantage of complementary mechanismsof action to confer synergic benefits. However, disadvantages of thisstrategy could include the increased risk of drug-drug interactions,potentiation of side effects and also drug costs. Although oftenapplied in clinical practice, there is little controlled data in support ofthe utility and efficacy of combination strategies. The addition of tricyclicantidepressants to selective serotonin reuptake inhibitors(SSRIs) or vice versa has been attempted with varying success. Thecombination of monoamine oxidase inhibitors with SSRIs and otherantidepressants acting on the serotonergic system must be strictlyavoided due to potentially fatal interactions. Other, non-pharmaco-18 World Psychiatry 3:S1 - October 2004

logical augmentation strategies include psychotherapy, light therapy,sleep deprivation as well as electroconvulsive therapy. Recently thecombination with atypical antipsychotics was introduced withremarkable success. Altogether co-medication as well as augmentationstrategies help to address partial non-response or partial remissionin a number of patients. However, knowledge on the mechanismof action of these strategies remains incomplete.IS12.4.CO-MEDICATION IN PSYCHIATRY:WHAT HAS TO BE CONSIDERED?M. Ackenheil, K. WeberPsychiatric Hospital, Ludwig-Maximilians-University, Munich,GermanyPolypharmacy, the simultaneous prescription of more than one drug,is more the rule than the exception in psychiatry. According to somestudies, each patient is treated, on the average, with at least three psychotropicdrugs. Additionally, several elderly patients get medicamentsfor somatic diseases. Reasons for this polypharmacy arecomorbidity, resulting from new classification systems, and the availabilityof new very specific drugs. Many of these drugs show interactionsboth at the pharmacokinetic and the pharmacodynamic level.Psychotropic drugs, depending on their lipophility, are absorbed andwith the help of transporter proteins penetrate into the brain. They aremetabolised by various P450 cytochromes (CYP2D6, CYP2C19, 1A 3,etc.). This activity of the cytochromes is individually different andinfluenced by genetic factors as well as dietary habits. Drugs caneither inhibit or induce this activity. An alteration of this enzymeactivity modifies the elimination of the drug and of its metabolites.Increased or reduced blood levels are the consequences and even thepharmacological profile can be changed. At the pharmacodynamiclevel, synergistic or alternating effects are resulting from drug interactionsas well. Such interactions depend on the pharmacological profileof the drugs. Knowing the metabolising enzymes involved in thepharmacokinetics of each drug and the specific receptor profiles giveshints for useful combinations and helps to avoid unuseful interactions.Examples will be given for different psychiatric disorders likeschizophrenia, depression and bipolar disorders.IS13.THE EVALUATION OF PSYCHIATRIC TREATMENTSIS13.1.EVALUATING TREATMENTS FOR THE SEVERELYMENTALLY ILLG. ThornicroftInstitute of Psychiatry, King’s College, London, UKThis paper will give an overview of methods appropriate to evaluatetreatments and services for people with severe mental disorders.Specifically, the advantages and disadvantages will be described of: a)observational studies; b) quasi-experimental studies; c) randomisedcontrolled trials (efficacy and effectiveness studies). Attention will bedrawn to the importance of using rating scales with established psychometricproperties, especially in terms of reliability. Examples willbe given of the use of key types of study design.IS13.2.THE EVALUATION OF PHARMACOTHERAPYIN PSYCHIATRYW.W. FleischhackerDepartment of Biological Psychiatry, University of Innsbruck,AustriaA broad range of study designs are employed to evaluate pharmacotherapyin psychiatry. These range from small exploratory openstudies via the gold standard of the randomized placebo-controlledclinical trial to large pragmatic naturalistic studies. Outcome criteriahave traditionally focused on improvement of psychopathologicalsymptoms and on the assessment of safety and tolerability issues.More recently additional outcomes, previously considered as “softcriteria”, such as quality of life and social adjustment, have gainedimportance. Various rating scales and assessment instruments areavailable to reliably quantify changes in the parameters describedabove. Ideally, the evaluation of psychiatric treatments should bebased on studies of different design and scope to minimize the risk ofmisinterpretation. For instance, while any open clinical trial is subjectto an observer bias, randomized controlled trials have been shown tolead to a selection bias, that may hamper the generalizability of theresults obtained. An earlier use of non-inferiority trials, which have sofar been used exclusively in post-registration studies, is also encouraged.As the focus of safety/tolerability assessment has shifted from astrong emphasis on extrapyramidal motor dysfunctions to non-motoradverse events, such as metabolic and sexual dysfunctions, cardiacsafety and others, clinical trial designs need to account for this byincluding more specific side effect rating scales and laboratory tests.In addition, subjective tolerability and compliance need to beassessed with more vigor. In conclusion, a modern evaluation ofpharmacotherapy must go beyond traditional measures of psychopathologicalsymptoms and include real life outcomes such asquality of life, psychosocial reintegration and the subjective perceptionof a drug’s benefit/risk profile.IS13.3.ASSESSMENT OF PSYCHOTHERAPEUTICOUTCOMEG.A. Fava, C. Ruini, C. RafanelliAffective Disorders Program, Department of Psychology,University of Bologna, ItalyThere is increasing evidence on the efficacy of psychotherapy in anumber of psychiatric disorders, and particularly in mood and anxietydisorders. Compared to pharmacological approaches, psychotherapyappears to entail a more lasting recovery. However, randomizedcontrolled trails often fail to show significant post-treatment differencesbetween the two approaches. A crucial issue in evaluating outcomeappears to be the assessment of the degree of recovery. Psychometrictheory has been the basis for development of assessmentinstruments in psychiatric research. However, the psychometricmodel appears to be largely inadequate in the clinical setting, becauseof its lack of sensitivity to change and its quest for homogeneous components.Recently clinimetrics has offered a viable alternative to psychometrics,from both a conceptual and methodological viewpoint.Current diagnostic entities (DSM) are based on clinimetric principles,but their use is still influenced by psychometric models. This is exemplifiedby the occurrence of comorbidity in affective disorders. Veryseldom different diagnoses undergo hierarchical organization, orattention is paid to the longitudinal development of disorders. Sincecomorbidity may vary from one illness to another and from one19

patient to another, there is the need of clinimetric instruments whichmay allow a clinician to treat syndromes as heterogeneous constructswhich may entail different weights. On the contrary, the customarypsychometric goal is to achieve a unidimensional construct, in whichthe relatively homogeneous components all measure essentially thesame phenomenon. In this process, components that seem to be differentand may be likely to detect change may be discarded. Clinimetrictheory offers the conceptual and methodological ground for a substantialrevision of assessment parameters and for linking co-occurringsyndromes. From a research viewpoint, it may pave the way forinclusion criteria and assessment tools which are more suitable forthe purposes of evaluating psychotherapeutic changes.IS13.4.EVALUATING MENTAL HEALTH SERVICESM. TansellaSection of Psychiatry, Department of Medicine and Public Health,University of Verona, ItalyIn most countries mental health services are undergoing substantialchanges, a common element of the change being the transition from asystem of care predominantly hospital-based to one which is predominantlycommunity-based. Monitoring and evaluation are importantaspects of change. Monitoring needs to be carried out in a reliableway and for a relatively long period of time. Psychiatric case registers(PCRs) are useful tools for long-term monitoring and provide themost accurate way of estimating the uptake of psychiatric care by atarget population. Service evaluation includes randomised controlledtrials (RCTs), conducted in experimental settings to assess efficacy,trials conducted in “real world” to assess effectiveness, and welldesigned descriptive studies. The aim of this paper is to present evidenceof evaluative research conducted in the last 25 years in South-Verona, Italy, where a psychiatric service is operating since 1978. Thisservice is not experimental, avoids restrictive selection procedure forpatients and was implemented by national law. Continuity of care, alongitudinal perspective, and a balanced hospital-community care areensured to all those in need. After presenting data on long-term patternsof care, the results of several naturalistic studies, conducted onvarious cohorts of patients with schizophrenia and related disorders,followed up for 3-4 or 5 years, will be summarised. The assessment ofoutcome of psychiatric care was made using well standardised instrumentsfor evaluating quality of life, needs for care, satisfaction withservices and costs, as well as psychopathology and disability. Ratingswere made both by staff and patients.IS14.ADVANCES IN THE DIAGNOSIS AND TREATMENTOF BIPOLAR DISORDERIS14.1.RECENT DEVELOPMENTS IN THE DIAGNOSISAND TREATMENT OF BIPOLAR DISORDERH.S. AkiskalUniversity of California at San Diego, CA, USAThere has been a revolution in the epidemiology, clinical phenomenology,classification, pharmacological, psychotherapeutic and publichealth aspects of bipolar disorder. The advances are so enormousthat bipolar disorder should be considered a major subspecialty inpsychiatry. This is particularly true given the life long nature of the illness,the unpredictable exacerbations, the disruption in social, occupational,and conjugal life, substance use and medical comorbidity,and the high risk of suicide. Such an illness requires a coordination ofservices involving psychiatrists, nurses, social workers, psychologistsand pharmacists. It is no longer possible to think of solo practice inthe management of this illness. The spectrum aspects require attentionto diagnostic sophistication, not only in the patient, but also inthe family. This would achieve early case detection. This would be amodel of practice that is necessary to teach training psychiatrists andother mental health professionals. The substantial advances in scienceare unlikely to make any impact on prevention and public healthwithout such clinical units. It is regrettable that the number of suchunits has not substantially increased since the 1970s. Most programsdeliver research rather than care. It is the latter aspect that now needsto be instituted.IS14.2.EPIDEMIOLOGY OF BIPOLAR DISORDERSZ. RihmerNational Institute for Neurology and Psychiatry, Budapest,HungaryWith the introduction of operational criteria for well-defined psychiatriccategories (DSM-III, DSM-IV, ICD-10) it became possible toperform large-scale community surveys and studies of patients innonpsychiatric settings. Until recently, bipolar disorder was equatedwith classical manic-depressive (i.e. bipolar I) disorder, and it wasfound that the lifetime prevalence of bipolar disorder was around 1%.However, if the diagnosis of bipolar II disorder was considered, muchhigher lifetime prevalence rates of the bipolar spectrum disorders (atleast up to 5%) were reported. In addition, when considering the subthresholdforms of hypomania (i.e. minor bipolar disorders), the lifetimeprevalence rate of the broadly defined bipolar spectrum disordersrose up to 12%. In contrast to unipolar depression, the genderratio in bipolar disorder (all forms combined) is around 1:1. However,among bipolar II patients and in special subpopulations (winterdepression, dysphoric mania, depressive mixed states, bipolar depressionwith atypical features, rapid cycling bipolar disorder) females areoverrepresented. The age of onset of bipolar disorders is substantially(about 10 years) lower than in unipolar depression, being most commonlyaround 20 years of age. In contrast to unipolar depression andbipolar I disorder, bipolar II patients tend to belong to higher socialclass, and they are overrepresented among socially active, creativepersons. Bipolar patients in general show more frequently substanceuse and anxiety disorders comorbidity, marital breakdown and suicidalbehaviour than unipolar depressives. If bipolar I and bipolar IIpatients are analyzed separately, anxiety disorders comorbidity andsuicidal behaviour are more frequent in the bipolar II, whereas substanceabuse comorbidity is more frequent in the bipolar I subgroup.IS14.3.EVIDENCE-BASED PHARMACOLOGICALTREATMENT OF BIPOLAR DISORDERG.M. GoodwinUniversity Department of Psychiatry, Warneford Hospital, Oxford,UKBipolar disorder has been and remains a relatively neglected condition.This has two divergent consequences. First, there is a perceptionthat treatment could and should be improved. Second, because of arelative dearth of high quality research, the confidence with which wecan advocate particular treatments is limited. It is an unfortunatetruth that where uncertainty abounds, guidelines may proliferate. Evi-20 World Psychiatry 3:S1 - October 2004

dence-based guidelines are systematically derived statements that areaimed at helping individual patient and clinician decisions. They areintended to improve the quality of care. The recommendations usuallyapply to the average patient. They need to be graded according tothe strength of the evidence from appropriate, preferably randomisedtrials. The British Association for Psychopharmacology guidelines fortreating bipolar disorder specify the scope and target of treatment andare based explicitly on the available evidence. They are presented,like previous clinical practice guidelines, as recommendations to aidclinical decision making for practitioners. They may also serve as asource of information for patients and carers. A one day consensusmeeting, involving experts in bipolar disorder and its treatment,reviewed key areas and considered the strength of evidence and clinicalimplications. The guidelines were drawn up after extensive feedbackfrom participants and interested parties. The strength of supportingevidence was rated. The guidelines cover the diagnosis ofbipolar disorder, clinical management, strategies for the use of medicinesin short term treatment of episodes, relapse prevention andstopping treatment.IS14.4.PSYCHOSOCIAL APPROACHES TO BIPOLARDISORDERE. VietaBipolar Disorders Program, Hospital Clinic,University of Barcelona, SpainAlthough genetic and biological factors are crucial in the pathophysiologyof bipolar disorder, the importance of psychosocial factors intriggering or mitigating relapses warrants the implementation of psychotherapeuticinterventions. Psychoanalysis, psychoeducation,group therapy, family therapy, cognitive-behavioral therapy, andinterpersonal therapy have been used in the long-term treatment ofbipolar patients, but very few have established efficacy on their ownin controlled clinical trials regarding hospitalization, recurrences orsuicidal behavior, as medication alone does. However, psychoeducationand cognitive-behavioral techniques (CBT), either in group orindividually, have started to yield the first positive results in high standard,controlled trials of the combination of medication plus psychosocialintervention versus medication alone. These approachesfocus primarily on information, treatment compliance, early detectionof relapse, and illness management skills. A key issue is to startpsychoeducation or CBT when the patient is in remission. CBT doesnot seem to work too much for cross-sectional symptoms, and itsbenefits are more likely to be noticed in the long term. For this reason,the main components of CBT in bipolar disorder are the psychoeducationalones, giving further support to the psychoeducationalmodel, that has been supported by two well-designed, positive randomizedclinical trials. At the present time, and in face of current evidence,not adjuncting psychoeducation to medication should be consideredunethical, unless the patient is still too sick to benefit fromthis approach.IS15.RECENT ADVANCES IN PHARMACOGENOMICSIS15.1.ENDOPHENOTYPES ACROSS NEUROPSYCHIATRICDISEASE - A NOVEL APPROACH TO AN OLDQUESTION: WHAT UNDERLIES GENETIC VARIABILITYIN NEUROPSYCHOPHARMACOLOGICAL RESPONSEAND ADVERSE EFFECTS?M. Masellis, V.S. Basile, H.Y. Meltzer, J.A. Lieberman,S.G. Potkin, S.E. Black, J.L. KennedyDepartments of Neurology and Psychiatry, University of Toronto,CanadaGenetic data will be presented from a large, multicenter, prospectivestudy sample (n=185) examining the phenotypes of response and sideeffects to antipsychotics, with a particular focus on clozapine. Weassess global clinical response to clozapine, and then dissect out individualgenetic components contributing to change in positive andnegative symptoms, and neuropsychological functioning after clozapinetreatment. Data will also be presented examining pharmacogeneticpredictors of typical antipsychotic-induced tardive dyskinesia. Wefound a significant association between a 5-HT 2Areceptor gene(HTR2A) polymorphism, which alters the amino acid sequence(His452Tyr), and clinical response to clozapine (allele: p=0.01; genotype:p=0.04). No significant associations with clozapine responsewere identified for the HTR2C, HTR6, and dopamine D 2(DRD2)genes. When examining individual endophenotypes, there was noevidence of association between HTR2A, HTR2C, HTR6, and DRD2and change in positive and negative symptoms after clozapine treatment.Negative findings were also observed between these genes andchange in neuropsychological functioning after clozapine treatment.Dopamine D 1receptors (DRD1) are located in high concentration inthe prefrontal cortex and are thought to play an important role inmodulating mesocorticolimbic circuitry and thereby neurocognitivefunctioning in schizophrenia. We observed a significant associationbetween a DRD1 polymorphism and change in scores on the WisconsinCard Sorting Test, a test of working memory, categorizationand attention shifting, all aspects of executive functioning, assessedafter treatment with clozapine (p=0.002). We have also found a trendsuggesting that this DRD1 polymorphism is associated with modulationof prefrontal cortex metabolic activity, as assessed by 18-fluorodeoxyglucose(18-FDG) positron emission tomography (PET), afterclozapine treatment and that this is predictive of measures of clinicalresponse. With respect to adverse effects of antipsychotics, we havedemonstrated an association between a Ser9Gly polymorphism in thedopamine D3 receptor gene (DRD3) and typical antipsychoticinducedtardive dyskinesia (p

IS15.2.THE GENETIC DETERMINATION OF RESPONSETO ANTIDEPRESSANTS AND ANTIPSYCHOTICSUNDER ROUTINE CLINICAL CONDITIONSW. Maier, A. Zobel, K.-U. Kühn, B. HöfgenDepartment of Psychiatry, University of Bonn, GermanyThe selection of the most appropriate psychotropic drug and the predictionof response and side effects during treatment are still a matterof “trial and error” in our field. The lack of predictive power of clinicalcharacteristics of patients is probably due to individual determinantsfor drug response which are to a large extent defined by thesequence variability of the human genome. The search for geneticdeterminants of drug response is also motivated by the observation ofnon-random familial resemblance of response to psychotropic agents.In spite of substantial efforts to identify molecular-genetic predictorsfor antidepressant and antipsychotic treatment, the replicable successfulfindings remain rare. Reasons might be: a) lack of standardizationand control of intervening factors like co-medication, dosage,variability of plasma levels, and b) lack of appropriately designedprospective studies. On the other hand, the practical relevance of predictorsrequires their transferability to clinical routine. We reportfrom a clinical programme established to explore the relationship ofsequence variants in candidate genes with response (therapeutic, sideeffects) to standardized antidepressant treatment (citalopram, mirtazepine)in patients with unipolar depression, and response toantipsychotic treatment (amisulpride, olanzapine) in patients withschizophrenia. Endocrinological measures and plasma levels of thesubstances under investigation define another phenotype whichmight be more closely related to genetic variants than clinicalresponse pattern.IS15.3.GENE VARIANTS AND SSRI RESPONSE:A SIX-MONTH FOLLOW-UPA. Serretti, P. Artioli, R. Zanardi, C. Lorenzi, L. Franchini,E. SmeraldiDepartment of Psychiatry, Vita-Salute University,San Raffaele Institute, Milan, ItalyWe previously reported genetic factors associated with short-termantidepressant treatment outcome. In the present study we investigatedthe same gene variants in a prospective six-month naturalistic follow-up.The sample included 185 inpatients affected by recurrentmajor depression consecutively admitted to the psychiatric inpatientunit of San Raffaele Hospital from 1998 to 2003 and prospectively followedup after their recovery. All the patients were undertaking maintenancetherapy. The functional polymorphism in the upstream regulatoryregion of the serotonin transporter gene (SERTPR), the tryptophanhydroxylase (TPH) A218C substitution, a variable number oftandem repeats (VNTR) polymorphism located 1.2 kb upstream ofthe monoamine oxidase-A coding sequences, the CLOCK geneT3111C and the per3 gene T1940G substitutions were analysed usingpolymerase chain reaction-based techniques. No association wasfound between clinical variables and relapses; subjects showing TTgenotype at CLOCK gene tend to show a relapse within six monthafter recovery more than TC and CC subjects. A non-significant trendof SERTPR s/s subjects to a lower frequency of relapse was alsoobserved. In conclusion, some remitted subjects after acute treatmentrelapse within six months, despite undertaking a maintenance treatment.The reasons are heterogeneous, but CLOCK gene variants mayinfluence the outcome in the medium term.IS15.4.PROGRESS IN PHARMACOGENOMICS: FOCUS ONADVERSE EFFECTSB. Bondy, P. ZillPsychiatric Clinic, University of Munich, GermanyCurrent pharmacotherapies for psychiatric disorders are generallyincompletely effective, as many patients do not respond well or sufferfrom adverse reactions to these drugs, which can result in poorpatient compliance and poor treatment outcome. Psychotropic drugsof the third and fourth generation have been considered to offer manyadvantages over conventional ones, as they are effective in treatmentand, in many cases, have a markedly lower incidence or different patternof side effects. Until today most pharmacogenetic studies investigatedantipsychotic efficacy and antidepressant response. Onlyrecently it became obvious that also the drug-induced adverse effectsare not only complex in nature but also genetically influenced.Although the list of the main common untoward effects of psychotropicmedications is long, including weight gain, sedation,hypotension, extrapyramidal symptoms, tardive dyskinesia, anticholinergiceffects, long-QT syndrome, blood lipid abnormalities, anddiabetes, pharmacogenetic studies have so far been conducted primarilyon the adverse effects of tardive dyskinesia and weight gain. Up tonow a relatively straightforward additive interaction between DRD3and CYP1A2 in the risk for tardive dyskinesia was identified: patientscarrying the glycine/glycine genotype at DRD3 and the C/C genotypeat CYP1A2 had the most severe tardive dyskinesia. Recently an associationbetween the –759 T/C single nucleotide polymorphism in theupstream putative promoter region of the 5-HT 2Creceptor gene andantipsychotic-induced weight gain was reported. These findings arean interesting beginning, and more preliminary data will be presentedto underline that much more work is necessary to confirm the role ofgenetic variants in adverse effects.IS16.THE PRESENT AND FUTURE OF REHABILITATIONIN PSYCHIATRYIS16.1.PSYCHIATRY AND REHABILITATIONM. FarkasCenter for Psychiatric Rehabilitation, University of Boston, MA, USAPsychiatrists have traditionally been responsible for the delivery oftreatment services for individuals with serious mental illnesses. Theemergence of psychiatric rehabilitation services, however, has beenled in different parts of the world by a variety of disciplines, includingpsychologists, social workers and occupational therapists. A greatdeal of confusion has existed concerning the role of psychiatrists inthe delivery of psychiatric rehabilitation services. Some systems havechosen to have psychiatrists focus on treatment alone and referclients to a psychiatric rehabilitation service. Others have chosen toincorporate psychiatrists in the day-to-day practice of psychiatricrehabilitation as ‘team leaders”, in others psychiatrists deliver psychiatricrehabilitation assessments and collaborate with other disciplinesin the delivery of planning and intervention components. This presentationwill review the different roles of psychiatrists in psychiatricrehabilitation along with the positive and negative experiences thathave been associated with each role in an attempt to answer the question:What should the role of psychiatrists be in the delivery of psychiatricrehabilitation services?22 World Psychiatry 3:S1 - October 2004

IS16.2.THE DIFFUSION OF THE PSYCHOSOCIALCLUBHOUSE MODELR. Warner 1 , J. Mandiberg 21 Mental Health Center of Boulder County, Boulder, Colorado, USA;2 Institute of Psychiatry, London, UKThe psychosocial clubhouse is a socialization and rehabilitation programco-run by people with mental illness and staff. The model wasfirst developed at Fountain House in New York City in the 1940s. Astrong diffusion effort began in the 1970s. By 2002 there were 295clubhouses, certified as adhering to the standards established by theInternational Center for Clubhouse Development, in 24 countries,including 15 European countries. There were none in Italy, France orSpain. The presenter will describe how a psychosocial clubhouseworks, examine reasons for the success of the model, and look forexplanations for the observed pattern of worldwide diffusion. Comparisonswill be made with the diffusion of the social enterprisemodel.IS16.3.EFFECTIVENESS OF A PSYCHOEDUCATIONALFAMILY INTERVENTION ON SOCIAL FUNCTIONINGOF PATIENTS WITH SCHIZOPHRENIAL. Magliano, A. Fiorillo, C. Malangone, C. De Rosa, C. Avino,A.G. Amato, M. Maj and the Italian Family Intervention WorkingGroupDepartment of Psychiatry, University of Naples SUN, Naples,ItalySome of the advantages of community care to patients with severemental disorders are attributable to everyday family support. However,only few data are available on the effects of family interventions onpatients’ disability. This study aims to assess the effect of a psychoeducationalfamily intervention provided in routine conditions onsocial functioning of patients with schizophrenia. In each of the 18mental heath services which were randomly selected to participate inthe study, the following main phases have been conducted: a) theattendance of two professionals to a 8-day training course on a wellknownpsychoeducational intervention, followed by 5 supervisionsessions in the subsequent six months; b) the provision of the interventionby the trained staff to five families of users with schizophrenia,of which three families were randomly selected to receive theintervention immediately, and two 6 months later. Preliminary sixmonthfollow-up results showed a statistically significant improvementin patient’s social functioning in the treated group. In particular,self-care and social activities were the areas of patients’ disability inwhich the greatest improvements were observed. On the contrary, nostatistically significant difference in patients’ disability was detectedin the control group. These results suggest that psychoeducationalintervention should be considered as an effective resource for therehabilitation of users with schizophrenia in their natural environment.IS16.4.‘INTENSIVE’ AND ‘STANDARD’ CASE MANAGEMENTIN COMMUNITY CARE OF INDIVIDUALS WITHSEVERE PSYCHOTIC ILLNESSEST. BurnsDepartment of Psychiatry, University of Oxford, WarnefordHospital, Oxford, UKHighly resourced continuing support services for the severely mentallyill are referred to as assertive community treatment (ACT) in the USand intensive case management (ICM) in Europe to distinguish itfrom standard case management (SCM). There has been a livelydebate about whether or not ICM and ACT are the same thing andthis debate has been fuelled by the failure of European studies of ICMto replicate the reductions in bed usage found in US ACT studies.This seemingly parochial spat about names and studies has howeverhelped us understand better what are the essential components ofsuccessful community care of the severely mentally ill. Rather thanseeing the differences in outcome as a problem to be explained, theywere actively explored to get a better understanding of treatmentcomponents. 20 components of care were identified by an expertpanel and these were sent to the principle investigators of 90 studiesof home-based care. From the 60 replies indicating the practices ofthe experimental services, those features commonly present wereidentified using correlations. These were then regressed to test fortheir association with reduction in hospital care. A distinctionbetween ICM and ACT is not supported by examination of practices.Differences in outcome between the early US and more recent Europeanresults reflect the distribution of ‘effective features’ of successfulcommunity support services between the control and experimentalservices in Europe (and latterly in the US). We can with some confidenceconclude that outreach (home visiting) and the integration ofhealth and social care at the level of the clinical team are the key featuresin successful support and rehabilitation of the severely mentallyill and that some of the other high profile (and expensive) featuresproposed for ACT may not be as vital.IS17.MANAGEMENT OF ALCOHOL-RELATED PROBLEMSIS17.1.EFFECTIVENESS AND COST-EFFECTIVENESSOF TREATMENT FOR ALCOHOL PROBLEMS:RESULTS OF THE UK ALCOHOL TREATMENT TRIALN. Heather, A. Copello, C. Godfrey, R. Hodgson, J. Orford,D. Raistrick, I. Russell, G. ToberSchool of Psychology and Sport Sciences, NorthumbriaUniversity, Newcastle upon Tyne, UKThe UK Alcohol Treatment Trial (UKATT), funded by the MedicalResearch Council, was a pragmatic, multi-centre, randomised controlledtrial with blind assessment and prospective economic evaluation.742 clients with alcohol problems attending five specialist treatmentservices around Birmingham, Cardiff and Leeds were randomisedto motivational enhancement therapy (MET) or to socialbehaviour and network therapy (SBNT), a new treatment developedfor the trial with strong support from theory and research regardingthe most effective treatments for alcohol problems. Of these, 704(95%) responded at three months and 617 (83%) at one year. Thetrial was designed to test two main hypotheses expressed in null form:a) less intensive, motivationally-based treatment (MET) is as effective23

as more intensive, socially-based treatment (SBNT); and b) moreintensive, socially-based treatment (SBNT) is as cost-effective as lessintensive, motivationally-based treatment (MET). A number of subsidiaryhypotheses regarding client-treatment interactions and therapisteffects were also tested.IS17.2.STEP BY STEP INTERVENTIONS IN ALCOHOLISMMANAGEMENTM. ReynaudDepartment of Psychiatry and Addictology, University HospitalPaul Brousse, Villejuif, FranceAlcoholism management must be adapted according to the type ofabuse (high risk use, hazardous use or abuse and dependency), severitycriteria and the degree of motivation. The following rating scaleswill be reviewed: clinical evaluation (Car Relax Alone Forget FriendsTrouble, CRAFFT; Cut Down Annoyed Guilty Eye-opener, CAGE;Alcohol Use Disorder Identification Test, AUDIT); motivation (Prochaska,other motivation questionnaires). Treatment is then proposedaccording to two criteria: patient motivation for life style and consumptionhabit modifications; the least intrusive treatment to obtain amaximum effect. Management methods range, by increasing intensity,from brief interventions (in an emergency setting, by the general practitioner,school physicians, company physicians), out-patient management(more or less intensive) and inpatient management (more or lesslengthy; more or less intensive). We will attempt to compare the efficacyand the advantages of these various methods, according to datafrom the literature. We will also attempt to clarify the indications ofthese various treatments according to the type of abuse, severity criteria(psychological, psychiatric and social) and patient motivations(some patients change easily their consumption during treatment andothers require a very long term management). This implies a networkphilosophy in order to offer a wide variety of services.IS17.3.PHARMACOTHERAPY OF ALCOHOL ABUSEK.F. MannCentral Institute of Mental Health, Mannheim, GermanyAlcoholism represents a major health problem in the world. It is estimatedthat about 6% of the adult population suffer either from thealcohol dependence syndrome or from harmful alcohol use. Irrespectiveof the exact diagnosis, these individuals have a reduced physicaland mental health as well as problems in social functioning and qualityof life. Research in different parts of the world has shown that psychiatriststoday have a choice of several validated therapies. In generalthey follow a stepped care approach with low-dose interventionsfor people with less severe problems up to intensive programs for peoplewith handicaps and problems in several domains of functioning.Since about ten years we dispose of a new pharmacological approachto treatment. This is rather revolutionary and can only be comparedwith the era of the introduction of neuroleptics or antidepressants.Modern pharmacotherapy to prevent relapses in alcoholics is currentlybased on two extensively tested medications: acamprosate andnaltrexone. Acamprosate acts by binding to glutamatergic receptorsand thus reduces neural hyperexcitability. So far twenty randomizedplacebo-controlled double-blind trials were done worldwide. A metaanalysiscompiled the 16 studies which show a benefit of acamprosateover placebo plus the 4 studies where no difference could be found.Naltrexone acts as an µ-opioid receptor antagonist and thus reducesthe rewarding effects of alcohol. It has been studied in 22 doubleblind,randomized controlled trials. A majority of studies show a benefitover placebo. In conclusion, on the basis of neurochemicalchanges, both acamprosate and naltrexone can significantly improvetreatment results in alcoholism.IS17.4.EFFICACY OF VALPROATE IN BIPOLARALCOHOLICS: A DOUBLE BLIND PLACEBOCONTROLLED STUDYI.M. Salloum, J.R. Cornelius, D.C. Daley, L. Kirisci,J. Himmelhoch, M.E. ThaseUniversity of Pittsburgh, PA, USAOver half of individuals with bipolar disorder also have an alcohol orother substance use disorder. Pharmacological treatments specificallytargeting this high-risk clinical population are lacking. The aim of thisstudy was to evaluate the efficacy of valproate maintenance indecreasing alcohol use in actively drinking, acutely ill bipolar alcoholics.Fifty-two patients with comorbid bipolar I disorder and alcoholdependence (DSM-IV/SCID) were randomized to two treatmentgroups: valproate + treatment-as-usual (TAU) (TAU included lithiumand psychosocial treatment) versus placebo + TAU. Subjects wereassessed biweekly for a 24-week period using the Timeline Followbackfor Drinking, the Hamilton Scale for Depression and the Bech-Rafaelsen Mania Scale. The Mixed Model was used to analyze longitudinaldata. The results revealed that valproate had a significantadvantage over placebo on having fewer proportion of heavy drinkingdays (p

atric population. Technical improvements have resulted in a morebenign side-effect profile; this coupled with its unsurpassed efficacyare responsible for ECT’s important place in modern treatment algorithms.We present data from Phase I of the recently completed multisite,National Institute of Mental Health (NIMH)-supported trialcomparing continuation ECT versus pharmacotherapy (lithium andnortriptyline). Phase I represents the acute course of ECT given priorto randomization to the two treatment arms in Phase II. In the Consortiumfor Research in ECT (CORE) study, patients with unipolarmajor depression, referred for ECT, received a standardized course ofbilateral ECT 3X/wk at 1.5X seizure threshold. A Hamilton RatingScale for Depression (HAMD24) score of ≥ 21 was required for studyentry and remission criteria included two consecutive HAMD24 ratingsof ≤ 10, with ≥ 60% reduction from baseline. HAMD24 ratingswere performed at baseline and 24 hrs after each ECT. We presentdata from 444 patients entered into the trial. Patient demographicsare as follows: age = 55.6±16.8 years, gender (% female) = 68.2(303/444), psychosis status (% psychotic) = 29.7 (132/444), race (%white) = 91.7 (407/444). Overall remission rate was 68.5% (304/444).Remission rate in those patients with psychotic depression was 75%(99/132). Patients ≥ 65 yrs of age had a remission rate of 71.3%(112/157). Patients responded very rapidly to ECT. After 6 treatments(2 weeks) 34.9% (155/444) of patients had reached remission criteria.ECT resolved suicidality very rapidly. 81% of patients with high baselinesuicide ratings were no longer suicidal after 6 treatments. Thesedata, from one of the largest ECT datasets in the modern era, confirmthe high and rapid efficacy of ECT in major depression, particularly inthe geriatric population and those with psychotic major depression.IS18.2.STEREOTACTIC NEUROSURGERY FORPSYCHIATRIC DISORDERSR. Cancro, D. Jeanmenod, R. Llinas, J. SchulmanDepartment of Psychiatry,New York University College of Medicine, New York, NY, USAThe history of psychosurgery is so befouled as to make virtually anydiscussion of surgical interventions almost impossible. In the face ofchronic psychosis, the response has frequently been zealous. The zealwas not restricted to surgeons but involved a variety of interventionsranging from intrathecal horse serum to pulling teeth in order toremove the focal infections. It is difficult therefore to present a newunderstanding of what surgical interventions may promise withoutrunning into strongly-held and emotionally-charged responses. Thereare a number of individuals with thalamic nuclei that display lowthresholdcalcium spike bursts. The bursts are related to a state ofmembrane hyperpolarization in the thalamic relay neurons. Whenthese bursts are produced rhythmically they occur in the theta-deltafrequency (3-6 Hz). These frequencies obviously appear on the cortexand can be seen with electroencephalography and magnetoencephalography.The cortical distribution is a function of the localizationof the source of the low-threshold calcium spikes. There is a corticalactivation as a result of this stimulation and the whole syndromeis referred to as thalamocortical dysrhythmia. The surgical treatmentof the resulting symptoms, which range from neurogenic pain, to tinnitus,to epilepsy, to neuropsychiatric disorders, involves magneticresonance imaging (MRI) target localization and microelectrode unitrecordings. A number of patients suffering from different “psychiatricdisorders” who were treatment resistant were sent for stereotactic surgery.Some materials will be presented on the utility of this techniquein assisting some otherwise untreatable cases.IS18.3.MAGNETIC BRAIN STIMULATION FOR DEPRESSION– NEW METHODS OF BRAIN STIMULATION WITHPOTENTIAL IN THE TREATMENT OF MAJORDEPRESSIONT.E. Schlaepfer, M. KoselKlinik für Psychiatrie und Psychotherapie, UniversitätsklinikumBonn, GermanyTranscranial magnetic stimulation is a non-invasive method of brainstimulation, which has been evaluated for the treatment of majordepression through the last decade. Only recently clinically usefulparameters seem to have been established. A novel form of this treatment,magnetic seizure treatment (MST), in which stimulationparameters are reached that can reliably and reproducibly inducetherapeutic seizures in the same setting as the one used for electroconvulsivetherapy (ECT), has been developed. Results of a recentrandomized, within-subject, double-masked trial comparing ECT andMST in 10 patients indicate that MST appears to have less subjectiveand objective side effects, is associated with faster recovery of orientationand is superior to ECT on measures of attention, retrogradeamnesia and category fluency. Although ECT has an unparalleled andwell-documented efficacy in severe depression, it is associated withcognitive side effects. MST is currently under study in several centerswith respect to its antidepressant efficacy, while its more benign sideeffect profile has been established already. We will review in thispaper the current data on magnetic therapies in depression and providean outlook on future developments.IS18.4.VAGUS NERVE STIMULATION THERAPY FORCHRONIC, RESISTANT MAJOR DEPRESSIONM.M. Husain 1 , A.J. Rush 1 , H. Sackeim 2 , M. George 31 University of Texas Southwestern Medical Center at Dallas, TX;2 Columbia University School of Medicine, New York, NY;3 Medical University of South Carolina, Charleston, SC, USAVagus nerve stimulation (VNS) therapy is a safe adjunctive treatmentfor pharmacoresistant epilepsy; the device has been implanted inmore than 22,000 persons since its approval by the US Food andDrug Administration in 1997. Improvements noted in the mood andalertness of epilepsy patients led to the investigation of VNS therapyfor treatment of chronic resistant depression (CRMD). Periodicassessments with the Hamilton Rating Scale for Depression (HRSD),Clinical Global Impression (CGI), Montgomery-Asberg DepressionRating Scale (MADRS), Beck Depression Inventory (BDI), Inventoryof Depressive Symptomatology-Self Report (IDS-SR 30), and ShortForm-36 (SF-36) were conducted at baseline and during acute courseand long-term follow-up. Response was defined as ≥ 50% improvementin HRSD scores and remission was HRSD score ≤ 10. Concomitanttreatments were permitted, but did not change during theacute phase (first 12 weeks) of the study. Of the 59 subjects in the feasibilitystudy, 18 (31%) responded by the end of the acute (12-week)study. One-year response rate was 44% (last observation carried forward,LOCF), while the remission rate was 27%. At 2 years, responseand remission rates were 44% and 22% (LOCF), respectively. In thepivotal trial, 12 month follow-up data with HRSD showed 29%responders and 16% remitters. This improvement was consistentacross multiple assessments (IDS-SR 30, MADRS, CGI). Of the 295subjects implanted during both the feasibility and pivotal studies, 270subjects were still receiving VNS therapy after 12 months. Results ofthe feasibility and pivotal studies show that, among these very diffi-25

cult chronic resistant major depressive subjects, VNS therapy waswell tolerated as an adjunctive treatment, with one-third meeting criteriafor response, and about one sixth achieving remission.IS19.ETHICAL AND LEGAL ASPECTS OF TREATMENTSIN PSYCHIATRYIS19.1.IS THERE AN OPTIMAL ETHICAL APPROACH FORTREATING PATIENTS IN PSYCHIATRY?S. BlochDepartment of Psychiatry and Centre for the Study of Healthand Society, University of Melbourne, AustraliaEthical concerns about the psychiatrist’s role and functions havedogged the profession for at least three centuries. Moral harms haveemerged from the abuse of the asylum as a custodial “warehouse”,misunderstanding of the transference relationship, the gruesomeeffects of physical treatments like leucotomy and insulin coma, themisuse of psychiatry for political purpose (as occurred in the formerSoviet Union) and systems of healthcare that jeopardize the needs ofthe individual purportedly to benefit the many. Psychiatrists have nochoice in the face of these profound ethical difficulties but to respondas moral agents. The task, however, is complicated by the lack of acoherent framework for ethical decision-making, a conclusion buttressedby two observations. Firstly, rationales and methods used toresolve ethical questions differ radically. Indeed, competing ethicaltheories may so contradict one another as to generate irreconcilabletensions for the clinician. Attempts to compromise may take the formof a checklist approach that filters the details of a case through variousalgorithms in an attempt to discern the best match. However, thisprocess often leads to conflicting remedies. For example, one psychiatristmay conclude that the features of a case support respect for thepatient’s autonomy, whereas his or her colleague reasons they justifya paternalistic role. Secondly, in the wake of contradictory ethicaltheories, a nihilistic or cynical response may be the unfortunateresult. Frustrated by conflicting claims, practitioners may dispensewith any attempt to bring reasoning to the situation and resort to personal,ill-founded preferences. As a profession, we need to preventthese unsatisfactory outcomes. As a contribution to the process, Ishall present an actual case (appropriately disguised) to illustrate thecomplex ethical decision-making required of the psychiatrist andthen offer ideas for an ethical framework that may fulfil the intricaterequirements of the psychiatric encounter.IS19.2.THE ADEQUACY OF RECENT DEFINITIONSOF DECISION-MAKING CAPACITYK.W.M. FulfordUniversity of Warwick, UKThe concept of capacity is at the heart of current debates about thedivide between medical uses and political abuses of compulsorytreatment in psychiatry. In this paper I examine the adequacy ofrecent definitions of decision-making capacity, developed mainlywith bodily disorders in mind, for mental disorders. Working withinthe methodological framework of linguistic-analytic philosophy, Iconsider the concept of capacity, and some of its mental-disorder cognates(e.g. ‘soundness of mind’), from the perspectives of three keydisciplines: law, clinical practice, and empirical social scienceresearch. This ‘triangulation’ suggests a negative and a positive conclusion.The negative conclusion is that recent legal definitions ofcapacity, based on essentially cognitive criteria, are incomplete. Suchdefinitions, while indeed helpful up to a point in cases of mental disorderinvolving disturbances of cognitive functioning (e.g. dementiaand confusional states), fail to capture the elements of capacity relevantin disorders involving other areas of mental functioning, such asemotion, desire, volition, belief, motivation and identity (e.g. thefunctional psychoses, such as schizophrenia and manic-depressivedisorder, the addictions, anorexia nervosa and personality disorder).The positive conclusion from our triangulation is that an understandingof capacity, if it is to be relevant equally to all kinds of mental disorder,must be developed within an agentic rather than merely cognitivemodel, i.e. a model which recognises that capacity may beimpaired through a defect in any part of what J.L. Austin called the“machinery of action”, that is, in emotion, desire, volition, belief,motivation and identity, as well as in cognitive functioning. A clearconsequence of this broader agentic (rather than narrowly cognitive)model is that assessments of capacity, notwithstanding their supposedlyobjective basis, necessarily involve value judgements as well asassessments of fact. Value judgements, I argue, while involved in principlein the assessment of capacity in all disorders, bodily as well asmental, are important also in practice in the assessment of capacity inmental disorders involving the non-cognitive elements of emotion,desire, volition, belief, motivation and identity, essentially becausethe values involved in these areas of mental functioning are particularlydiverse, and, hence, contestable. In the final section of the paperI indicate the importance of values-based (as well as evidence-based)assessments of capacity in negotiating the boundary between politicalabuses and medical uses of compulsory treatment in psychiatry. I alsooutline recent initiatives in the UK - in policy, training and research -designed to support the development of values-based, alongside evidence-based,mental health services.IS19.3.HOW ABSOLUTE IS CONFIDENTIALITY INPSYCHIATRY?A. CarmiUniversity of Haifa, IsraelThe doctor’s obligation to suppress information confided to him byhis patients is a basic condition of doctor-patient relationship andapplies to personnel in every branch of medicine. It is securely guaranteedby every type of medical code and requires the mutual trust ofboth parties. The principles of medical ethics embrace the obligationof confidentiality, whose purpose is threefold. It improves a patient’swelfare; it prevents additional harm to a sick person; it respects apatient’s autonomy. Medical confidentiality is intended to protect thepatient in his place of employment, to preserve his reputation and toprevent breaches in his personal relationships. The paper will refer tothree different approaches to the question of defense for a patient’sentitlement to privacy. The “desert island” approach assures him acomplete measure of anonymity and privacy. The “big brother”approach favors society with the right to know. The third approachcombines the conflict of interests between the other two by creating acompromise between the individual’s right of privacy and society’sentitlement to be informed. The last part of the paper will present thedivision of opinions with respect to the period of confidentialityrequired after the death of a patient.26 World Psychiatry 3:S1 - October 2004

IS19.4.MEDICAL RESEARCH ON VULNERABLEPOPULATIONSJ. Arboleda-FlorezDepartment of Psychiatry, Queen’s University, Kingston, CanadaMedical research depends substantially on the use of human subjects,either healthy ones, or those afflicted by conditions of interest to particularstudies. Often, some research populations are afflicted notonly by the condition of interest but, by virtue of demographic factors,effects and impacts of institutionalization, or impacts of thecondition on mental competence can be considered vulnerable andin need of further and more specialized ethical safeguards. This presentationwill review the nature of these populations, the ethical basesfor their vulnerability, and the nature of the ethical safeguards.IS20.DIAGNOSIS AND TREATMENTOF ATTENTION-DEFICIT/HYPERACTIVITYDISORDER (ADHD)IS20.1.ADHD: DIAGNOSIS, COMORBIDITY AND CRITICALTHERAPEUTIC TARGETSC.E. BerganzaSan Carlos University School of Medicine, Guatemala,GuatemalaAttention-deficit/hyperactivity disorder (ADHD) is a behavioral disorderaffecting a significant proportion of children, adolescent andadults in any community. It is characterized by developmentally inappropriatelevels of inattention, hyperactivity and impulsivity. Untreated,this syndrome can seriously impact the adjustment of the individualand be the source of considerable personal suffering and of highsocial and economical cost. Extensive research has contributed tounveil the nature of the syndrome, its biological concomitants and itspathophysiology. Establishing a firm diagnosis of ADHD requires collectinginformation from different sources, such as parents, teachersand other caregivers, in addition to the careful assessment of the individualpatient itself. In this presentation, the clinical description ofADHD, its differential diagnosis, its most important comorbid conditions,and ways of selecting the critical aspects to be treated in thespecific patient presenting for care will be discussed. Evidence fromthe clinical, as well as from the genetic and neuroscientific (includingneuropsychological) fields supporting the existence of this syndromewill be briefly reviewed. The need for a comprehensive evaluation ofthe patient presenting for treatment, in order to avoid misdiagnosisand mistreatment, will be emphasized.IS20.2.NEUROPSYCHOPHARMACOLOGY OF ADHDAND ITS MAIN COMORBID CONDITIONSJ. BiedermanHarvard University School of Medicine, Boston, MA, USAAttention-deficit/hyperactivity disorder (ADHD) is the most commonneurobehavioral disorder in children, estimated to affectbetween 4% and 12% of all school-aged children and 2% to 4% ofadults. Any treatment plan of ADHD must include the education ofthe patient and his/her family, and may encompass special educationprograms, psychological interventions, and pharmacological management.Stimulant medications, such as methylphenidate, D-amphetamine,D,L-amphetamine and pemoline, are the predominant pharmacologicaltreatment for ADHD at all ages. Approximately 70% ofpatients respond to the first stimulant agent administered with symptomaticimprovement that tends to persist as long as the stimulantmedication is taken. Recent advances in the formulation of thesecompounds have resulted in an increased effectiveness and flexibilityof pharmacological treatment as well as the acceptance of such treatmenton the part of the patient and his/her family. In this presentation,the neuropsychopharmacological bases of the syndrome as supportedby the current scientific evidence will be discussed. Main criteriafor selecting specific types of medications, as well as tactics as tomedication dosage and schedules, effectiveness assessment, specificdrug formulations and the combination of drugs will also be discussed.A brief description of side effects and potential long-termeffects of medications will also be presented, as well as ways of preventingand handling them in the everyday clinical work.IS20.3.NON-PHARMACOLOGICAL TREATMENTOF ADHD AND ITS MAIN COMORBIDITIESM. DöpfnerClinic for Psychiatry and Psychotherapy of Childhoodand Adolescence, University of Köln, GermanyAttention-deficit/hyperactivity disorder (ADHD) is a complex behavioraldisorder resulting from a combination of neurobehavioral andcontextual variables. Although for the short-term improvement of thesyndrome the pharmacological treatment has been proposed as predominantlyeffective, it is clear that, in the long run, the appropriatetreatment of this disorder must involve a multimodal approachencompassing such non-pharmacological strategies as education,counseling and training of parents, teachers and other caregivers, selfcontrol techniques, the development of social skills and peer relationshiptraining for the affected individual. In this presentation therationale for the inclusion of psychological components in the treatmentof the child, adolescent and adult patient with ADHD and itsmain comorbidities will be presented. The evidence comparingbehavioral/cognitive strategies with psychopharmacological oneswill be discussed. The main focus will be the treatment of childrenand adolescents and the empirical evidence based on studies aboutthe effects of multimodal treatment in these age groups.IS20.4.TREATMENT OF ADHD IN THE ADULT PATIENTM. Rösler, W. RetzNeurozentrum - Institut für Gerichtliche Psychologie undPsychiatrie (IGPUP), Universitätskliniken des Saarlandes,Saarbrücken, GermanyThe recognition of attention-deficit/hyperactivity disorder (ADHD)in the adult population is rapidly expanding, even though mostresearch on adult ADHD has been primarily carried out with primaryinterest in childhood ADHD. Although controversies remain concerningthe validity of this disorder in the adult population, a growingbody of evidence attests to the enormous importance of ADHD as asource of adult dysfunction and psychological comorbidity. This presentationwill focus on the specific strategies concerning the treatmentof the adults suffering from the syndrome. A brief review of the scientificevidence supporting the continuity of ADHD to the adult periodof life will be presented, as well as the variations in symptoms thatbecome more specific at this age. Special issues such as the risk of27

abuse of medications used to treat the syndrome and the treatment ofcomorbid conditions will also be discussed. The indication for thetreatment of the disorder will be discussed in the light of social problemsoccurring during the course in adult life.IS21.THE CURRENT MANAGEMENTOF OBSESSIVE-COMPULSIVE DISORDERIS21.1.CURRENT MANAGEMENTOF OBSESSIVE-COMPULSIVE DISORDERJ. ZoharDivision of Psychiatry, Chaim Sheba Medical Center, TelHashomer, IsraelLess than twenty years ago, obsessive-compulsive disorder (OCD)was considered to be a rare, treatment-resistant disorder of psychologicalorigin. Over the past two decades, several comprehensive epidemiologicalstudies have demonstrated that the prevalence of OCDis about 2% worldwide. Attendant to the realization that OCD isactually a common disorder, it was found that the disorder is uniquewith regard to treatment response. As opposed to other psychiatricdisorders such as depression, panic disorder, post-traumatic stressdisorder, etc., in which noradrenergic and serotonergic medicationswere found to be effective, OCD seems to respond preferentially toserotonergic medications. As per the dose, some fixed-dose studieswith fluoxetine and paroxetine found that medium to high doses arerequired. Other studies, with sertraline and citalopram, suggest thateven 50 mg (of sertraline) and 20 mg (of citalopram) are effective.Long-term studies point out that the beneficial effects are maintainedand that OCD patients need to remain on anti-obsessive medicationsfor a long period of time. Although serotonin is implicated in OCD, ithas become increasingly clear that it is not the only factor and thatother neurotransmitters such as dopamine are also implicated in thedisorder. Despite the introduction of selective serotonin reuptakeinhibitors (SSRIs) has revealed new avenues for OCD treatment, ithas become apparent that, in order to further our understanding ofthe disorder, better phenotypes are needed. Studying OCD subsets,such as early versus late onset, with tic disorder versus without tic disorder,OCD related to autoimmune pathology versus no autoimmunepathology etc., may provide us with finer therapeutic tools in treatingthis intriguing disorder.IS21.2.THE TREATMENT OF OBSESSIVE-COMPULSIVEDISORDER OVER A LONG-TERM PERSPECTIVEF. Bogetto, G. Maina, U. AlbertDepartment of Neurosciences, University of Turin, ItalyThe efficacy of serotonin reuptake inhibitors (SRIs) in the acute treatmentof obsessive-compulsive disorder (OCD) is now well acknowledged.Head-to-head comparative trials seem to indicate an equivalentefficacy of different compounds in the acute phase, while someevidence exists indicating a higher effectiveness of selective serotoninreuptake inhibitors (SSRIs) because of their better side effect profilewhen compared to that of clomipramine. The choice between differentdrugs is highly influenced by the consideration that OCD requiresin the vast majority of cases a long-term treatment. Data from systematicdiscontinuation studies after acute treatment indicate an 80-90%relapse rate. There are few studies on the long-term treatment ofOCD: they suggest that maintenance treatment is associated withboth a significantly greater reduction in relapse rates and a furtherimprovement in symptoms. Relapses due to premature drug discontinuationmight be less responsive to the reinstitution of the samedrug proven effective in the acute treatment, thus adding evidence tothe need of a maintenance therapy. Psychoeducational programsaimed at improving the adherence of patients to treatments are highlywarranted and preliminary data will be presented indicating theirefficacy. Drug treatment of OCD might be conducted over the longterm with doses half of those used in the acute phase, without significantincreases in relapse rates. Beyond efficacy, however, few dataexist on the long-term tolerability of antiobsessive drugs. Weight gainand sexual side effects appear to exert a significant influence onpatients’ adherence to treatments, and appear to be highly dependenton the compound used over the long term. A specific effect of femalegender on weight gain due to long-term treatment of OCD alsoemerged from recent studies.IS21.3.PSYCHOTHERAPEUTIC TREATMENTSFOR OBSESSIVE-COMPULSIVE DISORDERF. HohagenDepartment of Psychiatry and Psychotherapy,University of Lübeck, GermanyBoth pharmacological (i.e. administration of selective serotonin reuptakeinhibitors, SSRIs) and psychological treatment (i.e. cognitiveand behavioral psychotherapy, CBT) have been proven to be effectivein obsessive-compulsive disorder. While treatment with SSRIs aloneshows a relapse rate of 40-80% after discontinuation of the drug, CBTlong-term outcome studies show success rates between 50 and 80%.A recent study has shown that CBT combined with SSRI treatment isable to prevent relapse when the SSRI is withdrawn. Furthermore,the combination of CBT with SSRI is superior to CBT alone whenobsessions dominate and/or patients are suffering from a secondarydepression. The literature and the relevant psychotherapeutic interventionstrategies for obsessive-compulsive disorder will be discussed.IS21.4.TREATMENT OF PEDIATRICOBSESSIVE-COMPULSIVE DISORDERP.H. ThomsenPsychiatric Hospital for Children and Adolescents, Risskov,DenmarkObsessive-compulsive disorder in children and adolescents affectsapproximately 1% of the population. The clinical picture is almostidentical to that seen in adult populations. Randomised control trials,both with psychotherapy and medication, are still sparse compared tothe body of evidence in the literature on adult OCD. However, manyof the selective serotonin reuptake inhibitors have proven efficient inrandomised control trials. Only a few studies on cognitive behaviouraltherapy (CBT) have been performed, most of which are non-controlled.However, one new study comparing medication, CBT and acombination of the two showed that a combined treatment is themost efficient. The overall treatment response in the pediatric populationis approximately 70%, i.e. there remains a rather large populationwho does not respond sufficiently to the treatment. Differentaugmentation strategies can be tried, including the addition ofantipsychotics.28 World Psychiatry 3:S1 - October 2004

IS22.UNDERSTANDING AND MANAGING“COMORBIDITY” IN PSYCHIATRYIS22.1.TRUE AND SPURIOUS COMORBIDITYIN CONTEMPORARY PSYCHIATRYA. JablenskyUniversity of Western Australia, Perth, AustraliaThe study of comorbidity, defined as the co-occurrence of independentclinical entities, is an important tool of genetic and clinical epidemiologythat can provide clues to latent common aetiological factorsand pathogenetic interactions. In this sense, the systematicreporting of comorbid syndromes, diseases and marker traits shouldbe encouraged in the clinical setting, as well as in epidemiologicalresearch. However, the current versions of internationally used psychiatricclassifications tend to breed a spurious kind of comorbidity,which often amounts to a co-registration of facets of the same underlyingcondition. Part of the problem stems from the ambiguous statusof the classificatory unit of ‘disorder’ in DSM-IV and ICD-10 and thefragmentation of psychopathology into a large number of ‘disorders’,of which many are merely symptoms. In contrast, syndromes are basicconcepts for most clinicians, and much of their clinical knowledge iscognitively stored in this format. These are good reasons for reinstatingthe syndrome as the basic Axis I unit in future classifications.IS22.2.UNDERSTANDING AND MANAGING COMORBIDITYIN BIPOLAR SPECTRUMG.B. Cassano, P. Rucci, S. PiniDepartment of Psychiatry, Neurobiology,Pharmacology and Biotechnology, University of Pisa, ItalyThe growing availability of new drugs for treatment of bipolar disorderled to a renewed interest in the field of mood disorders. However,difficulties in defining universally accepted guidelines for treatment ofbipolar disorder depend on the variety of phenomenology, evolutionand course of mood disorders. Anxiety disorders comorbidity appearsto be the rule rather than the exception in bipolar patients but muchresearch is still necessary to shed light on the nature and clinical significanceof these syndromal complexities. Comorbidity betweenbipolar depression and panic disorder, either in its threshold and subthresholdforms, has been found to be associated with greater symptomseverity, more suicidal ideation and poorer response to both psychotherapeuticand pharmacological treatments. A recent study performedin Pisa on a cohort of 363 bipolar outpatients shows that only40% of bipolar patients have no comorbid anxiety disorder: panicdisorder was present in 37% of patients, social phobia in 16%, obsessive-compulsivedisorder in 27%. Multiple anxiety comorbidity isalso frequent, with rates around 18%. Data from a study performedjointly in Pittsburgh and Pisa indicate that unipolar patients present ahigh rate of comorbidity with anxiety disorders as well. The latentclass analysis separated a cluster of unipolars with high rate of hypomanicfeatures and anxiety spectrum comorbidity from a cluster withlower hypomanic and anxiety manifestations. Other clinical variantsof bipolar disorder are characterized by the presence of comorbidpersonality disorders, substance abuse, impulsive and/or aggressivefeatures and medical conditions. In order to maximize the proportionof patients who achieve sustained recovery, a better understanding isneeded of the clinical variability within patient populations that carrythe same categorical diagnosis. This objective requires a broad conceptualizationof mood disorders along with their common thresholdor subthreshold comorbidities.IS22.3.COMORBID DEPRESSION IN SCHIZOPHRENIA ANDITS INFLUENCE ON TREATMENTW.W. FleischhackerDepartment of Biological Psychiatry, Medical University,Innsbruck, AustriaDepression is a common comorbid syndrome in patients with schizophrenia.Up to 75% of schizophrenia patients suffer from a depressivesyndrome at some point of the course of their illness. The lifetimeprevalence of this comorbidity has been estimated to be between 60%and 80%. Depression in schizophrenia patients has been associatedwith a better prognosis of the disorder in very early studies, althoughit is very likely that there may have been a considerable diagnosticoverlap with schizoaffective and affective disorders in these reports.More recently, depressive features in schizophrenia patients wererelated to more frequent and longer hospitalizations, increasedrelapse rates, poor response to pharmacologic treatment, poor socialfunctioning, substance abuse and other complications. The pharmacologicalmanagement of comorbid depression has to be adjusted tothe stage of schizophrenia when depressive symptoms occur. Whiledepressive symptoms which accompany acute psychotic symptomsduring states of exacerbation usually remit in parallel with psychoticsymptoms following antipsychotic monotherapy (most second generationantipsychotics have shown advantages over traditional neurolepticsin this regard), post-psychotic depression usually calls forcombination treatments with antipsychotics and antidepressants.Although the evidence base for this approach is still far from beingsatisfactory, this is common clinical practice. Some of the second generationantipsychotics (for instance zotepine, ziprasidone) also blockmonoamine reuptake. Whether this leads to an inbuilt antidepressanteffect that can also be utilized clinically is still under investigation.The occurrence of a comorbid depressive syndrome in schizophreniapatients calls for careful differential diagnosis and subsequent clinicalmanagement. This is especially relevant in the context of the high riskfor suicidal behavior in such patients.IS22.4.SIMILARITIES AND DIFFERENCES IN THE ANXIETYDISORDERS: EPIDEMIOLOGY, COMORBIDITY ANDCOURSEC. FaravelliDepartment of Neurology and Psychiatry, University MedicalSchool, Florence, ItalySince the DSM-III abolished the concept of neurosis, most of the disorderspreviously called “neurotic” were grouped into the category ofanxiety disorders. The earlier aggregations of “anxiety neurosis” and“phobic-(obsessive) neurosis” were lost and split into a variety ofmore specific disorders. The initial consideration for this division wasbased on pharmacological dissection, by which panic and panic-likesyndromes would respond preferentially to antidepressants. Almost aquarter of a century later, though the pharmacological dissection isno longer true for distinguishing anxiety disorders, the division ofanxiety disorders is well-established in present psychiatric classifications.There are, however, several facts that indicate a significantdegree of similarity between panic disorder, social phobia, generalisedanxiety disorder, simple phobia, and others: an extremely highcomorbidity rate (having more than one anxiety disorder is the rule29

ather than the exception, both in clinical and in epidemiologicalsamples); b) family concentration; c) response to the same drugs(antidepressants) and hypersensitivity to drugs; d) common psychopathologicalfeatures (excess of anticipation, dramatisation, overestimationof risk, etc.). In the Sesto Fiorentino study, a representativesample (n = 2363) of the general population was interviewed bypsychiatrists. 16.9% of these subjects suffered or had been sufferingfrom anxiety disorders (11.3% excluding anxiety not otherwise classified),with an extremely high degree of comorbidity and a noteworthyoverlap of clinical features. On the basis of this naturalistic observation,the following hypotheses can be put forward: a) anxiety disordersare separate entities; b) anxiety disorders represent differentstages of the same, progressively changing, phenomenon; c) anxietydisorders represent different expressions of a common liability; d) theconcept of neurosis should be retained as the common basis of anxietydisorders, with differentiations due to modulating factors.IS23.ECONOMIC ASPECTS OF MENTAL HEALTH CAREIS23.1.ECONOMICS AND SYSTEMS OF CAREIN PSYCHIATRYS.S. SharfsteinSheppard Pratt Health System, Baltimore, MD, USAAs the science and art of psychiatric treatment have improved andmore patients can benefit from psychiatric diagnosis and care, thedemand for these valued services increases dramatically. The supplyof qualified practitioners, how they are organized in systems of care,and the cost of treatment are strategic issues for policy makers in boththe private and public sectors. Economics is the science and art ofrationing and can have a profound impact on how we are able to meethuman needs in the medical marketplace. This paper will examine thesupply and demand characteristics of the psychiatric medical marketplaceand focus on various strategies to promote access and containcosts. As psychiatric treatment has become more effective and individualized,the stigma associated with seeking such care hasdecreased, and the demand for care has increased dramatically. Howwe then organize the provision of such services becomes a matter ofvital concern to clinicians, patients and their families, and government.Various efforts at social insurance must consider economics inorder to understand the consequences of such financing for access tocare, quality, and costs. How these issues are evolving in the UnitedStates, at national and local levels, will be the main focus of thispaper.IS23.2.MENTAL HEALTH POLICY AND ECONOMICSRESEARCHM. MoscarelliInternational Center of Mental Health Policy and Economics,Milan, ItalyMental health policy and economics research is increasingly demonstratingits importance in providing decision-making with cruciallyneeded information on a wide range of issues, including: a) socioeconomicburden of mental and addictive disorders, and the coststhey impose on patients, family caregivers, workplace and society; b)impact of clinical, social, and financial interventions on health, qualityof life and economic well-being of the affected populations; c)costs of alternative management systems for providing comprehensiveclinical and social services, and the socio-economic impact ofpolicies encouraging community-based care; d) analysis of thecost/effectiveness of psychological or pharmacological interventionsin speciality and general practice settings; e) evaluation of the consequencesof different financing and reimbursement methods on healthcare provision, efficiency, and health outcomes; f) analysis of specialand particularly vulnerable populations (i.e. severely disabling mentalillnesses, co-morbidities of mental and addictive disorders) that needcomplex multilevel co-ordination of clinical, social and financialinterventions. Systematic interdisciplinary collaboration among psychiatrists,health services researchers, health economists, and publichealth researchers is required for obtaining sound scientific informationin this field. This integrated approach brings together thestrengths of each discipline to provide the best possible informationto support the complex policy decisions regarding the provision ofeffective interventions for prevention, care and rehabilitation, andtheir adequate proper financing.IS23.3.CONTEMPORARY EFFECTS OF MANAGED CAREIN THE USAD.B. BorensteinDepartment of Psychiatry, University of California at Los Angeles,CA, USAIn the late 1980s, as health care costs in the United States rose beyond11 percent of the gross domestic product, employers turned to managedcare in an effort to diminish their expenses. Most employersdecided that psychiatric illnesses and their treatments could not beevaluated and managed in same way as other medical illnesses. Managedbehavioral health care came into existence to fill this need. Atthe time, there was inadequate research to document the accuracy ofpsychiatric diagnosis and the cost-effectiveness of psychiatric treatment.This presentation will provide highlights of recent researchdocumenting the effects of behavioral managed care in the UnitedStates. It will focus on costs, quality of care and access to treatmentfor psychiatric illnesses.IS23.4.UNDERSTANDING MENTAL HEALTH SERVICE COSTDRIVERS: A NEW ZEALAND CASEMIXDEVELOPMENT STUDYG.W. MellsopAuckland Clinical School, University of Auckland, New Zealand“Casemix” methods of funding health services have been quite extensivelydeveloped in parts of the world. Attempts to developing mentalhealth casemix systems have usually been greeted unenthusiastically,because so little variance in the costing could be attributed to diagnosis,and so much variance appeared to be solely dependant on the idiosyncrasiesof the provider. A large research project was implementedin New Zealand to develop a pilot casemix classification which couldbe used for service management purposes, to inform funding, to providebenchmarks and to model the routine use of outcome information.Three major data blocks were captured for the study. These wereservice financial information, service utilisation data, and consumercharacteristics. These were entered into a regression analysis model toexplain the cost drivers of “episodes of care”. An episode of care wasarbitrarily defined as a 91-day period. 19,239 episodes of care werecaptured over a six-month study period. These were provided to a totalof 12,576 individuals. A 42-class, pilot, classificatory system was30 World Psychiatry 3:S1 - October 2004

developed. The branching tree from “all episodes” proceeded in thisanalysis 5 steps, which overall explained 78% of the variance. The firstsplit was into inpatient or community. Within each of those, next splitwas adult versus child and youth. Thereafter the splitters included age,Health of the Nation Outcome Scales (HONOS) items, legal status,ethnicity, and in a few cases, diagnoses.IS24.ASSESSMENT AND MANAGEMENT OF SOCIALANXIETY DISORDERIS24.1.DIAGNOSIS AND ASSESSMENT OF SOCIALANXIETY DISORDERB. BandelowDepartment of Psychiatry, University of Göttingen, GermanySocial anxiety disorder (SAD), also known as social phobia, is a highlyprevalent, generally chronic, and very disabling disorder. A corefeature of SAD is excessive fear of social or performance situationsinvolving unfamiliar people or scrutiny. The individual fears embarrassmentand negative evaluation in social situations, including publicspeaking, going to party, meeting strangers or initiating a date,talking to people in authority or expressing a disagreement, workingwhile being observed, or taking tests and exams. In the generalizedsubtype of SAD, fear or avoidance is elicited by most situationsinvolving contact with other people. Blushing, sweating, palpitations,trembling, and abdominal distress are among the most commonsomatic symptoms. Differential diagnoses include other anxiety disorders,depressive syndromes, body dysmorphic disorder, eating disorders,childhood and developmental disorders, psychotic disorders,and others. SAD also includes a broad range of symptoms that frequentlyoverlap with other diagnostic entities. In the past fewdecades, numerous rating scales have been developed for the assessmentof social anxiety disorder. Many of these are relatively brief andsimple to administer and could be easily incorporated into an initialevaluation or treatment session. The choice of which scale or scalesto use with a given patient at a given time will depend on the clinicalquestion being addressed, the time demands of the situation, and thestyle and focus of the clinician.IS24.2.PHARMACOTHERAPY OF SOCIAL ANXIETYDISORDERD.J. SteinUniversity of Stellenbosch, Cape Town, South Africa;University of Florida, Gainesville, USAThere is a growing database of randomized controlled trials for thepharmacotherapy of social anxiety disorder (social phobia). Early trialswith the irreversible monoamine oxidase inhibitors were importantin showing that this disorder could respond to medication. Trialswith the better tolerated reversible inhibitors of monoamine oxidaseA were, however, more equivocal. Furthermore, social anxiety disorderdiffers from depression in that it appears not to respond to tricyclicantidepressants. More recent work with the selective serotoninreuptake inhibitors and the noradrenaline-serotonin reuptakeinhibitors have provided a series of pharmacotherapy options that areboth effective and well tolerated. This paper reviews existing knowledge,as well as gaps in our knowledge, of the pharmacotherapy ofsocial phobia.IS24.3.PREDICTION OF RESPONSE TOPHARMACOTHERAPY IN SOCIAL ANXIETYDISORDER IN RELATIONSHIP TO TAIJIN KYOFUSHOAND SOCIAL WITHDRAWALT. NagataDepartment of Neuropsychiatry, Osaka City University MedicalSchool, Osaka, JapanThere are no previous studies focusing on prediction of response topharmacotherapy in patients with social anxiety disorder in relationshipto Taijin Kyofusho (TKS, offensive subtype of social anxiety disorder)or social withdrawal. We studied 71 social anxiety disorderpatients who took fluvoxamine (≥100mg/day), paroxetine(≥20mg/day) or milnacipran (≥100mg/day) for more than threemonths. TKS was diagnosed based on the original diagnostic criteria(Nagata et al. 2003), requiring the presence of “fear of offending orembarrassing”. The primary efficacy variable at the endpoint was theproportion of responders, i.e., patients defined as “much improved”(score=2) or “very much improved” (score=1) on the Clinical GlobalImpression scale (CGI) global improvement item as compared to thebaseline (pretreatment) score. Thirty-four (48%) of the patients wereresponders. There were no significant differences in age, age of onset,and presence of TKS between responders and non-responders. However,significantly more full-time employees (or students) respondedthan unemployed patients, and the patients with histories of socialwithdrawal (housebound lifestyle) responded poorly. Thus, TKSpatients responded to pharmacotherapy as well as other social anxietydisorder patients do, although such patients may be diagnosed asdelusional disorder somatic type in Western countries. However,patients with histories of social withdrawal (housebound) respondedpoorly to pharmacotherapy.IS24.4.PARENTAL REPRESENTATIONS ASSOCIATED WITHSOCIAL ANXIETY DISORDERS. Pallanti 1,2 , L. Quercioli 3 , V. Benedetti 31 University of Florence, Italy; 2 Mount Sinai School of Medicine,New York, NY, USA; 3 Institute of Neurosciences, Florence, ItalyIt seems likely that humans need close emotional relationships orbonds with others. According to the attachment theories, early parent-infantrelationships represent a fundamental step in the constitutionof a secure base, while early bonding abnormalities have beenassociated with a range of anxiety and depressive disorders in adulthood.However, no specific parental patterns have emerged for eachspecific disorder. Previous studies using the Parental Bonding Instrument(PBI) have shown a general trend for neurotic subjects to scoretheir parents as less caring and more protective. The present studyinvestigated parental over-protectiveness and its possible linkage tothe risk of social anxiety disorder (SAD) in adulthood. Three studygroups were recruited: 64 subjects with SAD (diagnosed according toDSM-IV), 62 subjects with “other than SAD” anxiety disorders (30%with obsessive-compulsive disorder, 25% with panic attacks, 20%with agoraphobia, 10% with simple phobia, and 10% with generalizedanxiety disorder), and 77 healthy subjects. These three groupshave been investigated using the PBI. A significant lower score in thepaternal care dimension has been found in the comparison of SADpatients with the healthy subjects (p

have a defiant pattern of type A and a bigger number of type C thanthe other two groups for the father (p

IS25.4.THE TREATMENT OF COMORBID DEPRESSION ANDANXIETY IN SCHIZOPHRENIAA.C. Altamura, R. Bassetti, D. Salvadori, E. MundoChair of Psychiatry, Department of Clinical Sciences“Luigi Sacco”, University of Milan, ItalyDescriptive and epidemiological studies have clearly documentedthat approximately half of schizophrenic patients have at least onecomorbid psychiatric or physical illness. Depressive and anxious featurescan occur as symptoms or combined as comorbid syndromalconditions. In particular, depressive symptoms occur in one-third ofpatients with schizophrenia but, despite this high prevalence, relativelylittle is know about their precise pathophysiology and course.Moreover, the emergence of depressive symptoms has been associatedwith poor outcome, increased medication usage, great morbidity,increased hospital rates, early relapse and higher rates of suicide. Onthe other hand, anxiety disorders may impair social and vocationalfunctioning, affecting the quality of life and the outcome in schizophrenicpatients: there is evidence that anxiety could be considered asa precipitating factor for psychotic exacerbations, relapses and suicidalbehavior. Moreover, anxious symptoms appear to be frequentlyrelated to substance abuse. Among anxiety disorders, obsessive-compulsivedisorder (OCD) occurs with a lifetime prevalence of 29.7%.In recent reports on social phobia, 20-30% of schizophrenic patientsmet diagnostic criteria for this disorder. From a pharmacologicalpoint of view, the co-occurrence of depressive and anxious symptomsoften leads to prescription of adjunctive pharmacotherapies, with anincreased risk of side effects and reduced compliance. In this perspectiveatypical antipsychotics may be more effective in patients sufferingfrom comorbid conditions, because of their wider pharmacodynamicspectrum. This presentation will be focused on the results ofa naturalistic study in which the association between schizophreniaand other psychiatric disorders (i.e. anxiety disorders and depressivedisorders) and its implications for pharmacological treatment havebeen investigated.IS26.FAMILY INTERVENTIONS FOR MENTAL DISORDERSIS26.1.FAMILY INTERVENTIONS FOR SCHIZOPHRENIA:RESULTS OF THE OPTIMAL TREATMENT PROJECTI.R.H. FalloonDepartment of Psychiatry, University of Auckland, New ZealandFamily interventions for schizophrenia that are integrated with optimalpharmacotherapy and are continued for at least two years areamong the most powerful strategies for preventing recurrent psychoticepisodes yet devised. Patients and carers who receive these programmesshow trends to full and stable clinical and social recoveryand reductions in stress and burden associated with the illness. However,in common with most psychosocial treatment, despite overwhelmingscientific evidence, these interventions are considered ofsecondary importance in routine services, and at best replaced bybrief group education for relatives or patients. An international collaborativegroup, the Optimal Treatment Project (OTP), has beendeveloped to promote the routine use of all evidence-based strategiesfor major mental disorders. For schizophrenic disorders this consistsof optimal pharmacotherapy, assertive case management, psychoeducationfor patients and carers together, cognitive behavioural familystrategies, including those designed to reduce residual symptoms, andintegrating social skills training within the family/carer problem solvingsessions. A field trial is in progress to evaluate the benefits ofapplying these evidence-based strategies over a 5-year period. Morethan 80 centres have been set up in 18 countries. There has been avery high drop out rate of centres, particularly in North America andBritain. This has been associated with inadequate administrative support.The preliminary outcome after 24 months and 5 years will bepresented. The data suggests that OTP appears to have replicated thebenefits associated with clinical trials of similar integrated family programmes.After 2 years, half the recent-onset cases had achieved fullrecovery from clinical and social morbidity. The vulnerability stresshypothesis suggests that integration of evidence-based family treatmentswith optimal pharmacotherapy will have synergistic effectsthat may lead to greater benefits than when these approaches are notprovided within a single multidisciplinary team.IS26.2.FAMILY INTERVENTION FOR SUBSTANCE MISUSEAND PSYCHOSISC. BarrowcloughDivision of Clinical Psychology, School of Psychological Sciences,University of Manchester, UKThe efficacy of family intervention for people with schizophrenia isnow well established. However, despite the high prevalence of substancemisuse in psychosis and the additional strains this puts onfamily relations, there are few reports of interventions which addressthe particular issues arising in families where a member has a substancemisuse problem in addition to the psychosis. This paper willreview the limited literature available about family issues with clientsexperiencing substance misuse and psychosis before describing atreatment approach focusing on drug or alcohol problems in thisclient group. The integration of motivational interviewing with individualand family cognitive behaviour therapy resulted in improvedpatient outcomes. This presentation will describe the family componentof the treatment and some of the difficulties arising in conductingfamily work in a “dual diagnosis” group.IS26.3.ENGAGING THE FAMILY IN THE COMBINEDTREATMENT OF BIPOLAR PATIENTSF. ColomBipolar Disorders Program, Stanley Research Center, Barcelona,SpainA very important change of paradigm in the treatment of bipolar disordersstarted some years ago; crucial findings on the usefulness ofpsychological interventions clearly support switching from an exclusivelypharmacological therapeutic approach to a combined, but hierarchical,model in which pharmacotherapy plays a central role butpsychological interventions may help covering the gap existingbetween theoretical efficacy and “real world” effectiveness. Most ofthe recently published psychotherapy studies report positive results inmaintenance as an add-on treatment, and efficacy in the treatment ofdepressive episodes. The psychoeducation of bipolar patients andtheir relatives is a crucial intervention specially as a prophylactic toolfor euthymic patients. Psychoeducation of relatives should includeboth compliance enhancement and early identification of prodromalsigns, information on the importance of life-style regularity, and theexploration of relatives’ beliefs on the illness suffered by the bipolarmember of the family. The Barcelona Bipolar Disorders Program has33

developed an evidence-based psychoeducational program that hasproven to be efficacious in the prophylaxis of relapses and theenhancement of drug adherence in bipolar patients. A second programinspired by the first is being tested to prove the efficacy of relatives’psychoeducation in the prevention of relapses and hospitalizations,with very promising preliminary results. As clinicians, it is ourmajor duty to offer the best treatment available to our patients, whichincludes a wide arsenal that goes from newer pharmacological agentsto evidence-based psychoeducation programs both for the patientsand their relatives.IS26.4.FAMILY INTERVENTIONS FOR MENTALDISORDERS: CHALLENGES AND OPPORTUNITIESIN DEVELOPING COUNTRIESR. Srinivasa MurthyEastern Mediterranean Regional Office,World Health Organization, Cairo, EgyptThere is a re-examination of the place of family members in the careof the persons with mental disorders all over the world. In the lastfour decades, the shift from considering families as ‘toxic’ to essentialpartners in mental health care has been a major development, as wellas the shifting of mental health care from institutions to the community.In developing countries, institutionalised care for persons withmental disorders has been insignificant, with most of the countrieshaving less than one bed for 10,000 inhabitants as compared to about6-10 beds in Europe and North America. Families have been the maincare providers in developing countries. Families are important in anumber of ways, such as early recognition of the symptoms of illness,seeking treatment in the acute phase of illness, ensuring regularity intaking treatment, providing a supportive environment for recovery,facilitating the rehabilitation and reintegration of the recovered individualsand fighting stigma and discrimination at the societal level. Inmost developing countries families have been partners in the care ofthe persons with mental disorders. In recent times families have cometogether to form self-help groups and also to pressure the state tochange policies and programmes. The needs of the families to take upthis important role are at three levels. Firstly, families need supportfrom the professionals to acquire the skills of care, respite care andcrisis support in emergencies, emotional support to meet their ownneeds and to maintain cohesion. Secondly, the state needs to supportfamilies financially to offset their caring responsibility and createopportunities to form self-help groups. Thirdly, professionals have tochange their attitudes and practices to develop a true partnershipwith the families and make the experiences of the family an essentialpart of the programme and policy development. Up to now the activitiesin developing countries in Asia, Eastern Mediterranean Regionand Africa have focussed on sharing of information and skills withfamilies. There are beginnings of a self-help movement in some of thecountries. The representation and advocacy roles and true partnershipbetween families and professionals are not yet a reality. Developingcountries have a unique opportunity to build mental health programmeson the strengths of families.IS27.MOLECULAR GENETICS AND GENOMICSOF PSYCHIATRIC DISORDERS: IDENTIFICATIONOF NOVEL DRUG TARGETSIS27.1.MOLECULAR GENETICS AND GENOMICSOF SCHIZOPHRENIAM.J. OwenDepartment of Psychological Medicine, University of WalesCollege of Medicine, Heath Park, Cardiff, UKGenetic epidemiological studies suggest that individual variation insusceptibility to schizophrenia is substantially genetic. However, likeother common disorders, the mode of transmission is complex andprobably reflects oligogenic inheritance against a polygenic background.Genomic approaches to schizophrenia are becoming increasinglyfeasible as data from the genome project accumulate and technologyimproves. Attempts to identify genes for schizophrenia havebeen based on several approaches: systematic linkage studies, associationstudies and studies of chromosomal abnormalities associatedwith the disorder. Several strongly significant linkages have beenfound and there is emerging consensus on at least some of the chromosomalregions likely to contain schizophrenia genes. However,moving from linked region to susceptibility gene is still difficult givenpoor understanding of pathophysiology and population genetics andthe complexity of the phenotype. In spite of this, a number of positionalcandidate genes have been identified and in several instances(neuregulin 1, dysbindin 1, regulator of G-protein signalling 4, G72and D-amino acid oxidase) support has come from several studies.These findings potentially converge upon abnormalities in glutamatergicneurotransmission in schizophrenia, for which evidencefrom a number of other sources has already been adduced. Finally,the high rates of schizophrenia seen in individuals with deletions ofchromosome 22q11, as well as linkage data, suggest that this chromosomalregion might contain a susceptibility locus.IS27.2.THE PHARMACOGENOMICS OF COGNITIVEFUNCTION: THE ROLE OF DOPAMINE ININFORMATION PROCESSINGJ.A. Apud, V. Mattay, B. Das, T. Goldberg, J. Iudicello, M. Egan,D. WeinbergerClinical Brain Disorders Branch; Genes, Cognition and PsychosisProgram, National Institute of Mental Health, Bethesda, MD,USAAbnormalities of dorsolateral prefrontal cortical (PFC) function havebeen associated with genetic risk for schizophrenia. A potential susceptibilitymechanism involves regulation of prefrontal dopamine(DA). DA stabilizes PFC function and modulates the response of PFCneurons during working memory. We studied the relationship of afunctional polymorphism (Val108/158Met) in the catechol-Omethyltransferase(COMT) gene, which accounts for approximately atwo-fold variation in enzyme activity and dopamine catabolism, withboth PFC cognitive function and PFC physiology. In patients withschizophrenia, their unaffected siblings, and normal volunteers, theCOMT genotype was related to performance on the Wisconsin CardSorting Test. In this context, the Val/Val allele, which encodes thehigh-activity COMT variant, predicted decreased cognitive performance.The Met/Met genotype, which encodes the low-activity COMTvariant, predicted a more efficient cognitive performance. These find-34 World Psychiatry 3:S1 - October 2004

ings indicate that COMT may play a unique role in regulating DA fluxin the PFC. Further, we explored if tolcapone, a COMT inhibitorwhich penetrates the blood brain barrier, improves efficiency in PFCfunction. In a double-blinded placebo controlled trial with tolcapone,15 healthy volunteers underwent two blood-oxygen-level-dependent(BOLD) functional magnetic resonance imaging (fMRI) scans on aGE Signa 3T scanner with a gradient echo EPI sequence while performingthe N-back working memory task. Analysis of variancerevealed a significant main effect of tolcapone at 2-Back and 3-Backtasks with greater activation in the PFC bilaterally, anterior cingulateand right parietal region on the placebo condition relative to tolcapone(p

tional academic and professional organisations. Drug abuse, in additionto the risk of addiction, is strongly associated with organisedcrime and the increasing spread of HIV, hepatitis and other infectiousdiseases. It threatens the social structures and economies of wholecountries. There is therefore an urgent need for prevention, made allthe more intense because drug abuse has a particular impact on thefreedom and development of young people, who represent the mostvaluable asset of every country. In addition to the effect on particularindividuals, drug abuse also has a significant impact on families,friends, and eventually the whole community. Although alcohol isclearly a major component of substance abuse worldwide, this paperfocuses on controlled drugs because there is sufficient complexity justwithin this more limited area. However, there will inevitably be agood deal of common ground with other substances. The preventionof drug abuse is becoming more difficult partly because of the rapidgrowth of messages in the environment that promote drug abuse. Byfar the greatest influence on many young people is the general toleranceof, and even the promotion of recreational drug use and abuse inpopular culture, and particularly in popular music. In addition, moreinformation on drugs is available to more people than ever beforethrough the internet. There are many different pages on the WorldWide Web devoted to the production, manufacture and use of illicitdrugs. In this environment, prevention is not easy, not least becausethe underlying causes of substance abuse are complex and multifactorial.Rather than simple solutions, a comprehensive approach isrequired which acknowledges the diversity of populations at risk, thecomplexities of causal and risk factors, the importance of the economicand social environment, and the inability of health measures torid roughshod over the prevailing customs and attitudes of a community.No form of non-medical drug use is healthy and substance abuseprevention should therefore be seen as one part of general publichealth measures to ensure a healthy society. While the elimination ofall forms of drug experimentation, use and abuse will never beachieved, this should not be used as a reason to give up on prevention,the ultimate aim of which is to achieve a mainly low level of drugabuse. When dealing with substance abuse, the usual distinctionsbetween primary, secondary and tertiary prevention can usefully bereplaced by considering supply reduction, demand reduction, andreduction of harms associated with substance abuse. The first two aremeasures of primary prevention; the third involves secondary and tertiaryprevention. Since both demand and supply drive drug abuse, itis necessary not only to control the production and distribution ofdrugs, but also to try to slow growth of the drug market by reducingconsumer demand. Demand reduction programmes for illicit drugshave to take into account a vast range of factors that influence people’stendencies to take drugs and must attempt to change attitudesand behaviour by tackling all environmental variables in a comprehensivemanner. The importance of demand reduction was recognisedby all governments to be essential to a stepped-up global effortto fight drug abuse and trafficking, and therefore they adopted theDeclaration on the Guiding Principles of Drug Demand Reduction atthe Special Session of the United Nations General Assembly in 1998.In recent years there has been an increased emphasis on developingevidence-based demand reduction programmes and it is clear thattheir effectiveness varies according to the cultural context and environmentin which they are implemented. Treatment, in all its forms,can be seen as just one part, albeit a very important part, of a comprehensivedemand reduction strategy.IS28.2.GLOBAL CHALLENGES IN THE PREVENTION ANDMANAGEMENT OF SUBSTANCE USE DISORDERSFROM THE WHO PERSPECTIVEV. PoznyakDepartment of Mental Health and Substance Abuse,World Health Organization, Geneva, SwitzerlandPsychoactive substance use is associated with substantial mortalityand morbidity worldwide. Apart from social costs, alcohol is responsiblefor 1.8 million deaths and 58.3 million disability adjusted lifeyears (DALYs) globally and illicit drugs for 0.2 million deaths and11.2 million DALYs. The World Health Organization (WHO) estimatedthat globally 76.3 million people suffer from alcohol use disordersand at least 15.3 million from drug use disorders. Injecting druguse associated with drug dependence is fuelling HIV epidemics inmany parts of the world. The number of injecting drug users (IDUs)worldwide is estimated at 12.6 million and the majority (9.4 million)are in developing and transitional countries. Results of the WHODrug Injection Study Phase II highlight scope and patterns of injectingdrug use and seroprevalence of HIV and hepatitis B and C amongIDUs in 13 cities around the world. The WHO CollaborativeResearch Project on Drug Dependence Treatment and HIV/AIDSfocuses on pharmacotherapy of opioid dependence as HIV preventionand treatment strategy, and preliminary results of this project willbe presented and discussed. Global burden resulted from substanceuse is not only associated with substance dependence. Hazardousand harmful use of alcohol is responsible for substantial health andsocial costs. Results of the WHO Collaborative Research Project onAlcohol and Injuries, implemented in 12 countries of the world,showed that alcohol involvement in injuries varied from 4% in CzechRepublic and Canada to 46% in South Africa. There is a substantialevidence of benefits of screening and brief interventions (SBI) in primarycare for alcohol problems. For that purpose WHO developedthe widely used Alcohol Use Disorders Identification Test (AUDIT).There is a need for effective SBI procedures for other substances,including the illicit ones. The Alcohol, Smoking and SubstanceInvolvement Screening Test (ASSIST) has been developed and validatedin the framework of the WHO ASSIST project. Phase III of theproject aims at assessing efficacy of brief interventions for illicit substanceuse linked to screening with the ASSIST instrument. A WHOsurvey on available resources for the treatment and prevention of substanceuse disorders in the world provided important information onuneven distribution of resources and their scarcity in many parts ofthe world. Concerted efforts of different partners, including governments,professional associations, local communities, consumergroups as well as private sector, are needed to strengthen health caresector response to the challenges associated with substance use disorders.IS28.3.IMPLEMENTING INTEGRATED TREATMENTSFOR DUAL DISORDERSR.E. DrakeDartmouth Psychiatric Research Centre, Dartmouth, NH, USAIntegrated dual disorders treatments involve combining and blendingthe delivery of mental health and substance abuse interventions forpersons with co-occurring disorders. These interventions are nowwidely accepted as a critically important evidence-based practice incommunity mental health care. The rationale is simple. First, substanceabuse has a prevalence of 50% or more among persons with36 World Psychiatry 3:S1 - October 2004

severe mental illness. Second, co-occurring substance abuse isresponsible for a range of negative client outcomes, including rehospitalization,incarceration, homelessness, victimization, and hepatitisC. Comorbidity also produces high costs in the family system, themental health system, and the criminal justice system. Finally, integrateddual disorders treatments are demonstratably more effectivethan parallel mental health and substance abuse treatments deliveredin separate settings or by separate programs. Nevertheless, integrateddual disorders treatments, like other evidence-based practices, aregenerally not available in routine mental health settings. Implementationof complex programs includes promoting practice change, whichinvolves focusing efforts on all stages of the change process, frominspiring people to change, to helping them make the change, to reinforcingthe change. Motivating efforts educate and engage stakeholdersso that they want to work for the change. Enacting the practiceinvolves putting the change in place by learning new behaviors andrestructuring the flow of the daily work so that clinicians routinelygive care in the new way. Sustaining efforts focus on reinforcing thenew practice to ensure that it will persist over time. In a complex system,all stakeholders can play helpful roles in promoting implementationand the more elements of the system of care that can be marshaledto support change (and reduce resistance), the more likely thepractice implementation will occur. In other words, intensity of effortappears directly related to success in studies of practice change.IS28.4.COMMUNITY MOBILIZATION FOR PRIMARYPREVENTION OF SUBSTANCE ABUSE AMONGYOUNG PEOPLES. Saxena, M. NkowaneWorld Health Organization, Geneva, SwitzerlandSubstance abuse is causing a large and increasing health and socialburden in low and middle income countries. Young people are especiallyvulnerable. The World Health Organization is co-ordinating aglobal project on primary prevention of substance abuse in 8 low andmiddle income countries (Belarus, the Russian Federation, SouthAfrica, Tanzania, Thailand, Viet Nam, and Zambia). The core objectiveis to mobilize communities through non-governmental organizationsto develop culturally and socially relevant strategies for primaryprevention of substance abuse among young people and to test theireffectiveness. Key personnel from non-governmental organizationswere trained in basic aspects of substance abuse, before they developedsmall project proposals to undertake preventive work in theirarea. The common element of all activities was community mobilization.Systematic baseline assessment of substance abuse problems inthe target community was followed by implementation of the preventionprogramme. A follow-up assessment of the impact was conducted.The process and outcome evaluation clearly demonstrated thattarget communities improved their knowledge, attitudes and practicesrelated to substance abuse and associated problems. In somecommunities this also led to decreased substance abuse problemswithin the target population of young people. The non-governmentalorganizations, the majority of them without any earlier experiencewith substance abuse prevention, reported being skilled and empoweredto undertake similar work in future. The implications of theseresults are significant for developing national and local policies forprevention of substance abuse in low and middle income countries.IS29.PSYCHOTROPIC DRUGS AND COGNITIVEFUNCTIONSIS29.1.ANTIPSYCHOTIC DRUGS AND COGNITIONIN SCHIZOPHRENIA: AN OVERVIEWA.S. DavidSection of Cognitive Neuropsychiatry, Institute of Psychiatry,De Crespigny Park, London, UKOver a decade has passed since the introduction of the second generationof ‘atypical’ antipsychotic drugs. In many parts of the worldthese have become standard and first line treatments. One of theadvantages claimed for such drugs is the beneficial effect on cognition.Cognitive impairment should be regarded as a core feature ofdisorders such as schizophrenia and has a major impact on socialfunctioning. Considerable research has been undertaken to examinethe effects of second-generation drugs on cognitive functioning. Thishas been subjected to systematic review and meta-analysis. Methodologicalproblems remain, such as the difficulty in teasing out ‘pure’cognitive effects from more general symptom effects. Nevertheless,there is evidence of small to moderate effects on various aspects ofcognition, including attention, memory and executive functioning.Functional neuroimaging has also demonstrated changes attributableto second-generation drugs in schizophrenia but in small samples.The impact of this on functional outcome and quality of life is stillunclear and requires further scrutiny. There is now the prospect of theuse of drugs in psychosis with alternative modes of action including‘anti-dementia drugs’ which act primarily on the cholinergic systemand early trial data is beginning to be published.IS29.2.COGNITIVE DYSFUNCTIONS IN PATIENTS WITHSCHIZOPHRENIA: EFFECTS OF NOVELANTIPSYCHOTICSS. Galderisi, A. Mucci, D. Sorrentino, A. Tonni, M. MajDepartment of Psychiatry, University of Naples SUN, Naples,ItalySchizophrenia is characterized by a variety of cognitive impairments,involving memory, attention, executive functions and general cognitiveabilities. Substantial evidence of relationships between cognitivedysfunctions and poor outcome has stimulated interest for the impactof antipsychotic drugs on cognition. In the present study the effects ofatypical antipsychotics on cognitive functioning were investigated in24 outpatients with schizophrenia treated with either clozapine orrisperidone. Relationships between cognitive, psychopathological andextrapyramidal symptoms (EPS) improvement were explored. Neuropsychologicalassessment was carried out by tests exploring executivefunctions (Wisconsin Card Sorting Test, WCST; Spatial and Non-Spatial Conditional Associative Learning Task, SCAL and NSCAL;Self-Ordered Pointing Task, SOPT), attention/short term memory(digit and block span) and incidental learning (Hebb’s digit recurringsequences and Corsi’s block tapping task). Clinical evaluation includedthe Scales for Positive and Negative Symptoms and the Simpson-Angus scale for EPS. All assessments were carried out after a drugwash-out period of at least two weeks and after six months of treatment.Indices showing significant improvement included the totalnumber of errors and mean time on the SCAL, the mean time on theNSCAL and the perseveration index on the SOPT for drawings. Noassociation was found between cognitive improvement and ameliora-37

tion of psychopathological dimensions and of EPS. Only the reductionof the total number of errors on the SCAL was associated with theimprovement of disorganization. Our findings suggest that atypicalantipsychotics have a favourable effect on cognition, which is not secondaryto the amelioration of either psychopathology or EPS.IS29.3.IMPACT OF MOOD STABILIZERS ON COGNITIVEFUNCTIONSA. Martínez-AránClinical Institute of Psychiatry and Psychology, Hospital Clinic,University of Barcelona, SpainThe effect of medication on cognition has been extensively studied inschizophrenia but scarcely investigated in bipolar disorder. One ofthe main difficulties is that most bipolar patients are not in monotherapy.They are treated with lithium and/or anticonvulsants. Moreover,antipsychotics or antidepressants may be usually added as maintenancetreatment in an important subset of patients to prevent(hypo)manic or depressive relapses. Some mood stabilizers such aslithium or valproate have been postulated to have a neuroprotectivecapacity in preclinical studies, but overall studies of bipolar patientshave found little evidence for improved cognitive performance. Someearly studies about cognitive effects of lithium showed psychomotorslowness and memory deficits. However, small samples as well as thelack of control of clinical variables were the main limitations. On theother hand, valproate and carbamazepine have been associated withsubtle cognitive deficits. Among newer antiepileptic drugs, lamotrigineand gabapentin have shown a better cognitive profile in bipolarpatients, whereas topiramate has a more negative cognitive profilecompared to other anticonvulsants. Further studies are required todetermine whether cognition may be enhanced by lithium and anticonvulsantsin bipolar patients. The number of drugs and doses aswell as subjective complaints may be also important factors to be controlled.The evaluation of cognitive functioning should be integratedwithin clinical assessment of these patients as a routine to help theclinicial in medication regimen decision.IS29.4.EFFECTS OF HYPNOTICS ON COGNITIVEFUNCTIONSC.R. Soldatos, D.G. DikeosDepartment of Psychiatry, University Medical School, Athens,GreeceCarry-over residual effects of hypnotic drugs are among the importantside effects of this class of pharmaceutic agents, usually taking theform of memory deficits and/or reduced psychomotor and cognitiveperformance. As a result, daytime functioning after a night of hypnoticuse might be impaired which could lead to traffic accidents, fall andhip fractures, other accidents as well as feelings of sedation and cognitivedifficulties which impair quality of life. The use of the olderbenzodiazepine hypnotics, which were characterized by long halflives,was particularly associated with carry-over effects during theday. The shorter acting benzodiazepines which were subsequentlydeveloped did not have such a propensity to cause residual effects,but their use was associated with sometimes severe memory deficitsand impaired cognitive functioning, particularly for the time period oftheir high plasma concentration. These side effects seem to be associatedto the half-life of the hypnotics, other pharmacokinetic factorssuch as the time they need to reach their highest concentration, aswell as to pharmacodynamic characteristics relating to their bindingaffinity and binding site on the GABA receptor complex and otherreceptors. The newer benzodiazepine-like hypnotics, which havebeen more recently developed, seem to be less prone than the olderdrugs to cause significant cognitive side effects.IS30.“DIFFICULT” CHILDREN AND ADOLESCENTS:UNDERDIAGNOSIS AND OVERDIAGNOSISOF MENTAL DISORDER AND RELEVANTTREATMENT ISSUESIS30.1.THE DIFFICULT CHILDJ.K. BuitelaarDepartment of Psychiatry, Nijmegen, The NetherlandsThe difficult child is not a specific categorical diagnosis but a clinicalnotion indicating a child who has clear signs of impaired functioning,various types of symptoms, and is difficult to manage in the treatmentsetting. Among the different types of difficult children that can be discernedare those with multiple psychiatric comorbidities, with somaticcomorbidities, with multiple environmental risk factors, with complicatedfamily systems, with a long history of unsuccessful priortreatments, and with a complicated temperament. In line with thenotion that a difficult child escapes a one-dimensional definition isthe fact that simple and straitforward therapeutic solutions usually donot exist. However, several general principles may be outlined thatconstitute a framework that is a precondition for ultimate therapeuticprogress. The principles are: establish a solid working alliance withthe parents and the child; give hope; build on (hidden) strengths, useprotective factors, be patient, do not force, press or manipulate, andbe consistent.IS30.2.AN INTEGRATIVE-DYNAMIC MODELOF THE DIFFICULT CHILDI. ManorGeha Psychiatric Hospital, Petach-Tikvah, IsraelUnderstanding the phenomenon called the “difficult child” is basedon our perception of three major components: integration among personalitycomponents, interaction between the child and the environment,the dynamic of these processes. In our view, alongside the integrationof the three axes, there is an additional important component:the time continuum. Since development is dynamic, the child progressivelychanges from one point in time to another. This stems fromtwo reasons: the biological clock and the fact that disorders existingat a certain age are likely to appear totally different at another pointin time, again due to changes in the interactions they create betweenthe child and conditions and situations that develop, causing a mechanismof transactional duality. To all intents and purposes, therapyconstitutes an additional factor, which creates different interactions,biological, as well as psychological and social.38 World Psychiatry 3:S1 - October 2004

IS30.3.PARENTS AND TEACHERS AS TREATMENTPARTNERS: SCHOOL- AND COMMUNITY-BASEDPSYCHOEDUCATIONAL INTERVENTIONS FORDIFFICULT CHILDRENY. YazganMarmara University Faculty of Medicine, Istanbul, Turkey;Yale Child Study Center, New Haven, CT, USAAmong “difficult” children, those with attention-deficit/hyperactivitydisorder (ADHD) accompanied or complicated by a conduct disorder(CD)/oppositional defiant disorder (ODD) or a mood disorder areoften unresponsive to pharmachotherapy alone. Helplessness amongparents and teachers as well as children themselves is the commonexperiential feature in these conditions, so that empowering parentsand teachers via psychoeducational strategies is a first-step intervention.We also found general public education as a strengthening factorfor helping difficult children and their families and teachers. Psychoeducationis based on an understanding of the condition (explanation),the pharmacological rationale (mechanism, limits and targetsof treatment), and “what to do”. We transformed our experience ofutilizing community based approaches with large populations affectedby natural disasters into the area of “ADHD plus ....” conditions.These difficult conditions included mainly CD/ODD, traumatic stressand mood disturbance added on ADHD. The intervention proved tobe effective in decreasing disruptive and difficult behavior amongchildren with traumatic stress. The structured psychoeducational programsbased on the principle of empowering teachers and parentsshould be an essential complement of psychopharmacotherapyoffered to “difficult” children.IS30.4.PEDIATRIC MANIA ORATTENTION-DEFICIT/HYPERACTIVITY DISORDER?J. BiedermanHarvard University School of Medicine, Boston, MA, USADespite ongoing controversy, the view that pediatric mania is rare ornon-existent has been increasingly challenged not only by casereports but also by systematic research. This research strongly suggeststhat pediatric mania may not be rare but that it may be difficultto diagnose. Since children with mania are likely to become adultswith bipolar disorder, the recognition and characterization of childhood-onsetmania may help identify a meaningful developmentalsubtype of bipolar disorder worthy of further investigation. The majordifficulties that complicate the diagnosis of pediatric mania includeits complex pattern of comorbidity, that may be unique by adult standards,especially its overlap with attention-deficit/hyperactivity disorderand conduct disorder, and its response to treatment, that is atypicalby adult standards.IS31.GENDER-RELATED ISSUES IN PSYCHIATRICTREATMENTSIS31.1.ADVERSE EFFECTS OF ELEVATED PROLACTINLEVELS IN WOMEN RECEIVING PSYCHOTROPICDRUGSM. Rondón 1,2 , P. Allende 21 Hospital E. Rebagliati; 2 Universidad Peruana C. Heredia, Lima,PeruTypical and atypical antipsychotics, as well as antidepressants, stimulatethe secretion of prolactin from the pituitary. This is not surprising,as dopamine is the main neurotransmitter controlling prolactin secretion,mainly via D2 receptors located on lactotrophs. Female patientsare especially sensitive to this effect, since pre-standing hypo-estrogenismhas been postulated in schizophrenic women and the mooddampeningeffects of prolactin are particularly unwanted in depressivepatients, who are mostly female. This presentation will reviewcurrent literature on hyperprolactinemia and its implications forwomen receiving psychopharmacological agents. Prolactin elevationis underdiagnosed but can have serious short-term and long-term consequences.These result from the direct effect of prolactin on target tissuesor from the indirect effects of decreased gonadal hormones.Short-term problems include menstrual irregularities, sexual dysfunction,and depression. Long-term problems related to prolactin elevationinclude decreased bone density and osteoporosis, relapse of psychosisbecause of poor compliance due to sexual dysfunction ordepression, and perhaps cancer. Although hyperprolactinemia is presentin more than half the population of children and adolescentsreceiving antipsychotic treatment, its long-term effects in this population,including pubertal maturation and bone density, are unknown.Several authors have found an increased incidence of depression,anxiety and hostility in female patients with hyperprolactinemia. Postpartumpatients matched for prolactin levels with hyperprolactinemicwomen showed about the same levels of hostility.IS31.2.GENDER AND PSYCHOTHERAPYC.C. Nadelson, M.T. NotmanHarvard Medical School, Boston, MA, USAGender is an important variable in psychiatric treatment. It can influencethe patient’s choice of therapist, the ‘fit’ between therapist andpatient, and the sequence and content of the clinical material presented.It also affects the diagnosis, treatment selection, length oftreatment, and even the outcome of therapy. These issues will be thefocus of our presentation. We will also examine developmental andlife experiences, gender differences in personality styles, and theeffects of stereotypes and values on psychotherapy.IS31.3.IS THERE A ROLE FOR SEX HORMONESIN THE TREATMENT OF PSYCHIATRIC ILLNESSIN WOMEN?D.E. StewartUniversity Health Network, Toronto, CanadaAlthough rates of depression and anxiety in girls and boys are equal,they double in women within a year of puberty and begin to decreaseonly after menopause. This raises interesting questions about the role39

of gonadal steroids in the etiology and treatment of psychiatric disordersin women. The published evidence to date shows that estradiolmay alleviate postnatal depression in some women. However, evidencefor its use as prophylaxis is tenuous. The role of estradiol intreating mood disorders in perimenopause as monotherapy or as anaugmentation agent is controversial. Estradiol is also being investigatedas treatment for psychosis in perimenopausal and menopausalwomen. Selective estrogen receptor modulators (SERMs), androgensand dehydroepiandrosterone are also undergoing active investigationas treatments in women with mood disorders. Progestins, in contrast,have a mood dampening effect in some women. This presentationwill summarize the evidence for and against the use of sex hormonesfor the treatment of psychiatric illness in women. The evidence will beevaluated in light of recent large US and UK trials of estrogen for theprevention and treatment of medical conditions and the potentiallyserious adverse risks described.IS31.4.TREATMENT OF LIFECYCLE RELATEDDYSPHORIAS IN WOMENU. HalbreichDepartment of Psychiatry,State University of New York at Buffalo, New York, NY,USAThe prevalence and 12-month incidence of affective disorders inwomen is double than that of men. This sex difference starts at adolescence,and is persistent during reproductive age and probably alsoduring menopause. During reproductive age women are more vulnerableto depressions and anxieties during periods of hormonal instability.These periods include the post partum, perimenstrual and perimenopauseperiods. It is suggested that the hormonal fluctuationsduring these periods trigger dysregulation of brain processes that maycause symptoms in vulnerable women. Therefore treatment may beaimed at the trigger (the hormonal changes) or the brain processes(mostly neurotransmitters that are putatively involved in regulation ofmood, behavior and cognition). Targeted psychosocial interventionshave been developed as well. Currently available treatment modalitiesinclude a) selective serotonin reuptake inhibitors (SSRIs), whichare efficacious for treatment of dysphorias during the three periods infocus; b) suppression of ovulation, for treatment of premenstrual dysphoricdisorder and c) continuous estradiol, for perimenopause dysphorias.Several other hormonal interventions are in developmentalstages.IS32.NEW STRATEGIES FOR THE CAREOF THE MENTALLY RETARDEDIS32.1.ASSESSMENT, DIAGNOSIS AND TREATMENTOF SCHIZOPHRENIA SPECTRUM DISORDERSIN PEOPLE WITH INTELLECTUAL DISABILITIESN. BourasInstitute of Psychiatry, London, UKThere has been a transformation in the care of people with intellectualdisability over the last 40 years, including different terminology.The most important changes include the movement towards integration,participation and choice for people with intellectual disability asa facet of larger disability, civil, and human rights movements internationallyand within nations. Advances in a number of fields anddisciplines, including genetics, psychopharmacology, developmentalneuropsychiatry, psychology, and education have also shown promisesfor improving the treatment and lives of people with intellectual disability.Historically, people with intellectual disabilities were seen asbeing incapable of suffering from a mental illness. More recent epidemiologicalstudies, however, consistently refute this, showing thatpeople with mild intellectual disabilities have a higher frequency ofmental health problems than the general population. In particular,people with intellectual disabilities are at higher risk of developingschizophrenia-spectrum psychoses than other disorders. However,there is a paucity of research evidence into clinical presentation of thedisorder in comparison with research into schizophrenia spectrumpsychoses in people without intellectual disabilities. The results fromrecent evidence-based research on the risk factors of receiving a diagnosisof schizophrenia spectrum psychosis, symptomatology in peoplewith and without intellectual disabilities and treatment with atypicalantipsychotic medication will be presented.IS32.2.USEFULNESS OF THE DESCRIPTION ANDEVALUATION OF SERVICES FOR DISABILITIES(DESDE) FOR MAPPING AND PLANNING SERVICESFOR INTELLECTUAL DISABILITIES IN SPAINL. Salvador-CarullaDepartment of Psychiatry, University of Cadiz, SpainIn the recent years considerable efforts have been made to assessregional and national differences in organisation, planning, and availabilityof services for intellectual disabilities (ID) in Europe. However,there is an urgent need for a tool for the standard description andclassification of services that can be used at the international leveland allow national and international comparisons on service availabilityand utilisation. The Description and Evaluation of Services forDisabilities (DESDE) is a service mapping tool based on the EuropeanService Mapping Schedule (ESMS), which is widely used inmental health service research in Europe. This tool has been developedin cooperation with the Spanish Institute of Social Services(IMSERSO), through a focus group process. Feasibility, reliabilityand descriptive validity have been already tested. ID services of Cadiz(Southern Spain) have been mapped and the information providedhas been used for health policy planning. A full understanding ofregional differences in treatment patterns cannot probably be attainedwithout standard information on service provision and utilisation atthe small health area level.IS32.3.PSYCHIATRIC SERVICES FOR PEOPLE WITHMENTAL RETARDATION. THE HONG KONGEXPERIENCEH. KwokPsychiatric Unit for Learning Disabilities, Kwai Chung Hospital,Hong Kong, ChinaIn recent years, a debate has been ongoing on the most appropriatemodel of mental health care for people with mental retardation. Inaddressing this issue, local differences in economy, culture, healthcare system and other social factors need to be taken into account.With the wider promotion and acceptance of the concepts of normalizationand anti-discrimination, the mental health needs of peoplewith mental retardation are increasingly being recognized in HongKong. Instead of generic psychiatric services, specialized units areestablished to provide psychiatric care to this group of patients with40 World Psychiatry 3:S1 - October 2004

complex needs. These units are hospital-based with a significant inpatientcomponent for both acute care and longer term rehabilitation. Afew beds are also reserved for respite care as people with challengingbehaviours or mental illness often face difficulties in finding a suitablerespite in centers run by social services. On the other hand, there isalso an equally important community component consisting of outpatientclinics, community partnership clinics (CPC) and outreachservices. These units have a multidisciplinary team. All memberswork closely and meet frequently. Treatment strategies include behaviouraltherapy, psychotherapy and medications. Occupational therapyand physiotherapy are readily available. In addition, complementarytherapies such as sensory stimulation, music therapy and art therapymay be provided according to each individual’s care plan. Theoutcome is an overall improvement in the quality of care. An increasingnumber of long stay hospital patients are being discharged andpatients are better supported in the community setting. However,quality assurance programmes should be implemented for more systematicevaluation of this service model and to address the changingservice needs.IS32.4.THERAPEUTIC INTERVENTIONS IN THEMANAGEMENT OF MENTAL DISORDERSASSOCIATED WITH THE AUTISTIC SPECTRUMG. HoltYork Clinic, Estia Centre, South London and Maudsley NHSTrust, London, UKPeople with autistic spectrum disorders are vulnerable to the developmentof mental health problems. Reasons for this association willbe reviewed together with interventions aimed at maintaining mentalhealth and treating mental illness when it occurs. Current treatmentusually is multidisciplinary, involving collaboration between the individual,family, carers and the professionals involved. It may incorporatespecial education, behavioural management, social and communicationskills training psychological interventions and medicationwhen indicated. The evidence-base of these will be considered.IS33.EPIDEMIOLOGY AND PREVENTION OF SUICIDEIS33.1.SUICIDE PREVENTION: KEY ISSUES FORNATIONAL STRATEGIES AND PROGRAMMESJ.M. BertoloteDepartment of Mental Health and Substance Abuse,World Health Organization, Geneva, SwitzerlandBehind the great lines chosen for suicide prevention programmes,there are a few key issues that not always receive the necessary attentionfor their evaluation, among which there are: a) the clear identificationof specific objectives, target event (i.e. completed or attemptedsuicide) and target populations, for each intervention; b) the preciseand adequate selection of indicators; c) the due consideration of timetrends of suicide rates, before the implementation of the programme.The importance of these issues will be discussed and illustrated withconcrete examples, in order to both highlight the pitfalls these programmescould face and improve their cost-effectiveness and impact.IS33.2.SUICIDE PREVENTIVE STRATEGIES:FROM HEALTHCARE SERVICES TO THE GENERALPOPULATIOND. WassermanSwedish National and Stockholm County Centre for SuicideResearch and Prevention of Mental Ill-Health, National Institutefor Psychosocial Medicine/Karolinska Institute, Stockholm,SwedenApproximately one million people commit suicide each year in theworld. According to World Health Organization’s estimates, 1,53 millionpeople will die from suicide in the year 2020 and 10-20 timesmore will attempt suicide worldwide. There is a clear trend ofincreased suicide rates with age. An average global suicide rate formen is 25 suicides per 100 000 per year; for women the correspondingfigure is 7 per 100 000 per year. In suicide prevention, strategies canbe directed at the general population or the healthcare services. Sincesuicide risk is high among psychiatric patients, adequate treatment ofpsychiatric disorders and improved detection of psychiatric illnessesin the general population are essential. Suicide-preventive effects oftreatment with antidepressants, lithium, neuroleptics, dialecticalbehavioural therapy and cognitive behavioural therapy to date areencouraging. Suicide risk is particularly high among psychiatricpatients in the immediate aftermath of their discharge from hospital.Careful follow-up and rehabilitation plans should therefore be providedto help patients adjust to their new life situation. Some patientsneed long-term treatment - in chronic cases for several years. Moreover,psychiatric patients should be informed and prepared to seekhelp when new stressful events come to a head and their coping abilityonce more deteriorates when facing difficulties in new circumstances.In future suicide-preventive work, the emphasis needs toshift to an earlier stage of the suicidal process. A public-healthapproach, involving a change in attitudes towards the mentally ill,and also programmes aimed at disseminating knowledge of healthpromotingmeasures, are important. Population-oriented suicide preventionfocuses on building up supportive networks and strengtheningthe coping skills that enable people to deal with difficult life circumstances.Perestroika in the former USSR was history’s most effectivesuicide-preventive programme for men. Strict limitations wereimposed on the sale of alcohol, and a new discouraging attitudetowards alcohol consumption was actively promoted. Some examplesof suicide prevention in schools and of population-oriented suicideprevention - including environmental measures, such as restriction ofaccess to dangerous means of committing suicide - will be given. Variouspsychiatric treatments have had very well-documented effects insuicide prevention. Nonetheless, for maximum overall impact, it isadvisable for a public-health approach to go hand in hand with ahealthcare approach.IS33.3.FATAL AND NON-FATAL REPETITIONOF SELF-HARM: LINKS IN THE CHAIN OF EVENTSD. OwensAcademic Unit of Psychiatry, School of Medicine,University of Leeds, UKThere is clear evidence that around a quarter of suicides are precededby non-fatal self-harm in the previous year, making self-harm themajor risk factor for suicide. Recently, health departments in manycountries and the World Health Organization (WHO) have embarkedon unprecedented suicide-reduction programmes. There cannot be a41

etter time to stress the connection between suicide and earlier hospitalattendance due to self-harm, so often overlooked. I will reportbriefly the findings of our recent systematic review of the internationalliterature that quantifies the two most important outcomes afterself-harm: establishing the connection between self-harm and suicide,and providing robust estimates of non-fatal repetition rates.These figures are needed for power calculations in the planning ofbetter intervention studies for those who have harmed themselves –where our current evidence is shown, by the Cochrane systematicreview of interventions following self-harm, to be very weak. I willalso describe the findings from our current 16-year follow-up study ofmortality after an attendance at hospital due to non-fatal self-poisoning.I will set out rates of subsequent suicide and our exploration forfactors predictive of suicide. Finally, I will describe our recently publishedretrospective study of completed suicides, which identifiedmany attendances at accident and emergency units due to non-fatalself-harm, shortly before suicide. The findings point to a pressingneed for accident and emergency departments, when dealing withnon-fatal self-harm, to work more closely with mental health servicesthan they do at present.IS33.4.SUICIDE BEHAVIOR IN THE GENERAL POPULATIONIN BRAZILN.J. Botega, M.B.A. Barros, H. BoscoFaculty of Medical Sciences, University of Campinas, BrazilCampinas, the Brazilian site of the World Health Organization(WHO) Multisite Intervention Study of Suicide Behavior (SUPRE-MISS) is located in the most populous and industrialized region ofthe country, 90 Km far from São Paulo. The city has 1 million inhabitants,98% of whom are in the urban area. Suicide rates are around 4per 100,000 per year. There was no data about suicide ideation, planor attempt in the general population. The sample surveyed 516 randomlyselected subjects aged 14 years or more. Questions aboutsociodemographics, medical history and suicide behavior as well aspsychometric instruments were used in the interview. There were just16 (3.7%) refusals to participate. The life prevalence estimates in thegeneral population were 17.1% (95% CI: 12.9 – 21.2) for suicideideation, 4.8% (95%CI: 2.8 – 6.8) for suicidal plans and 2.8% (95%CI: 0.09 – 4.6) for suicide attempts. Suicide ideas were more frequentamong women (20.6 vs. 13.3, p = 0.02) and young adults (20-39 yrsold) and seemed not to be affected by marital and occupational status,level of education and religion. Suicidal behavior (suicide ideas,plans and attempts) was higher among those who were or had beenon psychiatric treatment. Among every 17 inhabitants who hadalready “seriously thought about committing suicide”, 3 “made a seriousattempt” and only one required medical attention at an emergencydepartment for it. This was the first national survey about suicidebehavior based on general population information. This is essentialto collect information on the “submerged part of the iceberg” inthe field of suicide.IS34.MANAGEMENT OF MENTAL DISORDERSIN OLD AGEIS34.1.MULTIDISCIPLINARY, INTERDISCIPLINARYAND TRANSDISCIPLINARY MANAGEMENT STYLESIN OLD AGE PSYCHIATRYE. ChiuAcademic Unit for Psychiatry of Old Age,University of Melbourne, AustraliaThe development of old age psychiatry in the past four decades hasestablished this discipline within psychiatry to have some definingcharacteristics. From the traditional multidisciplinary style withingeneral psychiatry practice, old age psychiatrists have moved to interdisciplinarypractice and, in recognition that some countries do nothave the many health care disciplines enjoyed by the economicallyadvantaged world, advocated for a transdisciplinary approach. Thispaper will address the concept and practice of multidisciplinary,interdisciplinary and transdisciplinary styles as applied to a variety ofold age psychiatry environments. This discussion will include theconcept of personhood and holism in the management of older personswith mental disorders and how it may be integrated into the styleof management in old age psychiatry.IS34.2.PSYCHOLOGICAL AND PSYCHOSOCIALMANAGEMENT OF MENTAL DISORDERSIN OLD AGEV. CamusClinique Psychiatrique Universitaire, Centre Hospitalier RégionalUniversitaire, Tours, FranceThere are several reasons that can explain the increasing interest inthe non-pharmacological management of mental disorders in old age.In many cases, the pharmacological treatment alone is not enough toobtain a complete remission of symptoms and, in the elderly, is associatedwith a higher risk of potentially severe side effects. Consequently,accompanying psychological interventions are needed toobtain a better compliance to the pharmacological management, andto achieve a more complete improvement in perceived well-being andquality of life. Moreover, there is no conceptual reason to believe thatpsychotherapeutic techniques that have shown some efficacy inadulthood could not be effective in the elderly. In fact, there are someevidence-based data that have demonstrated a good efficacy of cognitiveand behavioural therapies, as well as interpersonal therapy, systemicinterventions and rehabilitation techniques, in a wide range ofmental disorders affecting elderly patients. Finally, according to thegreat importance of family and relatives in care giving, as well as themajor impact of community and social support, psychosocial interventionshave been successfully trialled in mentally ill and disabledelderly patients. The presentation will illustrate this improvement inthe non-pharmacological approach to mental disorders in old age, bysummarizing recent evidence based data on psychological and psychosocialinterventions in depression, dementia and late-life psychosis.42 World Psychiatry 3:S1 - October 2004

IS34.3.SYSTEMATIC REVIEW OF PSYCHOLOGICALAPPROACHES TO THE MANAGEMENT OFNEUROPSYCHIATRIC SYMPTOMS OF DEMENTIAC. Katona 1 , G. Livingston 2 , K. Johnson 2 , J. Paton 21 Kent Institute of Medicine and Health Sciences,University of Kent; 2 Department of Mental Health Sciences,University College of London, UKThe neuropsychiatric symptoms of dementia are common. Studieshave found an average prevalence of 61% in people with dementia inthe community, with one third having clinically significant symptomsat any one time. This rises to about 80% of people with dementia livingin 24 hour care settings. Neuropsychiatric symptoms are a majorfactor in caregiver burden and institutionalisation of people withdementia. Psychotropic medications are often given to manage thesesymptoms, but there are concerns about their safety and efficacy inthis group of people who are often particularly frail. Psychologicalapproaches are likely to have fewer side effects and be more acceptable,but there are a large variety of approaches and some may not beefficacious. This systematic review has been completed by the OldAge Taskforce of the World Federation of Societies of Biological Psychiatry.It includes any therapy which was derived from a psychologicalor psychosocial model. It aims to help clinicians to make evidence-basedrecommendations for psychological treatment.IS34.4.THE PRACTICALITIES OF MANAGEMENT IN CAREHOMES: A UK PERSPECTIVEN. GrahamRoyal Free Hospital, London, UKAdvances in the prevention and treatment of disease mean that mostpeople will live longer and can expect to be healthy in later life. However,a number of older people do develop physical and mental healthproblems. The likelihood that this will happen increases as people getolder especially as they get into their 80s and 90s. Most older peoplewith these problems remain in their own home, but a small number arealways going to need nursing care, either because they have no relativesable to look after them, or because relatives are simply elderlyand exhausted themselves. The wish by older people themselves tostay at home as long as possible and the wish by governments toencourage this means that the population in care homes has becomevery old indeed – average age around 90 years. People now beingadmitted to care home will have a number of chronic health and socialproblems. Around 4/5 people will have a dementia, the factor whichoften finally precipitates admission. This situation is very different tothe one that existed more than half a century ago, when people choseto retire and enjoy life in residential homes. Although we do not knowwhat causes dementia or how to cure it, we do know much more aboutearly detection, assessment and diagnosis. We know the factors in theenvironment that make the management of people with mental healthproblems a great deal easier, such as good light, safe space to wanderaround in, a routine to the day, trained caring staff and group activities.Individual care, good nutrition, and attendance to physical health allcontribute to the better quality of life both for the person with theproblems and for the families and staff who look after them. There isurgent need for a radical change in philosophy of care and staffingstructures in homes throughout this country as well as worldwide if weare to deliver an acceptable quality of life to residents in care homes.This presentation will make recommendations on how to make thesechanges based on experience and research evidence.IS35.THE CURRENT MANAGEMENT OF PANICDISORDER AND GENERALIZED ANXIETYDISORDERIS35.1.TREATMENT OF PANIC AND ANXIETY:WHAT OR HOW?C. FaravelliDepartment of Neurology and Psychiatry,University Medical School, Florence, ItalyA variety of treatments have been proven to be effective in panic disorder(PD). These include pharmacological and non-pharmacologicalinterventions. Among psychotropic drugs, monoamine oxidaseinhibitors, tricyclic antidepressants, serotonin reuptake inhibitors,other newer antidepressants, benzodiazepines, but also anticonvulsants,beta-blockers, calcium antagonists, inositol, clozapine, olanzapinehave given at least some evidence of efficacy. This notwithstanding,the long term outcome of PD remains poor, with high levels ofchronicity, impairment and disabling sequelae being commonlyreported. This may be explained with the fact that the adherence totreatment on the part of the subjects suffering from PD is one of theworst in all the panorama of psychiatric disorders. Several reasonsmay account for this: cultural orientations, unrealistic expectations,hypersensitivity to side effects, drug phobia, phobia of being phobic,cinestophobia, and others. It is speculated that the way a treatment isconveyed to the patient is at least as important as the type of drug.IS35.2.DRUG TREATMENT FOR PANIC DISORDER ANDGENERALIZED ANXIETY DISORDER: AN UPDATEB. BandelowDepartment of Psychiatry, University of Göttingen, GermanyTreatment of panic disorder and generalized anxiety disorder with anumber of pharmacological agents has been established as efficaciousin the short and long term. These include selective serotonin reuptakeinhibitors (SSRI), selective noradrenaline reuptake inhibitors (SNRI),tricyclic antidepressants, benzodiazepines, and monoamine oxidaseinhibitors. Pregabalin, a novel compound under development for thetreatment of anxiety disorders, may also be an option. This drug actson the alpha2 subunit of the voltage-dependent calcium channels. Asubstantial number of patients with panic disorder and agoraphobiamay remain symptomatic after standard treatment. Non-response todrug treatment could be defined as a failure to achieve a 50% reductionon a standard rating scale after a minimum of 6 weeks of treatmentin adequate dose. When initial treatments have failed, the medicationshould be changed to other standard treatments. In a next step,drugs should be used that have shown promising results in preliminarystudies. Combination treatments may be used, such as the combinationof an SSRI and a benzodiazepine. A treatment algorithm for unresponsivepatients will be provided. Psychological treatments such ascognitive behavior therapy have to be considered in all patients,regardless whether they are nonresponders or not. According to existingstudies, a combination of pharmacological treatment with cognitive-behaviourtherapy can be recommended.43

IS35.3.FOR HOW LONG SHOULD WE TREAT PANICDISORDER WITH PHARMACOTHERAPY?H. Katschnig, P. BergerDepartment of General Psychiatry, University of Vienna, AustriaAccording to long-term follow-up studies, the course of panic disorderis varied. Around 30% of the patients seem to run a chronicunremitting course, around 20% have single episodes of panic disorderrunning for several weeks or months with full remission, andevery second patient has an intermediate course with episodes notcompletely remitting or coming again. It is difficult to predict towhich group a specific patient belongs and such predictors would benecessary in order to determine the length of pharmacological treatment.Selective serotonin reuptake inhibitors (SSRIs) and some highpotency benzodiazepines have proven to be effective in treating panicdisorder. Since benzodiazepines are problematic in the long-termtreatment – they lead to withdrawal syndromes and possible dependency– the SSRIs are the pharmacological treatment of choice for thelong-term treatment of panic disorder. Studies with placebo-controlledcontinuation of drug treatment in patients who had respondedto acute treatment consistently show an advantage of the continuationof the drug for at least one year. However, a small size studyfound that the rate of relapse after discontinuation of six months oftreatment with imipramine was identical to the rate of relapse after 12to 30 months of treatment. This suggests a prophylactic effect but nota specific curative effect of long-term drug treatment and the problemof relapse prevails even after long-term treatment. Furthermore, about20% of the patients may not need long-term treatment if acute treatmenthad resulted in full remission for years. Thus, clinical predictorsfor early relapse after acute treatment would be helpful in the decisionof the need for further treatment. The studies on this issue are equivocal:some could not find any predictors for relapse, and others suggestthat more depressive symptoms at baseline and more phobicavoidance are predictive for relapse. In our own study we found thatthe comorbidity of other anxiety disorders predicts rapid relapse.Another issue is the combination of drug and cognitive-behaviouraltreatment. The combination of such treatments can reduce the rate ofrelapse in panic disorder compared to drug treatment alone and thusmay reduce the need for long-term treatment with pharmacotherapy.In conclusion, up to date there is no clear evidence from studies onthe necessary duration of treatment for panic disorder. In the absenceof definite knowledge about the pathophysiology of panic disorderand a treatment founded on that rationale, we can choose only apragmatic approach founded on research on the course of the disorderand possible predictors for rapid relapse. Based on the limitedknowledge on this issue, we suggest that the drug treatment of a firstepisode of panic disorder should be continued for one year after fullremission of symptoms. If relapse occurs rapidly, e.g. within one yearafter discontinuation of the initial medication, another trial with theprevious medication should be started and continued for severalyears. In the case of a remission for years, treatment limited to theepisodes might be sufficient. The addition of cognitive therapy or, incase of agoraphobia, exposure therapy until full remission may reducerelapse and thus the need for long-term medication. Further studieson predictors for relapse and controlled studies with different durationsof treatment and subsequent follow-up are needed to give amore accurate estimate on how long to treat panic disorder.IS35.4.THE PSYCHOTHERAPEUTIC TREATMENTOF ANXIETY DISORDERSG.A. Fava, L. Mangelli, S. Fabbri, C. BelaiseAffective Disorders Program, Department of Psychology,University of Bologna, ItalyA large body of evidence suggests that psychotherapeutic approachesare effective in the treatment of anxiety disorders. In most of the casesthese approaches could be subsumed under the rubric of cognitivebehavioral therapy. There are striking differences between the sustainedrecovery which can be obtained with cognitive behavioral strategiesand the high likelihood of relapse when drug treatment is discontinued.The combination of psychotherapy and pharmacotherapy hasbeen advocated for obtaining a more sustained and complete recoveryin anxiety disorders. The data, however, are rather conflicting. Severalstudies point to the fact that use of psychotropic drugs may result inshort term benefits, but may be detrimental in the long term.IS36.THE MANAGEMENT OF NON-SCHIZOPHRENICPSYCHOTIC DISORDERSIS36.1.OVERVIEW ON THE DIAGNOSTIC AND TREATMENTSPECTRUM OF NON-SCHIZOPHRENIC PSYCHOTICDISORDERSW. GaebelDepartment of Psychiatry, Heinrich-Heine-University, Düsseldorf,GermanyPsychotic symptoms can occur in the course of many mental disorders,but usually not as a defining feature. Psychotic disorders are aheterogeneous group of disorders of which schizophrenia is the mostimportant one. The occurrence of psychotic symptoms is nosologicallyunspecific, but indicates a dysfunction of underlying neuronal circuitsbeing involved in different disorders with varying etiologies andpathogenetic mechanisms. Non-schizophrenic psychotic disorders,which are distinguished from schizophrenia on the basis of the kindand duration of symptomatology, cover conditions such as schizophreniformdisorder, schizoaffective disorder, delusional disorder,brief psychotic disorder, shared psychotic disorder, and psychotic disordernot otherwise specified. They have to be differentiated in particularfrom psychotic disorder due to a medical condition or substance-inducedpsychotic disorder. DSM-IV provides decision treesfor differential diagnosis of the various kinds of psychotic disorders.Treatment recommendations for non-schizophrenic psychotic disordersare generally not at variance with those for schizophrenia,although an empirical evidence base is still lacking for most of theseconditions. The present paper will report on available practice guidelinesand their respective quality standards.IS36.2.MANAGEMENT OF SCHIZOAFFECTIVEAND OTHER NON-SCHIZOPHRENIC PSYCHOSESS. KasperDepartment of General Psychiatry, Medical University of Vienna,AustriaSchizoaffective and other non-schizophrenic psychoses need to bedifferentiated from schizophrenia from a treatment viewpoint.44 World Psychiatry 3:S1 - October 2004

Patients suffering from schizoaffective psychoses have a better outcomethan those with schizophrenia when treated with atypicalantipsychotics, which could give the hint that monotherapy with anatypical antipsychotic is effective. However, there is a lack of data tojustify this in everyday clinical practice, and the addition of a moodstabilizer is often needed. Other non-schizophrenic psychosesinclude psychotic depression as well as organic brain disorders. Forthe treatment of psychotic depression, it has been demonstrated inrecent trials that the addition of an atypical antipsychotic to a selectiveserotonin reuptake inhibitor (SSRI) is effective. For the treatmentof organic psychoses, it is of utmost importance not to include treatmentregimens which have intrinsic anticholinergic properties or arein need of adding anticholinergic medication for the management ofextrapyramidal symptoms. Lower doses of atypical antipsychoticshave been proposed in pilot studies for the latter indication. Giventhe better tolerability and specifically the lack of anticholinergic sideeffects and a dose-dependent lack of extrapyramidal side effects, atypicalantipsychotics seem to be specifically beneficial for the managementof schizoaffective and other non-schizophrenic psychoses.IS36.3.ASSESSMENT AND MANAGEMENT OF SECONDARYSCHIZOPHRENIASS. LewisUniversity of Manchester, UKSo-called secondary schizophrenias can be divided into schizophrenia-likepsychoses secondary to systemic physical disease and psychoseswhich arise secondary to intracranial lesions. Imaging studiessuggest that the prevalence of the latter type is probably about 5% ofcases of schizophrenia, although the impact on management is notusually significant. In first episode schizophrenia, full neurologicalexamination is essential. Standardised rating scales such as the Positiveand Negative Syndrome Scale will aid clinically the assessment ofsymptoms which are suggestive in some cases of underlying organicdisease, such as visual hallucinations. The exclusion of underlyingphysical disease is important and routine investigations shouldinclude thyroid and liver function, plasma calcium, electroencephalogramand computed tomography or magnetic resonance scan.In addition, baseline assessments such as electrocardiogram andlipids are recommended in the light of known effects of drug treatment.IS36.4.MANAGEMENT OF SYMPTOMATIC PSYCHOSES(INCLUDING SUBSTANCE ABUSE) ANDPSYCHOSES DUE TO NEUROPSYCHIATRICSYNDROMESF. Müller-SpahnDepartment of Psychiatry, University of Basel, SwitzerlandOrganic psychotic disorders have to be distinguished from schizophreniaby means of history, psychopathology, physical examinationor laboratory tests of a specific organic factor that is judged to be etiologicallyrelated to the disturbance. They cover conditions such asdelirium, organic delusional syndrome, organic hallucinosis, andorganic personality syndrome, relating to a brain disorder, a medicalcondition or a substance-induced disorder. DSM-IV provides decisiontrees for differential diagnosis of the various kinds of organic andnon-organic psychotic disorders. Treatment of organic psychotic disordersprimarily requires treatment of the underlying organicfactor(s). Symptomatic treatment of the psychotic syndrome,although not generally at variance with the antipsychotic treatment ofschizophrenia, requires special consideration of the organic condition.SPECIAL WHO/WPA SYMPOSIASPS1. FROM ADVANCES IN NEUROSCIENCE OFSUBSTANCE USE DISORDERS TO NEW TREATMENTAPPROACHESSPS1.1. FROM NEUROSCIENCE OF SUBSTANCEUSE AND DEPENDENCE TO PUBLIC HEALTHRESPONSESV. Poznyak, I. Obot, M. MonteiroWorld Health Organization, Geneva, SwitzerlandPsychoactive substance use is one of the leading risk factors to health.According to World Health Organization (WHO) estimates, in 2000,tobacco, alcohol and illicit drug use accounted for 12.4% of totalglobal mortality (6.9 million deaths) and 8.9% of the global diseaseburden expressed in Disability Adjusted Life Years (DALYs) (128.6million). Rapid advances in neuroscience open up new possibilitiesfor prevention and treatment of substance use disorders and forreducing the burden associated with substance use and dependence.The report “Neuroscience of Psychoactive Substance Use and Dependence”published by the WHO provides an overview of scientific evidenceon brain mechanisms of substance use and dependence andimplications for public health responses. The report compiles informationon neurobiology, neuroanatomy, psychopharmacology, geneticsas well as biobehavioural processes underlying substance use anddependence. Special chapters address comorbidity and ethical issuesin neuroscience research. The report affirms that substance dependenceis a medical disorder and treatment must be accessible to all inneed. Effective interventions exist and can be integrated into healthsystems. Involvement of primary health care in identification andmanagement of substance use disorders is of particular importancefor adequate public health responses.SPS1.2.THE NEUROSCIENCE OF ADDICTION:IMPLICATIONS FOR TREATMENTF.J. VocciDivision of Treatment Research and Development, NationalInstitute on Drug Abuse, National Institutes of Health, Bethesda,MD, USANeuroscience research has shown that drugs of abuse exert powerfuleffects on motivational, emotional, and cognitive systems in brain. Prolongeduse of drugs of abuse can result in a shift of motivational priorities,Pavlovian conditioning to both internal and external stimuli pairedto drug seeking and drug taking, alteration of stress responses, a weakeningof frontal lobe inhibitory systems and a shift in cognitive templatestowards drug seeking. Thus, appetitive mechanisms are strengthenedtowards drug seeking, while inhibitory systems are weakened,narrowing the cognitive and behavioral repertoire of the addicted individual.Modulation of appetitive processes and stress responses areimplicated as treatment approaches. The neurochemistry underlyingthese processes is being elucidated, yielding potential medications.45

Similarly, the discovery of the chemistry and pharmacology of strengtheningof inhibitory processes is also yielding pharmacological targets.Examples of the potential pharmacotherapies that could modulateappetitive processes and strengthen inhibitory processes will be given.SPS1.3.NEUROSCIENCE MEETS CLINICAL PRACTICE:TOWARDS A RATIONAL TREATMENT OFALCOHOLISMK.F. MannCentral Institute of Mental Health, Mannheim, GermanyChronic alcohol consumption leads to neuroadaptive changes in thecentral nervous system (CNS). While GABAergic transmission isreduced, the glutamatergic system is up-regulated. When alcohol isdiscontinued the imbalance results in a CNS hyperactivity. It is likelythat alcohol cues can induce a similar hyper-excitatory state evenmonths after abstinence and thus trigger relapse. Functional magneticresonance imaging (f-MRI) studies show an activation of cueinduced craving in the nucleus accumbens and frontal cortex whichcorrelates with treatment outcome. Modern pharmacotherapy to preventrelapses in alcoholics is currently based on two extensively testedmedications: acamprosate and naltrexone. Acamprosate acts bybinding to glutamatergic receptors and thus reduces the hyperexcitabilitydescribed above. So far twenty randomized placebo-controlleddouble-blind trials were done worldwide. A meta-analysiscompiles the 16 studies which show a benefit of acamprosate overplacebo plus the 4 studies where no difference could be found. Naltrexoneacts as an µ-opioid receptor antagonist and thus reduces therewarding effects of alcohol. It has been studied in 14 randomizedcontrolled trials in general of only three months duration. The resultsare somewhat less clear-cut than with acamprosate but a majority ofstudies shows a benefit over placebo. In conclusion, on the basis ofneurochemical changes, both acamprosate and naltrexone can significantlyimprove treatment results in alcoholics.SPS1.4.SHORT- AND LONG-TERM STRATEGY TO COMBATAND MANAGE SUBSTANCE USE PROBLEMS: ANEGYPTIAN PERSPECTIVEA. OkashaWHO Collaborating Center for Training and Research, Institute ofPsychiatry, Ain Shams University, Cairo, EgyptA unique short-term and long-term program to combat the use ofnarcotics in Egypt, in collaboration with all those working in thisfield, will be outlined, together with its implementation. The rationalefor not using replacement therapy in Egypt is discussed and the availableprograms, taking cultural and religious factors into consideration,are presented. A paradigm of how to combat and manage narcoticproblems in a developing country with limited resources,achieving the same results as in developed countries with sufficientresources, will be reviewed.SPS2.NOSOLOGICAL VALIDITY AND DIAGNOSTICVALIDITYSPS2.1.HISTORICAL PERSPECTIVES ON NOSOLOGICALAND DIAGNOSTIC VALIDITIESP. HoffUniversity of Zurich, SwitzerlandThis paper outlines three major historical approaches to the conceptof mental disorders: mental illness as a real “natural” object(realistic approach), as a predominantly psychopathological convention(nominalistic approach), and as a result of biographical andother individual factors (biographical approach). The significantimpact of these different pathways on the function of psychiatricdiagnosis and on the conceptualization of psychiatric research willbe discussed.SPS2.2.PHILOSOPHICAL PERSPECTIVES ONNOSOLOGICAL AND DIAGNOSTIC VALIDITIESK.F. SchaffnerGeorge Washington University, Washington, DC, USAIn addition to the four traditional concepts of face, descriptive, predictive,and construct (external) validity, two more philosophicalaspects of nosological validity will be explored in this paper. Thefirst, “clinical” validity, borrows from predictive validity, and alsofrom other components of clinical “utility”, but does not accept thesharp distinction recently urged by Kendell between utility andvalidity. The second, “reductive etiopathogenic” validity, is characterizedas strong integration of disorders with etiological and pathophysiologicalknowledge, anticipated to be based on genetic andneurophysiological mechanisms. It is closely related to a reductionistapproach to construct validity, and may be identical with it undersome interpretations of “realism”. I argue that robust etiopathogenicvalidity is almost certainly a premature goal for the emerging ICD-11and DSM-V nosologies for a variety of reasons. Clinical validity canbe facilitated by evidence-based methodology, though whethernosologies that are clinically valid will prevail as etiopathogenicvalid assessments will only be resolved empirically. The paper concludeswith a discussion of diagnostic validity, against the backdropof the nosological account above. Here the emphasis is on the creativetensions involved in an individualized, empathetic, biopsychosocialapproach to a patient in the context of both clinical andetiopathogenic based nosologies.SPS2.3.CULTURAL PERSPECTIVES ON NOSOLOGICALAND DIAGNOSTIC VALIDITIESL.J. KirmayerDivision of Social and Transcultural Psychiatry, McGillUniversity, Montreal, CanadaAlthough recent years have seen increased attention to culture in psychiatricnosology and diagnosis, important conceptual and practicalproblems remain. This presentation will consider the extent to whichcultural difference can be meaningfully integrated into psychiatricnosology. Current strategies for incorporating culture into nosologywill be reviewed. These include modifications to the textual presentationor clinical application of the diagnostic system (e.g. adding qual-46 World Psychiatry 3:S1 - October 2004

ifying comments or caveats, modifying diagnostic criteria); changes inbasic architecture (e.g. adding new disorders, reorganizing broad categories);and the creation of parallel systems of assessment (e.g. thecultural formulation, relational diagnoses). The merits and drawbacksof each approach will be reviewed along with the sort of evidenceneeded to establish each type of change. Ultimately, success inintegrating culture into nosology depends on taking seriously boththe epistemological dilemmas of cultural research and the pragmaticissues that arise in the diverse clinical and social contexts where psychiatricdiagnosis is applied.SPS2.4.DO GENETIC AND FAMILIAL CORRELATESPROVIDE VALIDITY CRITERIA OF DIAGNOSTICCATEGORIES IN PSYCHIATRY?A. JablenskySchool of Psychiatry and Clinical Neurosciences, University ofWestern Australia, Perth, AustraliaAdvances in molecular biology and genetics have a growing impacton classifications in medicine and neurology, where genetic discoveriesare generating new organising principles for the clustering ofdisorders, such as mitochondrial diseases or disorders due tonucleotide triplet expansion. Although the majority of psychiatricdisorders are genetically far more complex than previously assumed,genetic research is likely to play a role in redefining their boundariesand, to a limited extent, in their diagnosis. At present, this is more ofa promise than actual performance, except for a small number of disorderswith a simpler genetic architecture, including Huntingtondementia, familial Alzheimer disease, Rett syndrome, and several ofthe sleep disorders. However, complementing the current diagnosticcategories with carefully selected potential endophenotype markersand traits should further research aiming at a biologically better validatednosology of the complex psychiatric disorders.SPS2.5.CRITERIA AND MEASUREMENT OF DIAGNOSTICVALIDITY: EPIDEMIOLOGICAL CORRELATESR. KesslerHarvard University, Boston, MA, USAIn the absence of definitive biological data, decisions about criteriaand diagnostic validity hinge largely on the analyses of naturalisticpatterns in phenotypic data and of information regarding differentialtreatment response related to variation in these naturalistic patterns.The current report reviews opportunities for the first of these twotypes of analyses for the development of ICD-11. The presentation isdivided into two parts. The first part briefly reviews available strategiesfor the analysis of naturalistic patterns in phenotypic data. Thispart of the presentation highlights the importance of establishing adata collection system that allows rapid iteration between analysisand targeted collection of new data. The second part of the presentationoutlines a proposal for establishing a data collection system ofthis type for ICD-11 that features the creation of an internet-basedinternational practice network of clinicians who participate in aniterative series of short targeted surveys designed to refine criteria andmeasurement of diagnostic validity.SPS2.6.CRITERIA AND MEASUREMENT OF DIAGNOSTICVALIDITY: DESCRIPTIVE AND THERAPEUTICUSEFULNESSG. MellsopUniversity of Auckland, New ZealandThis paper will review the difference that perspective can make to anapparently value free concept such as validity, in relation to our psychiatricclassificatory systems. The views of pathologists, surgeonsand Humpty Dumpty will be discussed. It will then explore the role oftherapeutic usefulness as a determinant of diagnostic validity. Thepaper will also consider and appraise specific criteria and measures ofnosological and diagnostic validity as they have been proposed in thepast and will offer suggestions for the future.SPS2.7.VALIDITY OF DIAGNOSTIC STRUCTURES:HIERARCHICAL NOSOLOGYC.E. BerganzaSan Carlos University, Guatemala, GuatemalaThe hierarchical organization of the ICD-11 mental health componentis a critical theoretical and clinical challenge, because it concernsthe internal consistency of the classification of mental disorders,and its nosological validity and clinical usefulness. For example,the adequacy of the number of major classes in ICD-10 must bereviewed. The current grouping of 10 two-character major classes tobe divided by 10 three-character categories and so on has shownmore difficulties than the ones it intended to resolve. Human mentalmorbid conditions nowadays included in this classification do nothappen in groupings of 10. An illustration of this dilemma is F1, Mentaland behavioral disorders due to psychoactive substance use. Here,trying to accommodate the number of potential drugs acting as etiologicalfactors and the number of syndromes that they may cause ingroupings of 10 results an impossible task. A review should be includedof the current types of major classes composing the current systemand their internal organization. In this presentation, we discuss themajor caveats of the current hierarchical organization of ICD-10 andpropose alternatives to increase the internal consistency of the systemas well as to promote the research needed to resolve questions ofnosological groupings.SPS2.8.NOSOLOGICAL DEFINITIONS: CATEGORICAL,DIMENSIONAL, AND HYBRID MODELSC. PounceyDepartment of Psychiatry, Presbyterian Hospital, New York, NY,USAThe choice between a categorical and a dimensional nosology is oftenviewed as a fundamental decision that precedes psychiatric classification,and this decision has been named as a research priority bygroups such as the Nomenclature Work Group for DSM-V. However,categorical classification and dimensional diagnostic considerationsare not mutually exclusive. While a tension does exist between thetwo approaches, they can be – and often are – used together. If werecall what philosophers call the “theory-ladenness of observation”,we can see that the statistical methods used to investigate mental disorderspresuppose either a categorical or a dimensional approach toclassification. We use these methods to clarify or challenge aspects of47

a classification that already exist. We then modify that classificationin whole or in part according to ongoing research. By looking to thestatistical methods used for classification we will see that a) a nosologyneed not be uniformly categorical or dimensional, and b) the decisionto use a categorical or dimensional nosology need not precedeclassification but can modify an existing one.SPS2.9.NOSOLOGICAL AND DIAGNOSTIC VALIDITIESUNDER COMPREHENSIVE DIAGNOSTIC SCHEMASJ.E. MezzichMount Sinai School of Medicine, New York University, New York,NY, USAAs preparations are starting to develop a new generation of internationalclassification and diagnostic systems, such as ICD-11, the conceptof diagnosis and its validity are receiving pointed attention. Thisincludes an analysis of alternative notions of diagnosis, from a conventionalclassification of mental disorders to a full description ofhealth status. The latter notion involves an appraisal of the complexityof mind and health from various perspectives. One refers to thedomains to be assessed, from mental disorders to a full panel of existingillnesses and health-related problems to a consideration of both illand positive health aspects. Another refers to the descriptive tools tobe employed, including standardized typologies and dimensionalapproaches as well as idiographic narratives. A third perspective isconcerned with the evaluators involved, including clinicians, the consultingperson (patient), and the family and significant others. Furthermore,one should consider whether the concept of diagnosis isfundamentally a formulation or an interactive process. The concept ofdiagnostic validity is also being re-examined. Competing notionsinclude attempts at and results from “carving nature at its joints” tothe fulfillment of the expected purposes of diagnosis for clinical careand public health actions.SPS2.10.NOSOLOGICAL AND DIAGNOSTIC VALIDITY INCHALLENGING CLINICAL CONDITIONS:COMORBIDITY IN MENTAL AND GENERALMEDICAL DISORDERSI.M. SalloumWestern Psychiatric Institute and Clinic, University of Pittsburgh,PA, USAComorbidity, or the co-existence of more than one morbid condition,is the rule and not the exception in regular clinical practice.The presence of comorbidity poses significant challenges to diagnosticascertainment and treatment choices, and has significantimpact on treatment response and outcome. The prognostic significanceof comorbid conditions has been recognized for general medicaldisorders. Comorbidity in mental disorders presents additionalhurdles due to the lack of fully validated psychiatric disorders. Thechallenge of comorbidity is yet to be adequately addressed by modernclassification systems. This presentation will review evidence onthe prognostic significance of comorbidity and its relevance forenhancing the clinical utility or usefulness of current diagnostic systems.SPS2.11.CLASSIFICATION OF POSTNATAL MOODDISORDERS: TOWARDS ICD-11 AND DSM-VJ. CoxUniversity of Keele, UKContemporary classifications of mental disorders, to be useful,should reflect not only scientific advances in knowledge but alsopublic health and user perspectives. They should also facilitate awhole person approach to psychiatry, as encouraged by the InternationalGuidelines for Diagnostic Assessment proposed by the WPA.These principles are illustrated with reference to the well-knowndeficiencies in ICD-10 and DSM-IV with regard to the classificationof postnatal mood disorders. The recommendations of an internationalworkshop held in Sweden, which included a mandatory 3month post-partum onset specifier for psychosis (one year for nonpsychoticmood disorder) and the reinstatement of the diagnosticcategories of puerperal psychosis and postnatal depression, arereviewed.SPS2.12.NOSOLOGICAL AND DIAGNOSTIC VALIDITY ANDTHE INTERPERSONAL MATRIX: FROMPERSONALITY TO RELATIONAL DISORDERSL. KüeyBilgi University, Istanbul, TurkeyWhy does the description of the ill and healthy aspects of “the interpersonal”constitute a challenging clinical condition in terms of validity?On which bases can the concepts of nosological validity anddiagnostic validity be discussed and utilized in the context of humaninterpersonal relations? How can a scientific psychiatric classificationsystem and a comprehensive clinical description attain thepower of validity in defining distress, disability or deviance in interpersonalrelations? How much may the scientific evidence accumulatedin this field help us to differentiate between the patterns of normalityand abnormality in interpersonal relations? Do we need newempirical data or do we need new epistemological and methodologicalmeans? In an effort to provide a framework for the discussion ofthese questions, basic conceptual approaches and relevant researchdata on the classification and description of “the interpersonal andrelational issues and disorders” will be reviewed in this presentation.SECTION SYMPOSIASS1.CURRENT QUESTIONS IN THE TREATMENT OFBIPOLAR DISORDERS (Organized by the WPASection on Pharmacopsychiatry)SS1.1.IS THERE AN IDEAL MONOTHERAPY FOR ACUTEMANIA?G.M. GoodwinUniversity Department of Psychiatry, Warneford Hospital, Oxford, UKThere is now a range of effective treatments available to controlepisodes of mania. Whether any of these options could be describedas ideal depends upon their speed of antimanic action, tolerability,48 World Psychiatry 3:S1 - October 2004

liability to provoke a switch to depression and potential for use in thelong term. However, there is little independent comparative data tomerit the selection of any one medicine for all circumstances. Indeed,there is current uncertainty, evident in recommendations in clinicalguidelines, whether monotherapy should be preferred to a combinationof two medications. Atypical antipsychotics are the most studiedantimanic agents either as monotherapy or in combination with lithiumor valproate. Their effects as monotherapy and in combinationare convincingly demonstrated in placebo controlled trials. However,these trials contained variable numbers of patients who were at leastpartially refractory to lithium or valproate. Moreover, their design isdictated by the needs of licensing companies to convince regulatorsof their products’ safety and efficacy. The data this produces does notnecessarily generalize to ordinary clinical situations.SS1.2.IS A MOOD STABILIZER SUFFICIENTTO TREAT ACUTE BIPOLAR DEPRESSION?H.-J. MöllerPsychiatric Department, University of Munich, GermanyThis paper gives a critical review of recommendations concerning thedrug treatment of acute bipolar depression. The suggestions of differentguidelines and consensus papers, especially in US and Canadianpsychiatry, have a strong tendency against antidepressants in bipolardepression; they suggest the use of monotherapy with mood stabilizersand, in the case of co-medication with mood stabilizers and antidepressantsin severe depression, suggest to withdraw the antidepressantas early as possible. The intention of this restrictive use is toavoid the risk of mania and of rapid cycling induced by antidepressants.However, apparently the risk of suicidal acts, which is prominentin bipolar depression as in unipolar depression, has been totallyneglected. Furthermore, the fact that none of the mood stabilizers hasa proven antidepressive efficacy leads not only to the risk of depression-relatedsuicidal behavior but also to the risk of chronicity ofdepressive symptoms due to undertreatment. Altogether the viewexpressed in some guidelines and consensus papers appears not wellbalanced. Furthermore, the fact that apparently selective serotoninreuptake inhibitors and possibly some other modern antidepressantshave only a low risk of inducing a switch to mania should stimulate arewriting of the guidelines on drug treatment in acute bipolar depressionin a less restrictive way concerning the use of antidepressants.Lamotrigine, which was approved a few years ago for relapse preventionin bipolar disorders, has also undergone quite intensive evaluationin the acute treatment of both bipolar and unipolar depression.However, only one study in acute bipolar depression showed efficacy,and on a secondary efficacy parameter.SS1.3.IS POLARITY A NEW DIMENSIONFOR DECISION-MAKING IN THE LONG-TERMTREATMENT OF BIPOLAR DISORDERS?E. VietaBipolar Disorders Program at the Clinical Institute of Psychiatryand Psychology, Hospital Clinic, University of Barcelona, SpainFor many decades lithium was not only the mainstay, but actuallyalmost the only treatment that had proven efficacy for both the shortandlong-term treatment of bipolar disorder. There was little evidenceof the efficacy of drugs such as antidepressants or neuroleptics, thatwere used for the treatment of acute episodes and sometimes beyond.Carbamazepine and valproate were alternatives to lithium but datawere more convincing about their antimanic efficacy rather than antidepressantor prophylactic effectiveness. Within the last 5 years, animpressing and continuously growing number of trials is supportingthe use of second generation antipsychotics and one of the third generationanticonvulsants for the short- and long-term treatment ofbipolar disorder. Most trials have studied patients starting from amanic index episode. Only the lamotrigine trials enrolled patientsfrom both poles of the illness. It would make sense to start with lithium,valproate, carbamazepine or atypical antipsychotics on patientswith manic index episodes, whereas for index depressive episodes itwould look more meaningful to start with lamotrigine or lithium.However, things are more complex than they seem, as the best datafor lamotrigine comes from preventing depression after a manicepisode, and there is emerging data with atypicals (olanzapine, andespecially quetiapine) showing that they may also work well for bipolardepression and beyond.SS1.4.IS ANTIDEPRESSANT TREATMENT NECESSARYIN THE LONG-TERM TREATMENT OF A SUBGROUPOF BIPOLAR PATIENTS?H. GrunzeDepartment of Psychiatry, University of Munich, GermanyThe use of antidepressants in depressed bipolar patients has been amatter of controversy during the recent decade. Even more than forshort-term treatment, the usefulness of antidepressants has been disputedfor maintenance treatment of bipolar patients. The reasons areobvious: at least some groups of antidepressants, namely tricyclicantidepressants, are associated with a higher switch risk into(hypo)mania and, by this, may also accelerate cycling in bipolarpatients. However, there are also good arguments that most of theseswitches are not clinically meaningful, and combination treatment ofantidepressants with a mood stabiliser appears safe and more efficaciousthan mood stabiliser treatment alone. Due to the lack of evidencefrom large, double-blind controlled trials, the effectiveness ofantidepressant long-term treatment can only be deducted from naturalistic,prospective studies. The so far largest study of the StanleyFoundation Bipolar Network studied 84 depressed bipolar patientswho had been successfully treated with antidepressants (mainly antidepressantsof the newer generation, e.g., selective serotonin reuptakeinhibitors and bupropion) for their long-term outcome. Afterremission, 43 patients stopped antidepressant treatment whereas 41continued antidepressants for more than 6 months. Both groupsreceived at the same time at least one mood stabiliser. Comparing theoutcome at endpoint (after one year or dropout from the network),71% of patients who discontinued antidepressants had a depressiverelapse compared to 41% of those who continued antidepressants(p=0.04). Surprisingly, the rate of manic relapses was even higher inthe group who discontinued antidepressants (29%) compared tothose who continued antidepressants (13%), although this differencewas not statistically significant. Limitations of this study are its naturalisticnature and the limited generalizability due to selection ofacute responders to antidepressant treatment. Nevertheless, the resultof the study appears not only in line with a previous similar pilotstudy, but also with clinical practice, where a significant number ofbipolar patients receive antidepressants as part of long-term maintenancetreatment.49

SS2.DIAGNOSING PERSONALITY DISORDERS: DOES ITMATTER FOR TREATMENT? (Organized by the WPASection on Personality Disorders)SS2.1.BORDERLINE PERSONALITY DISORDER:DIAGNOSTIC VALIDITY ANDPSYCHOPATHOLOGICAL CORE DIMENSIONSC. MaffeiClinical Psychology and Psychotherapy Unit,Vita-Salute San Raffaele University, Milan, ItalyThe diagnostic validity of personality disorders is still suffering fromunresolved problems: some of them concern the knowledge of specificbiological, psychological and psychopathological mechanismsunderlying diagnostic criteria. The largest amount of research dataavailable concerns borderline personality disorder (BPD). Now itseems possible to deal with questions such as: a) Is BPD a categoricalor a dimensional diagnostic entity? b) Is BPD a unifactorial or a multifactorialdisorder? c) What are its core psychopathological dimensions?The practical importance of these questions regards the possibilityto identify homogeneous groups of subjects and to differentiatespecific pathological features, in order to establish specific treatment.In other words, rational treatment should derive from the identificationof subjects really suffering from personality disorder, the identificationof possible subgroups, and the differentiation of specific andstable pathological features from aspecific or unstable ones. Availableresearch data gives some answers: a) the categorical model seems tobe plausible; b) factor analytic studies seem to support multifactorialmodels, even if there is some evidence supporting a unifactorialmodel and suggesting a hierarchy in discriminatory power of criteria;c) results on core psychopathological dimensions are controversial,even if there is general agreement on the central role of impulsivity.The importance of this dimension is also consistent with findingsfrom temporal stability of criteria. Impulsivity, in turn, has been consideredas a unitary concept, whereas it should be better consideredas a multi-level entity, deserving accurate investigation.SS2.2.FIVE YEAR OUTCOME OF OUTPATIENTPSYCHOTHERAPY WITH BORDERLINE PATIENTSJ. Stevenson, R. Meares, R. D’AngeloDepartment of Psychological Medicine, Westmead Hospital,Westmead, AustraliaBorderline personality disorder (BPD) is a serious mental illness. Dueto the skepticism about the effectiveness of its treatment, the care ofthese patients is neglected. In this study we evaluated the effect oftreatment in patients with BPD five years after its ending. 30 subjectswere treated twice-weekly for one year by psychotherapy based onthe “conversational model”. Outcome measures included time in hospital,number of episodes of violence and self-harm, number of medicalappointments, drug use and work history. A “morbidity budget”made up of these items was collated for the year before treatment, theyear following treatment, and the year preceding the five year followup. Additional measures included DSM-III criteria and a self reportof symptoms. These outcomes were compared to a hypothetical naturalhistory of BPD constructed from the DSM scores of 150 borderlinepatients aged between 18 and 51. Except for one measure, theimprovements evident at one year following treatment were maintainedfour years later. This improvement was not predicted by thehypothetical natural history. These data suggest that a particular formof treatment of BPD has relatively long-lasting, beneficial effects.SS2.3.PREMORBID FUNCTIONING AND PERSONALITYIN FIRST EPISODE, NON-AFFECTIVE PSYCHOSISE. Simonsen, E.L. Mortensen, U. HaahrInstitute of Personality Theory and Psychopathology, Roskilde,DenmarkPremorbid personality has always been considered a risk factor fordevelopment of psychosis. However, it is hard to conceptualize thekind of link of personality and psychosis. Etiologically, personalitycharacteristics may reflect an underlying common core defect, may bea separate risk factor among others or may reflect deterioration due topsychosis itself. Thirty-two first episode, non-affective psychoticpatients participating in the Scandinavian Early Treatment and Interventionin Psychosis Study (TIPS) were examined for premorbidfunctioning, personality traits and personality disorders two yearsafter their inclusion in the study. The instruments were the PremorbidAssessment Scale (PAS), the Semi-structured Clinical Interview forDSM-IV, Axis II Disorders (SCID-II), the NEO Personality Inventory-Revised(NEO PI-R), and the Millon Clinical Multiaxial Inventory(MCMI-I and MCMI-II). SCID interviews suggest that about half ofthe patients had personality disorders belonging to cluster A(schizoid, paranoid, schizotypal), about one fourth had other personalitydisorders and one fourth none. The mean dimensional scores ofNEO-PI were high on neuroticism and low at extraversion comparedto a normal control group. High scorings were found at subscales onangry-hostility, self-consciousness, vulnerability, low at activity andself-discipline. MCMI personality disorders scores were high onsevere personality pathology (schizotypal, borderline, paranoid).There was a general high correlation of the SCID-II and MCMI-IIpersonality scales, except for dependent, antisocial, passive-aggressiveand borderline. In general premorbid depressive features on theMCMI-II were common. The MCMI schizotypal and schizoid scalescorrelated highly to low school performance, lack of adaptation toschool, problems with sexuality in late adolescence and low socialcontact and friendship in adulthood. This study suggests that mostfirst-episode psychotic patients prior to their psychotic breakdownbelong to the cluster A spectrum personality disorder. There is a highcorrelation between lack of social contact and competence in childhoodand adolescence and later schizoid and schizotypal personalitydisorder.SS2.4.IMPULSIVITY, CLUSTER B PERSONALITYDISORDERS AND DRUG ABUSEF.G. Moeller 1 , E.S. Barratt 2 , D.M. Dougherty 1 , A.C. Swann 1 ,J.L. Steinberg 1 , P.A. Narayana 1 , K.M. Hasan 1 , E.L. Reilly 1 ,P.F. Renshaw 31 University of Texas Health Science Center at Houston, TX;2 University of Texas Medical Branch, Galveston, TX;3 McLean Hospital, Boston, MA, USAThe incidence of drug abuse is increased in antisocial and borderlinepersonality disorders. Likewise, impulsivity is increased in these disorders.Recent research on brain function in individuals who are atrisk for development of drug abuse or who have already developeddrug abuse points to a common underlying neurobiology related toimpaired impulse control. These changes in brain function may beboth a risk factor for the development of drug abuse and a conse-50 World Psychiatry 3:S1 - October 2004

quence of drug abuse. Data will be presented from our group and otherson the neurobiology of drug abuse and cluster B personality disorderswhich points to a common underlying change in brain functionrelated to impulsivity. P300 auditory evoked potentials and functionalmagnetic resonance imaging data showing changes in brainfunction in drug abusing individuals will be discussed in light ofimpulsivity and personality disorders symptoms. These changes inbrain function lead to impaired impulse control, increase risk fordevelopment of substance abuse and complicate treatment of patientswith cluster B personality disorders in general. This data will be discussedin light of categorical versus dimensional approaches to clusterB personality disorders, and how treatments targeted at impulsivitycould improve substance abuse and other behavioral problems inindividuals with cluster B personality disorders.SS2.5.THE CURRENT STATUS OF THE GENERALNEUROTIC SYNDROME IN PSYCHIATRYP. TyrerDepartment of Psychological Medicine, Imperial College,London, UKThe general neurotic syndrome was a name proposed in 1985 for aco-axial diagnosis of mixed anxiety and depression (cothymia) and apersonality disorder within the cluster C group (dependent, avoidantand anankastic). It was suggested as an alternative to the multiplediagnostic grouping of conditions that seemed to be part of the samesyndrome (i.e., were consanguid rather than comorbid). It was alsopostulated that the general neurotic syndrome had a worse outcomethan other disorders within the anxiety-depression group and wouldbe more difficult to treat. The concept has received support from anumber of quarters. There is evidence that anxiety and depression arebest viewed as a one factor model, that the blurring of anxiety anddepressive disorders is too great to justify separation, that personalitydisorder has a significant effect on the presentation and subsequentrelapse of anxiety and depressive disorders and supports a unitarysyndrome, and that the condition has a poorer outcome than simpleanxiety and depressive diagnoses. Nevertheless, the fragmentary splittingof this group of disorders continues apace and we now have 5more diagnoses than 18 years ago. The possible reasons for this willbe discussed, and include hidden factors influencing diagnostic practiceas well as a reluctance to embrace co-axial diagnoses.SS3.THE EDUCATIONAL CHALLENGE OF IMPROVINGTHE QUALITY OF PSYCHIATRIC TREATMENT(Organized by the WPA Section on Education inPsychiatry)SS3.1.1CHALLENGES IN INTEGRATING CORECOMPETENCIES IN PSYCHIATRIC EDUCATIONP. RuizDepartment of Psychiatry and Behavioral Sciences,University of Texas Medical School at Houston, TX, USAGraduate psychiatry training programs in many countries of the Westernhemisphere as well as developed nations worldwide have experiencedin recent years major changes and challenges in the way thatcore competencies have been integrated and initiated. Nowadays, it isexpected that core competencies be used as the foundation for graduatetraining in all specialties and subspecialties in those countries,particularly in the United States. These core competencies are a)medical knowledge, b) patient care, c) practice-based learning andimprovement, d) interpersonal and communication skills, e) professionalismand f) system-based practice. While the enthusiasm andinterest in the integration of these core competencies is widespread,there are also a series of challenges in the ongoing implementation ofthese core competencies at the training program level. Some of thesechallenges relate to limited funding sources; others pertain to lack ofknowledge and skills on the part of the faculty with respect to someof the core competencies; still others have to do with resistances andfears vis-à-vis the necessary structural changes that are required forthe successful implementation of these new educational and trainingmodels. In this presentation, a review of the core competencies willbe done, the challenges related to their implementation will be examined,and potential solutions will be sought and discussed.SS3.2.THE CHALLENGES IN EDUCATING PRIMARY CAREPHYSICIANS IN BASIC PSYCHIATRY INDEVELOPING COUNTRIESM. Parameshvara DevaDepartment of Psychiatry, SSB Hospital, Kuala Belait, BruneiPsychiatry has been a recent entrant into the field of medical educationin many countries of the world. In countries that have languishedunder one form of colonial rule or the other, the lack of medical educationalinstitutions until recent times and the lack of economicresources have often meant that the quality of education in medicinehas often been left behind. In this process psychiatry has as often recognizedbeen a common casualty. Often the psychiatry that is taughtis based on concepts of psychoses as seen in the mental hospitals orasylums, where the most severe illnesses were thought mistakenly tobe the only illnesses of the mind that there were to be taught to students.The result has been a colossal lack of recognition of the vastmajority of mental illnesses seen in general practice settings in whichmost doctors practice. To turn this entrenched belief that psychosesare all that there are in psychiatry is a challenge in the re-education orre-orientation of doctors in primary care in developing countries.This needs to be met not by condensing psychiatry and repeating it tonon-psychiatrists, but by innovating methods of training based on thepsychiatry in primary care case mix. The methods of teaching have tobe based on facts in primary care settings as well as examples of casesseen in primary care. Another innovation is to tailor the training tothe needs of the busy primary care practices and their socio-economicenvironment that varies widely. In many if not most developingcountries there is no national health system nor any insurance systemthat allows the luxury of time off for training. The fee for servicemeans used widely ensures a general practitioner (GP) works from 8am or earlier to 11 at night or later 6 days a week with a good numberworking out of 24-hour clinics. Training has to based on good packaging,attractive and simple modules rather than extensive and complicatedtexts that no GP will follow in practice after the training. Thechallenges extend to follow up and continued links with the primarycare providers. All this requires commitment and resources not easilyfound in developing countries, where funding by pharmaceuticalfirms, so vital in training in more affluent countries, is seldom availableas medicines are often limited to low cost generics. The lack ofprofessional organizations and networks for continuing medical educationin service training also poses challenges. Despite these obstacles,gains have been made using rough and ready methods of trainingin a number of developing countries that use whatever resources51

available to improve mental health awareness and delivery to the primarycare doctor.SS3.3MENTAL HEALTH EDUCATION FOR THE GENERALPUBLIC IN A DEPRIVED INNER CITY POPULATIONIN THE UNITED STATESD. BaronDepartment of Psychiatry and Behavioral Sciences, TempleUniversity, Philadelphia, PA, USAUnfortunately, the stigma associated with mental illness continues tobe a worldwide problem. Many cultures do not view psychiatric diseasesas having a biological component and see them as distinct fromother “real” illnesses. This situation has resulted in a lack of parity forthe treatment of psychopathology, and patients with less than severesymptoms not seeking professional care. An effective and importantstrategy to consider in addressing this problem is establishing a grassrootseducation program for the general public. In the United States,this problem is particularly acute in poverty stricken inner-cityregions. With the assistance of the pharmaceutical industry, we wereable to offer a series of evening educational programs for the community.The format of the presentations was an initial overview of thetopic followed by an interactive question and answer/discussion period.The sessions were advertised in the local media as communityeducation and not solely for patients and their families. Topics wereselected based on timeliness (i.e. holiday blues around Christmastime and stress management around the anniversary of September 11)and overall appeal to a general adult audience. The overarching goalof the program was to increase awareness of the importance of mentalhealth issues, destigmatize mental illness, and educate the publicabout available treatment options in their community. Topics, presentationstyle and format could be adapted to the individual needs ofeach community. The key to success is keeping the programs interesting,engaging and relevant.SS3.4.THE REPRODUCTIVE MENTAL HEALTHPROGRAMME OF BRITISH COLUMBIA:AN EDUCATIONAL PERSPECTIVEM.R. Corral 1 , D. Bodnar 1,21 Reproductive Mental Health Programme, St. Paul’s and B.C.Women’s Hospitals; 2 Department of Psychiatry, University ofBritish Columbia, Vancouver, CanadaThe Reproductive Mental Health Programme is a tertiary referral cliniclocated in the metropolitan area of Vancouver, in the province ofBritish Columbia, the third largest province in the dominion of Canada.The mandate of the clinic is to promote the best possible mentalhealth for the women of the province and their families during theirreproductive years. The goals of the programme include the provisionof care and treatment for women with mental health problems connectedto reproduction and the promotion of education in reproductivemental health in the province. The programme has developedinnovative educational strategies to help meet the goal of educatingboth mental health professionals as well as the general public inreproductive mental health issues. Members of the programme areavailable to provide educational seminars in various remote locationsthroughout the province several times every year. These educationalevents take place over one to two days and comprise various educationalevents. These include seminars for community mental healthworkers, hospital grand rounds for generalist and specialist physiciansand evening forums for the general public. The events are wellreceived by members of the general public as well as public healthprofessionals and are an efficient way of disseminating information toremote areas of our province.SS4.SPIRITUALITY, TREATMENT AND HEALTH(Organized by the WPA Section on Religion,Spirituality and Psychiatry)SS4.1.SPIRITUALITY AND OUTCOME OF MEDICALTREATMENTSP. SpeckFaculty of Medicine, University of Southampton, King’s College,London, UKFor many years there has been a research focus on the importance ofpsychological factors in predicting a variety of symptoms accompanyingprogressive disease, especially associated with advanced cancer.For example, the experience of pain, the development of depressivesymptoms and anxiety states. Recently, spiritual belief has emerged asa factor that should be taken account of more. This echoes the seriesof studies by King, Speck and Thomas in which they concluded thatspiritual belief was more predictive of clinical outcome than the usualpsychological measures. This trend is to be seen in a growing numberof peer reviewed papers from the USA, UK and Europe, which showthat belief is of importance to a large proportion of people who enterhealth care (in the region of 70-80%) but is not always assessed andaddressed adequately. A key problem in such studies has been a failureto recognise the distinctiveness, but inter-relatedness, of expressionsof belief. A person who has a spiritual belief may or may not bereligious, especially if they choose not to express their belief within areligious framework. However, the majority of religious people willhave a spiritual belief. Others may choose to express their belief interms of a philosophical stance. This paper will discuss the importanceof these distinctions and review some of the recent studieswhich appear to indicate that there is a correlation between having aspiritual and/or religious belief and a variety of clinical outcomes,with reference to orthopoedic patients, cardiology patients, bereavementstudies and end-of-life care.SS4.2.ASKING ABOUT RELIGION AND SPIRITUALITYIN PATIENTS RECEIVING PALLIATIVE CARETREATMENTSS. DeinUniversity College of London, UKThe spiritual care of patients is an essential part of palliative care. Inthis study 105 case notes of hospice patients with cancer werereviewed to assess the information documented by nurses relating toreligion and spirituality. Although religious affiliation was recorded in87% of the case notes, only 40% of the notes contained any informationabout awareness of dying and the use of religion or spirituality inrelation to the dying process. The reasons for the nurses’ reluctance todiscuss spiritual issues are discussed. A teaching programme enablingpalliative care professionals to ask about spiritual issues in physicalillness is outlined.52 World Psychiatry 3:S1 - October 2004

SS4.3.SPIRITUAL QUESTIONING AND MENTAL HEALTHIN LATER LIFEP.G. ColemanUniversity of Southampton, UKErik Erikson’s discussion of the last psychosocial task of life – ‘integrityvs. despair’ – raises three fundamental issues relating to acceptance.The first, acceptance of the past without bitterness, has received themost attention. The second, acceptance of one’s own death, and especiallythe third task, acceptance of the society that will continue afterone’s own death, have received much less attention. “Questioning”appears to be central to these processes. However, struggle includingquestioning is not what society normally expects of older people. Theexpectation of stability and serenity extends also to ministers of religion,who often appear unprepared for the emergence of doubt in thewake of the losses and crises of later life, despite the fact that strugglewith despair is a common theme in the lives of saints and spiritualrole models. In studies with older people living in congregate housingwe have identified a large minority of persons who appear to remainin a chronic state of questioning, unable in particular to integratetheir perception of present and past standards of behaviour and theirformer and present spiritual beliefs. Bereavement appears to be amajor trigger of spiritual doubt and questioning. In a recent study followingup a sample of bereaved spouses from the first to secondanniversary of the death, we found depressive symptoms to be concentratedamong those of moderate to weak spiritual belief. Thosewith strong or no belief were more likely to be free of depression. Ourcase study format has allowed us to explore these issues at the level ofthe individual person, to tease out relationships between faith, doubt,personal loss, and contact with religious ministers, and to raise furtherquestions for enquiry. In current studies we have gone on toexamine older persons’ own expectations of ministers of religion insituations of loss. They illustrate the need for much closer liaisonbetween them and general mental health practitioners.SS4.4.THE ROLE OF RELIGIOUS LEADERS IN PATHWAYSTO TREATMENT FOR PEOPLE WITH SERIOUSMENTAL ILLNESSG. LeaveyBarnet, Enfield and Haringey Mental Health NHS Trust,London, UKIn Western societies, medicine and healthcare, of which psychiatry isa branch, had much of their evolution within religion-based institutions.However, the growth of the modern liberal state and the dominanceof the scientific paradigm have largely eclipsed, and may haveremoved any real role for religion in the medical treatment of patients.Thus, the view that Western societies are becoming increasingly secularistin nature is fairly persuasive. Nevertheless, to suggest a ‘cleanbreak’ heralding the unrivalled supremacy of scientific medicinewould be to underestimate the importance of spiritual and religiousbeliefs in the consideration of health and illness held by many people.Within some faith communities, health and spirituality are consideredas inseparable. Studies in the UK and in the USA indicate that a largeproportion of people with psychiatric problems obtain advice andsupport from people other than psychiatric professionals. Moreover,prior to coming into contact with psychiatry, many psychiatricpatients will first seek help from religious leaders. In part this maystem from the highly religious content of some psychotic illness, orfrom the patient’s religion-based explanatory models of mental illness.Patients and families may simply feel that they have no one elseto turn to. Whatever the reason, religious leaders are importantly situatedon the pathway to psychiatric treatment for many people andmay continue to play an influential role in the course of that treatment.Surprisingly, however, we know very little about how religiousleaders from different faith communities conceptualise mental illnessand what their role is in the help-seeking process. Are they a helpfulresource or a hindrance to appropriate psychiatric care? This paperwill outline the findings of a qualitative, London-based study of thebeliefs and attitudes of religious leaders on a range of issues relatingto mental illness and psychiatry.SS4.5.ARE RELIGIOUS AND SPIRITUAL BELIEFSASSOCIATED WITH BETTER MENTAL HEALTH?EVIDENCE FROM A NATIONAL SURVEY IN BRITAINM. KingRoyal Free and University College Medical School, London, UKThis study aimed: a) to compare the prevalence and characteristics ofreligious and spiritual beliefs in representative samples of the principalethnic populations in England and b) to examine associationsbetween religious and spiritual beliefs and common mental disorder.The study involved face-to-face interviews with a probabilistic sampleof 4281 adults from six ethnic populations living in private householdsin England. Common mental disorders (CMD) were assessedusing the revised Clinical Interview Schedule (CIS-R). Religious andspiritual beliefs were assessed using a brief questionnaire version ofthe Royal Free Interview for Religious and Spiritual Beliefs. Datawere also collected on quality of life, social function and support andpsychotic symptoms. 40.3% of people held a religious view of life,17.9% held a spiritual view but with no religious participation and41.8% held neither religious nor spiritual beliefs. South Asian peoplewere more likely to regard themselves as ‘religious’, and less likely as‘spiritual’ than white, Irish or Black Caribbean people. There was nodifference in prevalence of CMD between people who were religiousand those who were not. However, people who were not religious butwho expressed spiritual beliefs were 1.78 (CI 1.08, 2.94) times morelikely to have CMD than people who held religious beliefs. This associationremained statistically significant after adjustment for potentialconfounders, including physical health status and social support.Thus, lack of religious belief was associated with a higher prevalenceof CMD, but only in people who reported having a spiritual life view.This phenomenon may only occur in cultures where religious practicehas sharply declined in recent decades.SS5.ART AND THERAPEUTIC COMMUNICATION(Organized by the WPA Section on Art andPsychiatry)SS5.1.FROM THE ART OF THE MENTALLY ILL TO ARTTHERAPYJ. GarrabéL’Evolution Psychiatrique, Paris, FranceAt the beginning of the 20th century, several psychiatrists becameinterested in what was called at the time “mad people´s Art”. AugusteMarie organised before the First World War some exhibitions of picturesby mentally ill patients in Saint-Anne´s Hospital in Paris. The53

ook of Hans Prinzhorn “Bildenerei der Geisterkranken” (1922) wasdiscovered by the painters themselves, especially the surrealists. Fromthe exhibition organized by Volmat during the First World Congressof Psychiatry in Paris (1950) these works became known as PsychopathologicalArt. This approach was in opposition to that of “ArtBrut”. The use of Art as an activity in psychiatric institutions bringsout the problem of Art Therapy as well as that of the relationship withother psychotherapies and the training of Art-therapists.SS5.2.ART THERAPY AND EATING DISORDERSA.-M. DuboisCentre Hospitalier Sainte-Anne, Paris, FrancePatients with eating disorders often have a very good quality level ofverbal expression. However the speech is often stereotyped and structuredaround the internal necessity to deny disorders. Mental rationalisationis a frequent mechanism. Very frequently the use of theword is not for them a way of communication, neither with themselvesnor with others. The use of verbal communication is essentiallydefensive. That is why, in most of the cases, psychodynamic psychotherapiesare difficult to put in place. Psychotherapies with anartistic mediation have in the case of patients with eating disordersspecific advantages. It is these techniques and results (clinical andartistic) that we will present with the different artistic mediations thattake place in our center.SS5.3.HAIKU: A STRUCTURING THOUGHTN. Chidiac ObegiCentre d’Etude de l’Expression, Clinique des Maladies Mentaleset de l’Encéphale, Université Paris V, Paris, FranceFollowing a brief history of haiku and the structure of this poeticmeans of expression, we will present the writing workshop that takesplace at the Clinique des Maladies Mentales et de l’Encéphale, at theCentre Hospitalier Sainte-Anne in Paris. Different modalities andforms of writing are proposed in these workshops. The goals are: a) toprovide group structure as a “container” or structuring element; b) toencourage thought and creativity; c) to enhance pleasure. The articulationbetween writing and thought will be presented. The poeticform of haiku takes a predominant place for many patients. We willsee that, paradoxically, the limits imposed by this form of poetry(brevity, concentration, structure) open up a world of possibilities toexplore thoughts and feelings. Finally, a few examples of haikus andpoems created by some of the patients will be presented for illustrativepurposes.SS5.4.THERAPEUTIC CREATIVITYC. CarbonellHospital San Carlos, Madrid, SpainSeveral psychiatrists have used the artistic expression of mentalpatients as a way of communication. The determination to communicate,the ability to listen and try to make sense in the confused butoriginal images, can be one of the goals of the art therapy. Art providesa space in which thinking and emotional experience can be liberatedfrom the limits of reality and can be a bridge between thosewho suffer from mental illness and those that are engaged in artisticwork and professionally active in the artistic world. Art can be aninvaluable ally to improve patients’ creativity. The capacity to establishrelations unknown up to this moment, in other words, inventnew acquaintances, corresponds to creativity.SS6.DEVELOPING AND IMPLEMENTING TRAINING INOLD AGE PSYCHIATRY (Organized by the WPASection on Old Age Psychiatry)SS6.1.THE CORE CURRICULUM OF TRAINING IN OLD AGEPSYCHIATRYV. CamusClinique Psychiatrique Universitaire, Centre Hospitalier RégionalUniversitaire, Tours, FranceDuring the years 2000-2001, the WPA Section on Old Age Psychiatryhas conducted a survey among the 116 WPA Member Societies, inorder to identify local needs in teaching and training in the discipline.The development of post-graduate training in old age psychiatry hasbeen reported to represent the most pressing need by most of the MemberSocieties. At the same time, a joint initiative including the EuropeanAssociation of Geriatric Psychiatry, the WPA Section on Old AgePsychiatry and the World Health Organization (WHO) collaborativecentre for old age psychiatry has proposed some skill based objectivesfor training in old age psychiatry. With specific knowledge and learningobjectives, they constitute what could be considered as a core curriculumin old age psychiatry. The main topics of this curriculum will bepresented, as well as the way of implementing such a curriculum inFrance, a country where a formal recognition of old age psychiatry as anew sub-specialisation of psychiatry is now in an advanced stage.SS6.2.OLD AGE PSYCHIATRY: PERSPECTIVE OF THEWORLD HEALTH ORGANIZATION AND TRAININGEXPERIENCES IN THE UKN. Graham 1 , C. Katona 21 Royal Free Hospital, London; 2 Kent Institute of Medicine andHealth Sciences, University of Kent, UKIn 1996 the late Jean Wertheimer, old age psychiatrist in Lausanne,organised the first consensus statement on Psychiatry of the Elderly.This seminar and those that followed in subsequent years were jointlyproduced by the World Health Organization (WHO) and the GeriatricPsychiatry Section of the WPA, together with a number of internationalnon-governmental organizations representing some of thedisciplines involved with care of mentally ill elderly people. Theseseminars arose because of the growing recognition that people areageing fast in all countries, developing and developed, and mental illnessin older people requires special knowledge and skills as well asmulti-disciplinary collaboration. The document concluded that therewas ample justification to support the development of psychiatry ofthe elderly with its own training programmes, career structure andmulti-professional support network. This is a need throughout theworld. The UK was the first country to produce formal criteria for oldage psychiatry training in 1989 and to formally accept it as a specialtyin psychiatry. There are now about 500 consultants in old age psychiatryin the UK, more than anywhere else in the world. This talkwill give an overview of the consensus statements followed by a briefhistory of old age psychiatry in the UK, and describe how training inold age psychiatry is organised, together with a description of outcomemeasures for trainees.54 World Psychiatry 3:S1 - October 2004

SS6.3.TOWARDS TRAINING FOR OLD AGE PSYCHIATRY INEASTERN EUROPEN. TataruAmbulatory Psychiatric Clinic, Oradea, RomaniaOld age psychiatry is recognized as a specialty only in a few EasternEuropean countries: Czech Republic, Romania and Turkey. In thispart of the world, geriatric psychiatry is still not enough represented.The number of professionals working in the field is still very low tosatisfy the needs of care of elderly with mental disorders. In somecountries there are national geriatric psychiatry associations, whichtry to improve this situation organizing the training post-graduatecourses for young doctors. The third Lausanne consensus statementof 1998 was followed up by several meetings organised by the EuropeanAssociation of Geriatric Psychiatry, the WPA and the WorldHealth Organization (WHO) collaborating centre for old age psychiatry.The resulting document is a core curriculum based on knowledgeand skills to define the subspecialty of old age psychiatry. This curriculumis intended mainly to guide the training of psychiatrists andshould help each country to have a number of specialists who canprovide high level care in clinical service development, training andresearch. It has to be adapted to ensure local relevance and feasibility;thus, the local curriculum has to be externally validated. Specialisteducation and training in old age psychiatry should also help to developthe competencies of professionals in Europe to promote mentalhealth in old age, prevent mental disorders, care for older people withmental health problems, reduce stigma and discrimination. The trainingand teaching program comprises courses for health and social careprofessionals’ undergraduate, post-graduate and continuing education(general practitioners, young psychiatrists, geriatricians andother doctors, nurses, occupational therapists, social workers), coursesfor obtaining the old age psychiatry certificate, education, andinformation offered to carers, users and voluntary workers. A trainingpost-graduate one-year course is being organized in Bucharest,Romania for a diploma in psychogeriatrics for psychiatrists, geriatriciansand medical residents. The majority of European countries havenot yet accredited training programs in old age psychiatry. It is recommendedthat all European countries should set up national systems toaccredit such supraspecialists. Only a few psychogeriatric services andeven less special care services for dementia patients currently exist. Inall former communist countries there are economical problems andwe need national fund raising to support national psychogeriatricorganizations and services.SS7.HORMONES AS TREATMENTS OF AFFECTIVEDISORDERS (Organized by the WPA Sections onInterdisciplinary Collaboration and on AffectiveDisorders)SS7.1.TREATMENT OF DEPRESSION: PRESENT ANDFUTURER. PinderMedical Affairs, Organon, Oss, The NetherlandsEffective antidepressant treatments have been available for almosthalf a century. Antidepressant drugs, mood stabilizers, electroconvulsivetherapy and psychotherapies are, however, symptomatic treatmentsthat may have to be administered for sustained periods to preventrelapse and recurrence. Moreover, individual patients vary widelyin their response to different antidepressant drugs, and it is stillnecessary to have at hand a range of medications offering multiplemechanisms of action – tricyclics, monoamine oxidase inhibitors,selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenalinereuptake inhibitors (SNRIs), noradrenergic and specific serotonergicantidepressants (NaSSAs) and others. Many of the newer agentslack the side effect burden and the lethality in overdosage of the olderdrugs, but they have not in general offered anything in the way ofimproved efficacy. However, they are not all born equal and substantialevidence is emerging that dual action SNRIs and NaSSAs, and inparticular venlafaxine and mirtazapine, may offer advantages overtheir modern counterparts (the SSRIs) in terms of faster onset ofaction and greater rates of response and remission. The developmentof new concepts for treating depressive illness has embraced targetsother than monoamines, including neurokinin receptors, glutamatesystems especially N-methyl-D-aspartate (NMDA) receptors, sigmareceptors and various hormones. Drugs capable of combating hypothalamicpituitary adrenal (HPA) axis hyperactivity by blocking glucorticoidor vasopressin receptors may be peculiarly effective in rapidlyalleviating psychotic and melancholic depression, while corticotropinreleasing factor (CRF) antagonists may be more effective inanxiety-related disorders. Brain derived neurotrophic factor (BDNF)may play a vital role in maintaining neural plasticity, is lowered indepressive illness and during stress, and can be manipulated by drugtreatment including current antidepressants. New antidepressants areneeded and they are on their way.SS7.2.NEUROSTEROIDS AND MOOD: AN OVERVIEWA.R. Genazzani, F. Bernardi, N. Pluchino, E. Casarosa, M. LuisiDepartment of Reproductive Medicine and Child Development,Section of Obstetrics and Gynecology, University of Pisa, ItalyBrain and plasma concentrations of neurosteroids have been observedto modulate in animals behavioral and biochemical responses to acuteand chronic stress, anxiety, depression, aggressivity, convulsivity, anesthesia,sleep, memory, pain and feeding behavior. These observationshave suggested that fluctuations of neurosteroids might be involved inthe development, course and prognosis of some mental disorders.This has been hypothesized in depressive disorders, in premenstrualdysphoria, in anorexia and bulimia nervosa, in Alzheimer’s disease,where increased, decreased or dysregulated secretion of the mainneurosteroids and their metabolites has been observed, the impairmentscorrelating with some of the psychopathological aspects of themental disorders. In particular, decreased concentrations of allopregnanolonehave been found in depressed patients, and selective serotoninreuptake inhibitors normalize these levels. On the contrary,allopregnanolone levels are high in patients with panic disorder,reflecting a counterregulative mechanism against the occurrence ofspontaneous panic attacks associated with an hypothalamus-pituitary-adrenalaxis hyperactivity. The alterations in mood occurringduring reproductive events are associated with changes in neurosteroidslevels. Women suffering from pre-menstrual syndrome havelow basal and stimulated levels of allopregnanolone in the lutealphase and high dehydroepiandrosterone levels, indicating that theonset of premenstrual anxiety may depend on the interplay of neurosteroidswith different GABA A-receptor activity within the centralnervous system. The modifications in allopregnanolone levelsthroughout gestation and delivery seem to be related to the alterationsof mood and behaviour observed during pregnancy and postpartumperiod. In conclusion, neurosteroids seem to be involved in55

the central mechanisms controlling mood and reproductive function,and possibly mediate some steroid-dependent behavioral changes.SS7.3.PSYCHOTROPIC EFFECTS OF SELECTIVEESTROGEN RECEPTOR MODULATORS ANDESTROGENSU. HalbreichBiobehavior Program, State University of New York at Buffalo,NY, USAEstrogens effects multiple central nervous system (CNS) pathwaysthat are putatively involved in regulation of mood and behavior. Theireffects suggest potent antidepressant and neuroprotective actions.However, preliminary data suggest antidepressant efficacy only duringperiods of hormonal instability: the postpartum, perimenstrualand perimenopausal periods. Current data do not support an antidepressanteffect of estrogens during other periods. Recent reports alsodid not confirm the suggested neuroprotective effects of conjugatedestrogen in postmenopausal women. Several lines of recent researchpromise to improve previous disappointing results: a) the discovery ofat least two estrogen receptors (ERs) and their differential distributionin the CNS; b) varied affinities of various estrogens to the differentERs; c) the development of selective ER modulators (SERMs)with targeted tissues and ER antagonism and agonism; d) the beginningof a diagnostic shift as well as conceptualization of estrogens’activity in the context of a broader multidimensional field.SS7.4.ANTIDEPRESSANT INTERVENTIONS ON THE HPASYSTEM: USE OF GLUCOCORTICOIDANTAGONISTSA. Schatzberg, B. Flores, J. Keller, B. SolvasonStanford University, Stanford, CA, USAIn recent years increased attention has been paid to the use of glucocorticoidreceptor antagonists in the treatment of various depressivestates. This report reviews data from a series of studies on acutemifepristone therapy in patients with delusional depression. Data arefirst presented on a National Institute of Mental Health (NIMH)-funded study of 30 psychotic major depressives (PMD), 30 nonpsychoticmajor depressives (NPMD) and 30 healthy controls (HC) whowere assessed on cortisol and adrenocorticotropin hormone (ACTH)levels from 6.00 pm to 9.00 am, neuropsychological testing, and brainimaging. PMD patients demonstrated significantly elevated cortisolfrom 6.00 pm to 4.00 am compared to the other two groups. Neuropsychologicaltesting points to deficits in PMD patients in functionsmediated by prefrontal cortical, anterior cingulate, and mediotemporalregions. Then, we present recent data on 30 psychotic depressivesin whom 8 days of mifepristone therapy was significantly more effectivethan placebo in reducing psychotic symptoms. Data indicate thatchanges in cortisol slope from 1.00 am to 9.00 am from baseline today 8 appear to predict continuation of antipsychotic response to day28. Recent data from studies by others on bipolar nondelusionaldepression sponsored by the Stanley Foundation as well as industrysponsored trials in PMD are also presented.SS7.5.THYROID HORMONE AUGMENTATIONOF ANTIDEPRESSANTSB. Lerer 1 , R. Cooper-Kazzaz 1 , J.T. Apter 2 , R. Lapidus 3 ,S. Muhammed-Moussa 1 , D. Grupper 3 , L. Karagicev 1 ,M. E. Newman 11 Department of Psychiatry, Hadassah-Hebrew University MedicalCenter, Jerusalem, Israel; 2 Global Medical Institutes, Princeton,NJ, USA; 3 Mental Health Center, Beer Yaakov, IsraelAn effect of triiodothyronine (T3) to accelerate the action of tricyclicantidepressants (TCAs) and to potentiate their therapeuticeffects is supported by meta-analyses. Little is known of the mechanismof these effects and it is not clear whether they are demonstrablewith selective serotonin reuptake inhibitors (SSRIs). Studiesfrom our laboratory employing in vivo microdialysis indicated thatT3 administered to rats increases the availability of serotonin at centralsynapses and alters the sensitivity of 5-HT1A and 5-HT1Bautoreceptors and alpha-2 adrenergic heteroceptors located on presynapticserotonergic terminals, which control serotonin release. Aprospective, algorithm-based clinical study by our group supportedan augmenting effect of T3 in patients with unipolar depression whohad not responded to SSRIs. The effect was most striking in women.We are conducting a double blind, controlled trial in which patientswith unipolar major depression are randomized to treatment withsertraline (50 mg/day for 1 week and 100 mg/day thereafter if tolerated)plus T3 (20 mcg/day for 1 week, 40 mcg/day thereafter if tolerated)or sertraline plus placebo, for 8 weeks. The primary outcomecriteria for augmentation will be the proportion of responders(Hamilton Depression Scale, HAM-D improvement >50%) orremitters (final HAM-D

to employment. The improvement in employment for SSDI recipientsmay have been partly related to the relaxation in the SSDI earningslimitation in 1999.SS8.2DISABILITY PAYMENTS AND RESPONSETO AN INDIVIDUAL PLACEMENT AND SUPPORTINITIATIVE: USAR. RosenheckYale Medical School, West Haven, CT, USAPast studies have shown that the individual placement and support(IPS) model of vocational rehabilitation is effective at helping peoplewith serious mental illness return to competitive employment. Otherstudies have shown that receipt of public support benefits impedesemployment outcomes. Homeless veterans with mental illness (psychiatricdiagnoses, substance abuse and dually diagnosed) wererecruited in two sequential cohorts of 250 each at 10 sites. The firstgroup received standard case management and residential treatmentservices. The second group also received IPS. Mixed models will beused to examine the interaction of time, receipt of public support paymentsand exposure to IPS. It is hypothesized that IPS will have anespecially strong impact on veterans who receive disability paymentsbecause the employment specialist will be able to address apprehensionsabout loss of benefits. Both cohorts have been recruited andpreliminary analyses show superior employment outcomes for thesecond cohort which receives IPS. Final outcome data are being collectedand will allow timely completion of all proposed analyses. IPShas been shown in this sample to be an effective approach to rehabilitationof mental health consumers. Interactions with disability paymentswill be analyzed.SS8.3.DISINCENTIVES TO WORK WITHIN THE UKWELFARE SYSTEM (AND HOW TO OVERCOMETHEM)P. Seebohm, J. Scott, B. GroveSainsbury Centre for Mental Health, Kings College, London, UKPeople who are disabled or who experience mental health problemsincreasingly assert their right to participate in the labour market, freefrom discrimination. At the same time it is recognised that peoplewho cannot work because of ill health or disability need financialsupport to maintain a reasonable standard of living. However, welfaresystems can be abused and it is the duty of Government to maintain abalance between the interests of disabled people and its responsibilityto prevent fraud. Governments in the UK and elsewhere struggle toreconcile these different needs of disabled people with their responsibilityto police the welfare system. This study explores the relationshipbetween the welfare system that provides support for those whoneed it and the employment services that help them achieve theirambitions. The paper calls into question the underlying policyassumption that those who need support are a different group of peopleto those who would like some kind of employment. It also raisesquestions about the relative extent of fraud compared with the wasteof talent, resources and lives created by keeping people out of thelabour market unnecessarily. Finally, it proposes ways of smoothingthe path to employment while maintaining a reasonable level offinancial security within the constraints of the UK welfare system.SS8.4.DISINCENTIVES TO WORK WITHIN THE ITALIANDISABILITY PENSION SYSTEMA. FiorittiLocal Health Unit, Rimini, ItalyThe Italian welfare system developed during the 1970s and the 1980sis considered one of the most comprehensive in the industrializedworld. The nation health system provides health care to all citizensand in most areas of the country provides integrated social care toseverely disabled citizens under allowance schemes from the municipalities.Disability benefits are partly delivered by national agenciesand partly managed directly by health and social agencies locally. Apermanent income from disability benefits is rarely obtainable beforemany years of illness, and mentally ill patients usually live with theirfamilies indefinitely. Work is the most frequently perceived need bothby patients and caregivers, often for very practical economical reasons.Health and social agencies developed two main strategies toensure patients’ involvement in work activities: type B cooperativesand train-and-place schemes. The author examines advantages andpitfalls of each system and describes how the experimental introductionof a third kind of intervention (individual placement and support– a technique developed in the USA) has modified the views of usersand professionals.SS9.MANAGEMENT OF FIRST EPISODESCHIZOPHRENIA (Organized by the WPA Section onSchizophrenia)SS9.1.TREATMENT GUIDELINES FOR FIRST-EPISODESCHIZOPHRENIAW. GaebelDepartment of Psychiatry, Heinrich-Heine-University,Düsseldorf, GermanyCourse and outcome in schizophrenia are still unsatisfactory. Firstbreak and relapse develop and resolve in stages and may be precededby prodromal symptoms. According to the vulnerability-stress-copingmodel, the probability of occurence of a first episode or a futurerelapse depend on the degree of imbalance between vulnerability factors,stressors, protectors, and coping abilities. Contemporary treatmentstrategies refer to this model in first-episode schizophrenia bothfrom a preventive and a curative perspective. Illness and treatmentconcepts are usually not very well developed at these early stages, andillness insight may be temporarily lacking. As a consequence, treatmentacceptance and compliance are unsatisfactory at these earlystages, contributing to early treatment drop-out and consecutivelypoor illness course. Longer duration of untreated psychosis seems tohave an unfavorable influence on course and outcome, and withrecurring episodes response to antipsychotic treatment seems todecrease for yet unknown neurobiological reasons. It is against thisbackground that treatment guidelines need to be developed exclusivelyfor this population being at risk for chronic illness course.Guideline recommendations, optimally to be based on empirical evidence,should cover the whole field of clinical situations, rangingfrom early recognition and prevention to acute and long-term treatment,including biological and psychosocial interventions. The presentpaper explores - from an international perspective and within therespective activities of the WPA Section on Schizophrenia - the avail-57

ability of those recommendations in current treatment guidelines onschizophrenia and contrasts them with empirical findings especiallyon long-term drug treatment. It also focusses on the need, structureand function of special services for first-episode schizophrenia.SS9.2.DURATION OF UNTREATED PSYCHOSIS AND FIRSTEPISODE PSYCHOSIS: A STERILE DEBATE?P. McGorryDepartment of Psychiatry, University of Melbourne, AustraliaThe demonstration that lengthy delays in initiating effective treatmentfor young people with first episode psychosis were common acrossthe developed world initially surprised and shocked many cliniciansand researchers. This sentiment gave way to a detached critique inacademic circles as to whether these delays really mattered. Most clinicianssaw this debate as somewhat strange, yet it has slowed themomentum of reform in service provision for young people with earlypsychosis in some settings and undermined progress in others. Thedebate also distracted attention from the equally important issue ofquality and content of care in early psychosis. The evidence is nowmuch more clearcut. Duration of untreated psychosis (DUP) is modestlybut robustly correlated with a range of outcome measures inearly psychosis both in the short and medium term. It can be reducedthrough better community mental health literacy and improved serviceaccess. It is suggestive but not definitively proven that reducingDUP improves outcome and quality of care. Recent progress will bereviewed and the findings discussed in the context of the early psychosisreform paradigm.SS9.3.COMPLIANCE AND THE COURSE OF FIRSTEPISODE OF SCHIZOPHRENIAA.G. AwadHumber River Regional Hospital, Toronto, CanadaCompliance behaviour during the course of management of firstepisode schizophrenia is recognized as a significant issue that impactson the subsequent course of the illness and its outcomes. Yet, such animportant issue has not been adequately nor systematically examined.Surveying the literature, as in the case of compliance behaviour duringthe chronic course of schizophrenia, there is no consistency inreported factors considered as reliable predictors of non-compliance.Among the factors that have been identified are: younger age, morepositive symptoms, poor insight, cognitive deficits, frequent relapses,social isolation, side effects, attitudes and subjective responses tomedications. On the other hand, there is more consistency about thenegative impact of comorbid drug abuse on compliance behaviour. Itis my view that compliance behaviour in the early phases of schizophreniais not very different from that during the chronic phase of theillness and the incidence of non-compliance is almost similar, over50%. However, what is significant is the serious impact of non-compliance,in such an early phase of the illness, on the long-term course.This requires diligent early recognition and employment of appropriatestrategies. I wonder, in view of the frequency and the seriousimpact, whether compliance therapy needs to be instituted as animportant component in the early management approaches.SS9.4.STRATEGIES OF ACUTE DRUG TREATMENTIN FIRST-EPISODE SCHIZOPHRENIAR. EmsleyDepartment of Psychiatry, University of Stellenbosch, Cape Town,South AfricaThe second generation antipsychotic (SGA) drugs have had a majorimpact upon our approach to treating patients with schizophrenia.There is accumulating evidence that these drugs hold significantadvantages over their predecessors in terms of both efficacy and tolerability.The clinical advantages of these drugs appear to have mostimpact close to the onset of the illness, and they are rapidly takingover as first-line agents. Reduced relapse rate and improved long-termoutcome with SGAs has recently been empirically demonstrated inrandomised controlled trials. Patients suffering from a first episode ofschizophrenia are exquisitely sensitive to the effects of antipsychoticagents, particularly extrapyramidal side effects (EPS) and weight gain.The SGAs differ in their pharmacological, efficacy and side effect profiles,and the choice of an agent should be tailored to individualpatient profiles. Low-dosing strategies in first-episode patients arebest for risperidone and possibly amisulpride, but not necessarily forolanzapine and quetiapine. In countries where access to the SGAs isrestricted, considerable use still has to be made of the conventionalantipsychotics. Strategies to reduce the EPS burden with these agentsinclude the use of very low doses, prophylactic anticholinergicagents or low-potency conventional antipsychotics. However, theseapproaches do not appear to reduce the risk of tardive dyskinesia.SS9.5.LONG-TERM DRUG TREATMENT IN FIRST EPISODESCHIZOPHRENIAW.W. FleischhackerDepartment of Biological Psychiatry, Innsbruck, AustriaPatients suffering from a first episode of schizophrenia generallyshow higher response rates than patients with a more chronic courseof the disorder. Despite this, relapse rates are comparable for thesetwo groups of schizophrenia patients. This underscores the importanceof providing prophylactic antipsychotic treatment, which hasbeen unequivocally shown to prevent relapse in a high percentage ofpatients with both first episode and chronic schizophrenia. Althoughlong-term treatment with first generation antipsychotics has beenproven effective in many clinical trials, its acceptance both bypatients and clinicians left a lot to be desired. Potentially irreversibleside effects such as tardive dyskinesia made some psychiatrists reluctantto prescribe these medications on a long-term basis, while otherside effects of the drugs were not acceptable for patients. With theadvent of second generation antipsychotics the expectation was thatthese drugs, generally showing a better efficacy/safety ratio than theirolder counterparts, would also help to increase the acceptance ofantipsychotic relapse prevention, thereby improving outcomes. Twoindependent large scale clinical trials, comparing olanzapine andrisperidone to haloperidol, have demonstrated first encouragingresults in this direction. These findings are corroborated by a numberof smaller uncontrolled clinical trials that confirm this impression.58 World Psychiatry 3:S1 - October 2004

SS10.STRESS, DEPRESSION AND CARDIAC EVENTS(Organized by the WPA Sections on ConflictManagement and Resolution; on Women’s MentalHealth; on Psychiatry, Medicine and Primary Care;and on Occupational Psychiatry)SS10.1.BROKEN HEARTS: WOMEN, DEPRESSION ANDISCHEMIC HEART DISEASED.E. Stewart, S.L. Grace, S.E. AbbeyUniversity Health Network, University of Toronto, CanadaCardiovascular disease is the leading cause of death for both men andwomen throughout the Western world. Critical gender differencesexist for risk factors, symptom onset, time to treatment, and outcomesfor acute ischemic heart disease. This presentation will focus on genderdifferences in anxiety and depression in ischemic heart diseaseand the impact on treatment and outcomes using data from our Canadianstudies. Among other findings we found that women have moresymptoms before and during an acute event, and receive later and lesstreatment with thrombolytic drugs. Depression and anxiety werecommon in both sexes, but more common among women heartpatients and significantly worsened prognosis. We also discoveredthat women prefer more information and treatment decision makingabout their heart disease than men, but feel they receive less. For bothsexes, the perception that information needs were met and treatmentdecisional preferences respected was associated with better self-efficacy,more treatment satisfaction, less depression and improvedhealth behaviors. Recent depression treatment trials with cognitivebehavioural psychotherapy and selective serotonin reuptakeinhibitors in cardiovascular patients will also be reviewed.SS10.2.CRITICAL LIFE EVENTS, JOB STRESSAND RISK OF MYOCARDIAL INFARCTIONT. TheorellInstitute for Psychosocial Medicine, Stockholm, SwedenLong lasting stress (energy mobilisation) could be an important targetin the prevention of cardiovascular disease. The combination of highpsychological demands and low decision latitude at work (the 25%with the worst exposure in the working population) - mostly labelledjob strain - has been associated with increased risk of developingmyocardial infarction in several epidemiological studies (even afteradjustment for biological cardiovascular risk factors), and the etiologicalfraction (the proportion of cases that could be prevented if theworking conditions for the exposed subjects could be improved to thelevel of the rest of the working population) has been calculated to bein the order of 7-13%. A recent study of our own group showed thatimproved decision latitude could be obtained after a one-year lowintensitycourse in psychosocial factors for managers in a large insurancecompany. Lowered morning serum cortisol levels were observedafter this effort among employees in the experimental department butnot in the control department of the company. Our studies of lifeevents have shown that critical negative work events could increasemyocardial infarction risk substantially and that positive events couldimprove the risk factor patterns.SS10.3.DEPRESSION AND CARDIOVASCULAR DISEASEIN THE UNITED STATESE. SorelGeorge Washington University, Washington, DC, USACardiovascular disease and depression are among the ten leadingcauses of the global burden of disease. It has been anticipated thatdepression would be the second leading cause of the burden of diseaseby the year 2020. In fact, in the United States, depression is nowthe most prevalent medical condition among working Americans.Individuals who are prone to cardiovascular conditions and have anuntreated co-morbid depression are more likely to experience amyocardial infarct than those that do not have a co-morbid depression.The author presents current epidemiologic evidence regardingdepression and cardiovascular comorbidity, diagnostic, treatments,research challenges and opportunities, and their implications for education,training, and health care policy in the American and globalcontexts.SS11.SEXUAL HEALTH EDUCATIONAL PROGRAMME:AN UPDATE (Organized by the WPA Section onPsychiatry and Human Sexuality)SS11.1.INTRODUCTION TO THE WPA SEXUAL HEALTHEDUCATIONAL PROGRAMJ. MezzichInternational Center for Mental Health, Mt. Sinai School ofMedicine, New York University, New York, NY, USAThe development of the WPA Sexual Health Educational Program(SHEP) was stimulated by the results of an International Survey onPsychiatry and Sexual Health conducted on a large internationalsample of leading psychiatrists and sexologists. It documented theminimal and superficial manner in which sexuality and its problemstend to be handled in psychiatric (and even sexological) practice. TheSHEP has been developed by an international team composed ofexperts from the WPA Sections on Psychiatry and Sexuality, Classificationand Diagnostic Assessment, and Women’s Mental Health. Themain task has been the preparation of a knowledge base volumeorganized into three parts. The first part is devoted to the conceptualbases of sexual health. Of note, a definition of sexual health has beenworked out, using World Health Organization (WHO)’s definition ofhealth as a reference. The second part of the knowledge volume dealswith comprehensive diagnosis of persons experiencing sexual problems.A comprehensive diagnostic formulation is proposed, based onWPA’s International Guidelines for Diagnostic Assessment (IGDA).Additionally, a systematic review is presented of the classification ofsexual disorders organized by the phases of the sexual cycle, as wellas of their comorbidity with other psychiatric disorders and generalmedical conditions. The third part of the volume involves comprehensivecare of people experiencing sexual disorders. Biological andpsychosocial approaches pertinent to men and women are presented.Also reviewed are sets of therapeutic techniques relevant to specificsexual disorders. The volume ends with an illustrative clinicalvignette for which a comprehensive diagnostic formulation and treatmentplan are presented, as well as with the latest versions of pertinentdeclarations of the World Association for Sexology.59

SS11.2THE WPA SEXUAL HEALTH EDUCATIONALPROGRAM (SHEP): DIAGNOSTIC ISSUES ANDCOMORBIDITIESC.E. BerganzaDepartment of Child Psychiatry, Guatemala, GuatemalaSexual disorders, as most disorders in medicine in general and psychiatryin particular, are multifactorial in their etiology and phenomenology.Physical, genetic, developmental, cultural, individual psychologicaland interactional factors all operate in their causality andclinical course. Besides, a good number of difficulties in the sexualfunctioning of the individual are frequently associated with eitherphysical or other emotional conditions that require careful clinicalattention. Therefore, the assessment and diagnostic formulation ofthe clinical condition of the patient who presents for care with sexualdifficulties must be careful and comprehensive. In line with theseconcepts, the Educational Program on Sexual Health of the WorldPsychiatric Association has developed a body of principles for theassessment as well as appropriate schemas for the diagnostic formulationand classification of the sexual disorders seen in the everydayclinical work and their comorbidities. These principles and schemas,which will be discussed in detail during this presentation, are basedon an integrative view of the person of the patient, his/her partner,and his/her family, as well as on the most recent advances in the fieldof diagnosis proposed by the World Psychiatric Association.SS11.3.SEXUAL DYSFUNCTIONS IN A SAMPLEOF EGYPTIAN FEMALE PSYCHIATRIC PATIENTSS.A. Azim, M.A.A. Askar, M.M. Ahmed, N.M. El-FangeryPsychiatry and Gynecological Departments, Faculty of Medicine,University of Cairo, Egypt120 female psychiatric patients attending the outpatient psychiatryclinic of Cairo University Hospitals were screened for sexual dysfunction.They were compared with a matched control group from a gynecologicalclinic. Screening was done in both clinics using the ScreeningSexual Functioning Questionnaire. Marital adjustment was evaluatedusing the global version of the Marital Satisfaction Inventory;personality assessment was made by the Personality AssessmentSchedule. Results proved that psychiatric patients had a high rate ofsexual dysfunctions, including desire disorder 98.3%, orgasmic dysfunction95%, arousal dysfunction 83%, dyspareunia 48%, vaginismus23.3%. In patients seen at the Gynecology Department therewere 80% desire disorder, 82.2% orgasmic dysfunction, 60% dyspareunia,50% arousal dysfunction and 26% vaginismus. Psychiatricdisorders in patients with sexual dysfunction were mood disorder33%, anxiety disorders 25%, somatoform disorders 18.3%, others3.3%. Circumcision rate was 98.89%. In conclusion, female psychiatricpatients have more sexual dysfunctions than female gynecologicalpatients. This result has significant implications for clinical assessmentand management.SS11.4.PATIENTS’ SEXUAL SATISFACTION AND DOCTORS’ATTITUDESA. Pacheco Palha, M. Mota, C. CoelhoDepartment of Psychiatry, St. John’s Hospital, Oporto, PortugalThis study aimed to compare sexual life and doctors’ attitudes in apatient group of a psychiatric out-patient clinic with a communityhealth centre group, matched for socio-demographic data. Five adultclients of each group under 65 years old were selected and compileda schedule covering socio-demographic data, the opportunity to discusssexual life with doctors, and the Sexual History Form (SHF).Psychiatrists and general practitioners (GPs) filled in a schedule coveringdiagnosis, medications, kind of approach to sexual life. Themean SHF scores were 0.57 for the psychiatric patients group and0.39 for the primary care group (better functioning in the latter, p

nia makes apparent the intimate relationship between them. In thispresentation, I review how moral concerns about socially stigmatizingdiagnoses – especially schizophrenia – influenced early epistemologicaldiscussions about psychiatric classification. I provide my ownaccount of how nosologic changes are made and diagnostic criteriamodified. This account emphasizes a common confusion in philosophyof psychiatry between methodology and epistemology. Finally, Iconsider where ethical and epistemic values may direct decisionsabout whether to include new diagnostic techniques in the diagnosticcriteria for schizophrenia. I conclude that considering ethical andepistemological questions together provides a richer understanding ofhow social expectations might influence psychiatric science.SS12.3.SPIRITUAL EXPERIENCE AND PSYCHOSIS: A TESTCASE FOR EARLY DIAGNOSIS OF SCHIZOPHRENIAK.W.M. Fulford 1 , J.Z. Sadler 21 University of Warwick and Oxford, UK; 2 Department ofPsychiatry, UT Southwestern, Dallas, TX, USAThe distinction between spiritual experience and psychotic illnessremains controversial. In the DSM, criterion B (of ‘social/occupationaldysfunction’) is helpful in distinguishing adaptive from maladaptiveforms of psychotic experience. Assessment under this criterionmay also be helpful as the basis of cognitive-behaviouralapproaches to management. However, current scales for operationalisingcriterion B are unsatisfactory. Combined with the ambiguity ofother key concepts in psychiatric diagnosis (for example the conceptof ‘clinically significant’ as used in DSM), this raises particular difficultiesfor differential diagnosis at the early stages of a possible psychoticillness. A possible contribution to improved diagnostic methodsin this context will be described arising from recent internationalwork on the role of value judgements in psychiatric diagnosis.SS12.4.CONCEPTUAL ISSUES IN THE PRODROMEOF PSYCHOSISM.R. BroomeInstitute of Psychiatry, London, UKThe phase prior to transition to first episode of psychosis is increasinglybecoming of interest to schizophrenia researchers and clinicians.This talk will review historical conceptions of the prodromebefore discussing current conceptualisations and methods of assessment.Transition rates based upon these various measures will bereviewed and our own clinical cohort in South London described. Inparticular, the nature of their psychopathology and the prominentcomorbidity. The talk will conclude with how studying the prodromalphase of psychosis helps us, if at all, to understand schizophrenia andthe ethical concerns that have been raised regarding intervention inthis group.SS13.FAMILY FUNCTIONING AND FAMILYINTERVENTIONS IN AXIS I AND AXIS III DISORDERS(Organized by the WPA Section on Family Researchand Intervention)SS13.1.PSYCHOEDUCATIONAL MULTIFAMILY GROUPSIN FIRST EPISODE AND PRODROMAL PSYCHOSISW. McFarlaneDepartment of Psychiatry, Maine Medical Center, Portland, ME,USAIn nearly every case of first episode or prodromal psychosis, familymembers are intensely involved. For that reason alone, family interventionat this early stage of illness is essential. Moreover, twentyyears of research have demonstrated conclusively that family interventionhas powerful effects on the short and intermediate termcourse of schizophrenia and other psychotic disorders, while morerecent research has documented remarkable effects on functioning,negative symptoms and even reductions of medical illness in relativeswho participate as partners in treatment and rehabilitation. Psychoeducationalmultifamily group treatment is an elaboration of the modelsdeveloped by Carol Anderson, Ian Falloon, and Michael Goldstein.We have developed specific ways of working with families in along-term treatment model to help them develop increasingly sophisticatedcoping skills for handling the many difficult problems posedby mental illness in a family member. These problems include suchcommon issues as participation in aftercare programs, medicationcompliance, the use of illicit drugs, alcohol abuse, violence, and therange of positive and negative symptoms presented by the patient.Using our model of family psychoeducation, we have been able toreduce the rate of relapse of these patients to under 50% of whatwould have been expected had they received more traditional formsof treatment. This presentation will review the scientific and clinicaltheory and rationale for family psychoeducation and multifamilygroups and describe the treatment model in some detail. It will featurean approach that incorporates the key elements of several earliermodels and extends them by adapting them to prodromal and earlyfirst episode states. We will review the process of onset of psychosis,especially the interaction of biological and social processes, and therole that families can play in preventing or ameliorating onset, symptomsand eventual disability. Results will be presented from an ongoingstudy of effects on conversion to psychosis among 47 12-35 yearolds in the prodromal phase of psychotic disorders. During the firstyear, conversion has occurred in less than 25% of those at risk, andschizophrenia has occurred in less than 5%.SS13.2.FAMILY THERAPY AND FAMILY FUNCTIONING INPATIENTS WITH MOOD DISORDERSG. Keitner, C. Ryan, D. Solomon, I. MillerBrown University, Providence, RI, USAWe examined the impact of adjunctive family therapy on the functioningof families of patients with major depression and with bipolardisorders. Data are presented from two treatment studies: a) 92patients with bipolar disorder were randomly assigned to three treatmentconditions: pharmacotherapy alone (PT), PT + family therapy(FT); PT + multifamily psychoeducational group therapy; b) 121depressed inpatients were randomly assigned to follow-up care infour treatment conditions: medication + clinical management61

(MCM); cognitive therapy (CT) + MCM; FT + MCM; and CT + FT +MCM. FT and subjective and objective measures of family functioningwere based on the McMaster Model of Family Functioning. Bipolarpatients with poor family functioning at index episode significantlyimproved their family functioning in all but one dimension bymonth 28. Even patients with good family functioning at indexepisode significantly improved their family functioning in threedimensions. Improvement in family functioning was not related tosymptom reduction, whether measured by a priori (Bech-Rafaelsenand Hamilton Depression Rating) or post hoc (median split) definitions.Improvement was related to receiving family treatment.Depressed patients with poor family functioning significantlyimproved their family functioning by 6 months and were able to sustainthe improvement through 18 months. Patients with good familyfunctioning also improved by 6 months but then lost some of thegains. Improvement in family functioning was not related to improvementin symptoms based on a 50% reduction in Hamilton DepressionRating scores. Improvement in family functioning (by number of familydimensions that improved significantly and by level of significance)was related to receiving family treatment. In conclusion,despite improvement in mood symptoms, pharmacotherapy alonedoes not lead to improvement in family functioning in patients withmood disorders. Adjunctive psychosocial (especially family) interventionswere related to significant improvement in family functioning,particularly in families experiencing the greatest distress.SS13.3.RELATIONSHIP BETWEEN SELF-PERCEIVEDFAMILY FUNCTIONING AND PSYCHOLOGICALDISTRESS AMONG FAMILY MEMBERS OFJAPANESE BREAST CANCER PATIENTST. Saeki, S. Inoue, T. Mantani, S. Ozono, S. YamawakiDepartment of Psychiatry and Neurosciences,University School of Medicine, Hiroshima, JapanVery little research in Japan has focused on how cancer affects families.The present study aimed to investigate the relationship betweenphysical-psychological-social factors, including family functioning,and psychological distress, such as depression or anxiety, among familymembers of breast cancer patients in Japan. The subjects consistedof 115 family members of 74 early-stage breast cancer patients aftermastectomy. Documented informed consent for the study wasobtained from each patient. The subjects completed the FamilyAssessment Device (FAD), the Zung Self-Rating Depression Scale,and the Zung Self-Rating Anxiety Scale. Multiple regression analysisshowed that family-perceived general functioning assessed by theFAD, lower education, present physical illness, past psychiatric treatment,and anxiety of survivor correlated with anxiety among familymembers, and that lower education and unemployment of patientcorrelated with depression among family members. These findingssuggest that psychosocial interventions that could reduce patient’sanxiety and improve overall functioning of families might contributeto reducing family’s anxiety as well as promoting quality of life amongbreast cancer patients and their families.SS13.4.ALCOHOLIC FAMILIES: FUNCTIONAL TYPOLOGYREVISITEDT. KurimayPsychiatric Department, Saint John Hospital, Budapest, HungaryWe report on a study of an urban population including 64 alcoholicmembers and 36 control healthy index persons and their families.One of the hypotheses was that the relatives of alcoholics perceivetheir family functioning as dysfunctional comparing to the relatives ofhealthy controls. Semi-structured multigenerational interviews, theMiinchen Alcoholism Screening Test (MAST), a socio-economic statusquestionnaire and the McMaster Family Assessment Device(FAD) were used to evaluate the sample. The FAD is a 60-item questionnairebased on the McMaster model of family functioning. Themodel describes structural and organizational properties of the familygroup and the patterns of transactions among family members thathave been found to distinguish between healthy and unhealthy families.The Hungarian version of the FAD was implemented by Keitnerat al. during the 1980s for major depression. In our sample, the FADdifferentiates between families with alcoholic members and healthyfamilies. There were statistically significant differences in the dimensionsof problem solving, communication, affective responsivenessand affective involvement between the alcoholic sample and thecontrols, indicating more dysfunctional patterns in the alcoholicgroup. The general functioning score also differentiated significantlybetween the two groups.SS14.PREDICTORS OF RESPONSE TO THERAPIES FOREATING DISORDERS (Organized by the WPA Sectionon Eating Disorders)SS14.1PREDICTORS OF SHORT- AND LONG-TERMTREATMENT OUTCOMEIN ANOREXIC AND BULIMIC EATING DISORDERSM.M. FichterDepartment of Psychiatry, University of Munich and RoseneckHospital, Prien, GermanyThree large samples of consecutively admitted female patients treatedfor a major eating disorder (103 with anorexia nervosa, AN, 196 withbulimia nervosa, BN, 68 with binge eating disorder, BED) were studiedlongitudinally over a period of 12 years. They were assessed at 5cross-sections (admission, end of inpatient treatment, 2-3 year follow-up(FU), 6-year FU, 12-year FU) using expert rating (StructuredInterview for Anorexic and Bulimic Disorders, SIAB; Psychiatric StatusRating Scale; International Diagnostic Checklist) as well as selfratings(SIAB, Self Rating Version, SIAB-S; Eating Disorder Inventory;Anorexia Nervosa Inventory for Self-Rating, ANIS; Beck DepressionInventory; Symptom Checklist-90; Freiburg Personality Inventory).In addition we assessed a second independent BN sample fourweeks before treatment, at the beginning of treatment, at the end oftreatment and several times over an 18-months follow-up period.Results of this study showed that no change occurred pre-treatment,statistically and clinically significant and substantial change wasinduced by therapy and much of this was maintained over the followupperiod. Generally, the 6-year and 12-year course was lessfavourable for AN, compared to BN and BED. For BN and BED thegeneral pattern of results showed substantial improvement during62 World Psychiatry 3:S1 - October 2004

therapy, a slight decline during the first 2-3 years after treatment andfurther improvement and stabilisation from year 3 to year 12 posttreatment. 41.3% of the AN group, 17.1% of the BN group and 21.4%of the BED group had poor outcome at 12 year follow-up. 6.8% of theAN group, 2.0% of the BN group and 2.9% of the BED group haddied in the 12-year follow-up period. Causal models were calculatedbased on the longitudinal data testing a-priori postulated hypotheses.In a first step the postulated latent constructs were identified usingconfirmatory factor analysis. In a second step, the relationshipsbetween constructs were tested using path analytic procedures.Results of this and further models based on multiple regression analysisare presented for the short- and long term-outcome of anorexicand bulimic eating disorders.SS14.2.DO CENTRAL IMPAIRMENTS OF DOPAMINESECRETION PREDICT THE RESPONSE TOOLANZAPINE THERAPY IN ANOREXIA NERVOSA?F. Brambilla 1 , S. Fassino 2 , C. Ramacciotti 3 , P. Santonastaso 4 ,C. Segura-Garcia 51 Department of Mental Health, Sacco Hospital, Milan;2 Department of Psychiatry, University of Turin; 3 Department ofPsychiatry, University of Pisa; 4 Department of Psychiatry,University of Padua; 5 Chair of Psychiatry, University ofCatanzaro, ItalyIt has been maintained that psychopharmacotherapies are less effectivethan cognitive-behavioral therapy (CBT) in anorexia nervosa(AN). However, psychopharmacotherapies have been usually administeredto correct the nutritional approach of anorexics, without consideringthe mental pathology which is the background of the disorder.Moreover, the drugs have never been selected to correct brainbiological impairments, in particular serotonin and dopamine alterationswhich occur during the course and persist after recovery ofAN. The aim of our investigation was to explore whether the administrationof olanzapine (OLA), an atypical antipsychotic which mightinhibit the AN hyperactive central dopamine function, could be effectivein anorexics. Ten anorexics received OLA (2.5 mg/day for 1month and 5 mg/day for 2 months per os) together with CBT, while10 received CBT plus placebo, the protocol being double-blind. Wetested plasma concentrations of homovanillic acid (HVA), whichhave been consistently reported to mirror central dopamine function,and administered the Eating Disorder Inventory-2 (EDI-2), theBulimia Investigation Test Edinburgh, the Symptom Checklist-90(SCL-90), the Hamilton scale for depression, the Temperament andCharacter Inventory, the Buss-Durkee Hostility Inventory, the BarrattImpulsiveness Scale, and the Yale-Brown-Cornell Eating DisorderScale before and after 1, 2 and 3 months of therapy. The associationCBT-OLA induced significantly higher responses in the EDI-2, inparticular for perfectionism, body dissatisfaction, inefficiency, interpersonalrelationships, impulsivity, ascetism, and in the SCL-90 forobsessivity, depression, aggressiveness and vulnerability. Theseresults suggest that OLA plus CBT can be more effective that CBTalone to improve specific psychopathological subgroups of AN.SS14.3.SEROTONIN TRANSPORTER POLYMORPHISMSAND SSRI RESPONSE IN BULIMIA NERVOSAP. Monteleone, M. Fabrazzo, E. Castaldo, A. Tortorella,R. Bencivenga, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalyThe serotonin transporter (5-HTT) is the primary target of selectiveserotonin reuptake inhibitors (SSRIs). A long (l) and a short (s) variantof the promoter region of the 5-HTT gene, with different transcriptionalefficiencies, have been identified. It has been suggestedthat the “s” allele of the 5-HTT gene-linked polymorphic region (5-HTTLPR) is associated with poorer SSRI response in major depression.We investigated whether 5-HTTLPR was associated to SSRIresponse in patients with bulimia nervosa (BN). Forty-two bulimicwomen, aged 18-32 years, underwent a naturalistic treatment withSSRIs plus nutritional counselling. After 12 weeks, those patientspresenting a reduction in the binge/purging frequency greater than50% of the pretreatment value were defined as responder. Allelic variationin each subject was determined by using a PCR-based method.At the end of the observation period, 28 women were responder.Homozygotes for the “l” variant of the 5-HTTLPR were significantlymore numerous in responder than in nonresponder subjects (p =0.0002), whereas homozygotes for the “s” variant were significantlymore frequent in the nonresponder group (p = 0.005). The number ofheterozygotes (l/s) did not significantly differ between the two groups(p = 0.1). Although these data must be considered cautiously becauseof the naturalistic nature of the study, they suggest that the “l”homozygous condition for the 5-HTTLPR in BN is associated to ahigher chance of response to a combined treatment with SSRIs andnutritional counselling.SS14.4.ADIPONECTIN AND INSULIN SENSITIVITYIN ANOREXIA NERVOSA PATIENTS:EFFECT OF WEIGHT RECOVERYJ. Russell, A.D. Kriketos, K.-L. Milner, L. CampbellNorthside Clinic, University of Sydney and Garvan Instituteof Medical Research, St. Vincents Hospital, Universityof North South Wales, Greenwich, AustraliaAdiponectin is a protein produced by fat cells. Studies in patients withobesity and non-insulin-dependent diabetes mellitus have shown thatits levels are inversely related to fat mass, insulin resistance and inactivity.In anorexia nervosa patients, adiponectin levels have beenshown to be elevated and to decrease with weight gain, although interpretationof data concerning insulin action and sensitivity has beenless straightforward. Our study sought to examine these parametersduring weight recovery. Adiponectin, glucose, insulin and C-peptidelevels were measured after an overnight fast in 8 female anorexia nervosapatients at baseline, during an oral 75 gm glucose tolerance test,5 days later during 30 minutes of exercise on the stationary bike at 50rpm, at two weekly intervals during nutritional rehabilitation and 6weeks after the initial assessment. Insulin sensitivity was also assessedat each of these occasions using the HOMA method of extrapolationfrom insulin and glucose levels. Indirect calorimetry was performedbefore and after the glucose tolerance tests and exercise. Total andcentral fat mass was measured at the initial visit using DEXA. Glucosetolerance and exercise testing along with indirect calorimetry andmeasurements of fat mass were also performed in 6 healthy lean controls(mean body mass index, BMI=19) as an improved match for the63

patient subjects who had already regained 2-10 kgs and whose BMIwas close to the diagnostic threshold of 17. Adiponectin levels fellwith weight gain and central fat was relatively increased in weightrecovering anorexia nervosa patients. Metabolic parameters differed atbaseline, with increased carbohydrate oxidation in the anorexia nervosagroup, but there were no significant differences after a glucoseload or after exercise. Adiponectin in anorexia nervosa is of particularclinical relevance, as increased levels might be expected to protectagainst the diabetogenic effects of novel antipsychotic agents such asolanzapine, but caution might be warranted in their use during the latterphase of weight recovery.SS15.PSYCHIATRIC ISSUES IN PSYCHO-ONCOLOGY:A CHALLENGE FOR THE NEW MILLENNIUM(Organized by the WPA Section onPsycho-Oncology)SS15.1.DO DEPRESSION, SCHIZOPHRENIA ANDPSYCHOSES INCREASE THE RISK FOR CANCER?C. JohansenInstitute of Cancer Epidemiology, Danish Cancer Society,København, DenmarkThis presentation covers two studies which investigated the cancerrisk of patients hospitalized for depression and schizophrenia in twonation-wide cohort studies. In the study of depression, all 89,491adults admitted to hospital with depression as defined in ICD-8 inDenmark between 1969 and 1993 were identified, for a total of1,117,006 person-years of follow-up. The incidence of all and sitespecificcancers were compared with the national incidence rates forfirst primary cancer adjusted for sex, age and calendar time. A total of9,922 cases of cancer were diagnosed in the cohort, with 9,434.6expected, yielding a standardized incidence rate ratio (SIR) of 1.05.The increase was attributable mainly to an increase in risk for tobacco-relatedcancers. In the second study we investigated the cancerrisk in patients hospitalised with schizophrenia in a nationwidecohort study. All 22,766 adults admitted with schizophrenia, ICD-8295, in Denmark between 1969 and 1993 were followed up for cancerthrough 1995. A reduction in risk for all tobacco-associated cancers,prostate and rectal cancer was observed in male schizophrenics. TheSIR of lung cancer risk was marginally reduced (0.86; 95% CI:0.65,1.02) in male schizophrenics, due, however, to a reduction in therisk of older patients. Breast cancer risk was increased in femaleschizophrenics (1.20; 95% CI: 1.05,1.38). The data provide no supportfor the hypothesis that psychiatric disorders, independently,influence the risk for cancer, but emphasize the unfortunate effectthat these disorders can have on lifestyle factors.SS15.2.PSYCHIATRIC COMORBIDITY IN CANCER PATIENTSAND NEED FOR PSYCHOSOCIAL CAREU. Koch, A. MehnertInstitute of Medical Psychology, Hamburg-Eppendorf University,Hamburg, GermanyThe relevance of psychological comorbidity is indicated by data suggestingthat patients with additional psychological disorders have ahigher risk of morbidity and mortality, a higher risk of chronicization,a poorer quality of life, longer hospital stays and lower compliance. Areview of comorbidity studies from psycho-oncological research andthe results from a questionnaire-based study performed at the Institutefor Medical Psychology of the Hamburg-Eppendorf UniversityClinic are presented. Among different cancer groups, a considerablerisk of comorbidity for psychological disorders was found, with anincidence ranging from 10% to 30%. The frequency of psychologicaldisorders requiring treatment appears to be dependent on numerousfactors, including socio-demographic variables, illness-related variables(e.g. stage and prognosis of the illness, severity of physicalimpairment), and psycho-social variables (e.g. available copingresources and social support). A qualified treatment (psychotherapeutic,psychopharmacological, or combined) by trained and experiencedspecialists (e.g. medical or clinical psychologists or psychiatrists)is thus necessary. Psychological comorbidity in cancer patients,however, is frequently unrecognized by those responsible for primarytreatment for several reasons (e.g. diversity of the psychopathology,overlap of somatic and psychological symptoms, underestimation ofpsychological disorders, lack of knowledge about psychological disordersand treatment). Oncologists responsible for the primary care ofcancer patients must be better educated in the diagnosis of psychologicalcomorbidity during their training.SS15.3.CREATING A SUPPORTIVE CARE DEPARTMENTFOR CANCER PATIENTS: HOW TO DETECT ANDSELECT PATIENTS IN NEEDS. DolbeaultPsycho-Oncology Unit, Institut Curie, Paris, FranceThe Interdisciplinary Supportive Care Department for the OncologyPatient (DISSPO) has been implemented to improve care of patientsfacing complex and multiple physical or psycho-social problems as aresult of their disease. DISSPO is composed of 5 care units: mobileunit of support and continuous care, psycho-oncology unit, socialservice, functional rehabilitation unit, nutrition unit. Patients referredto the DISSPO are supposed to require intervention of 3 of them. Inneed for screening instruments to detect and select the complexpatients, a list of clinical criteria was selected and applied. Sensitizationprograms with doctors and nurses were organised, helping themto realise this screening step by themselves. Clinical guidelines are onwork in order to organise a structured way of giving care to the concernedpatients, and to orientate them in an appropriate manner.Finally, we started a clinical study in order to assess the DISSPOeffect on patient satisfaction with the care received. 100 consecutivepatients referred to the DISSPO will be prospectively compared with100 control patients matched on age, gender and care setting attendance.Information will be collected on the quality of life and perceptionsof care quality of DISSPO patients.The diagnosis and treatment of cancer results in various sequelaesuch as emotional destabilization, an alteration of the physicalintegrity and self perception, insecurity with regard to social roles andresponsibilities, and a modified relationship with the environment.64 World Psychiatry 3:S1 - October 2004

SS15.4.HOSPITAL AND COMMUNITY PROGRAMS INPSYCHO-ONCOLOGY: THE ITALIAN EXPERIENCEL. Grassi 1 , P. Gritti 2 , M. Biondi 3 , R. Torta 41 Section of Psychiatry, University of Ferrara;2 Department of Psychiatry, University of Naples SUN;3 Department of Psychiatry, La Sapienza University, Rome;4 Psycho-Oncology Unit, S. Giovanni Battista Hospital,Turin, ItalyPsychiatrists are only in part aware of the significant consequences ofcancer on the patients’ mental status. Although a number of Italianstudies have been carried out in the field, it is the exception ratherthan the rule that the departments of mental health (DMH) areinvolved in the care of cancer patients. While several studies haveshown that referral to psycho-oncology services from oncologists islow, the referral to oncologists from psychiatrists is also low. However,many similarities exist between mental health services and cancerservices, as far as the integration of care in a multidisciplinary team isconcerned. Recent organizational models have been developed withinthe community and hospital settings with the aim of fostering theliaison between cancer health services, DMH and community medicine.An integrated approach to cancer should in fact involve all thedifferent health professionals (oncologists, general practitioners, palliativecare physicians, clinical psychologists and psychiatrists) caringfor the patients and their family along the process of the disease (fromthe diagnostic phase to treatment, from recovery to recurrence anddeath). Results from recent studies carried out in Italy show the efficacyof involving mental health services in the different areas of psycho-oncology(e.g. child psychiatry with regard to children growing infamilies where one of the members is a cancer patient or died of cancer,adult psychiatry with regard to the psychiatric complications ofcancer or the most recent theme of euthanasia and physician-assistedsuicide).SS16.TREATMENT OF EATING DISORDERS INPSYCHOANALYTICALLY INFORMED PSYCHIATRY(Organized by the WPA Section on Psychoanalysisin Psychiatry)SS16.1.THERAPEUTIC ALLIANCE IN ANOREXIA NERVOSAJ.A. BarrigueteRio San Angel 63-1, Guadalupe, MexicoThe treatment of anorexia nervosa can only result from a therapeuticalliance. This emphasizes the importance of the very first interview,whose setting can benefit from a psychoanalytic elaboration. Thisallows us to grasp the current symptomatology according to its transgenerationaldimension. This approach’s aims are to allow the patientto make choices about her present and future reality, and to help herto implement her re-constructive capacity (self-awareness and selfeffectiveness).SS16.2.A NETWORK TREATMENT FOR ANOREXIANERVOSAM. BotbolClinique Dupré, Sceaux, FranceThis communication is based on the understanding of anorexia nervosathrough the adolescence separation processes. In these processesthe adolescent faces a paradox that attacks his/her autoerotic capacities.When these capacities are overflowed, the adolescent is driven touse the external world to cope with the conflicts he/she cannot containin his/her inner world. Anorexia nervosa may appear as a solutionto find a way out from this paradox. Through a clinical example, weshall discuss what consequences these theoretical observations shouldhave on community treatment projects.SS16.3.PSYCHOANALYTIC AND PSYCHODYNAMICAPPROACHES TO EATING DISORDERSM. CorcosIMM, Paris, FranceOur personal experience is based on a population of severe anorexicsand bulimics with major symptoms, usually evolving over severalyears. This practice, which combines a large number of cases andlong-term, personalised individual treatments, has enabled the emergenceof a certain amount of data from which a number of questionshave arisen concerning the mental functioning of these patients.These observations have led us to believe that the essential difficultyof these adolescents lies within their personalities and their capacityto deal with conflict, and particularly to feel and to contain a depressiveaffect. These characteristics find a common ground in the conceptof dependency. In all these personalities there is a predispositiontowards an exaggerated dependency on certain people in the outsideworld: parents, brothers and sisters, etc... with a lack of autonomyand areas of confusion between one’s self and these people. In a psychodynamicapproach we understand the defensive meaning of theanorectic and bulimic conduct, and its value, as a reorganizing ofobject relations: difficulties in investing, antagonism between theobjectal inclination of these patients and the need to protect theirnarcissistic balance. The psychopathological significance of theseconducts and its therapeutical consequences are discussed.SS16.4.APPLYING A TRANSCULTURAL APPROACH IN ACASE OF BULIMIAI. AtgerClinique Dupré, Sceaux, FranceDoes a transcultural approach to eating disorders make sense in clinicalpractice, and to what extent, depending on whom and on what?We discuss the case of a bulimic patient whose father is Algerian andwhose mother is Kabyle, treated in a therapeutic community at theclinique Dupré of Sceaux. A detailed analysis shows that transgenerationalinteractions and parental projections are to be taken intoaccount, as well as the young girl’s dependency and oedipal conflicts.Culture may either favour or obstacle treatment.65

SS17.BIOLOGICAL CORRELATES OF DISTURBED SLEEP(Organized by the WPA Section on Psychiatry andSleep Wakefulness Disorders)SS17.1.NEUROPHYSIOLOGIC FINDINGS IN INSOMNIAD.G. DikeosInstitute of Psychiatry, London, UKInsomnia is characterized by difficulty in initiating and maintainingsleep or complaining about nonrestorative sleep upon awakening,while it is often associated with impaired daytime performance. Thesymptom of insomnia may be secondary to various medical psychiatricconditions or sleep-wake schedule disturbances, such as thosedue to work shift or jet lag, while primary insomnia occurs in theabsence of such factors. The presence of high beta activity before andduring sleep and intrusions of alpha activity into sleep stages is themost prevalent electroencephalographic change in primary insomnia.The 24-hour levels of adrenocorticotropin hormone (ACTH) and cortisolare higher in insomniac patients than in normal controls. Finally,patients with primary insomnia demonstrate an increased 24-hourwhole body metabolic rate, increased core body temperature, andlonger Multiple Sleep Latency Test (MSLT) times (indicating higherarousal) than sleep deprived controls, whose day following bad sleepis characterized by decreased metabolic rate, lower body temperature,and short MSLT times. All these findings suggest that primary insomniais a disorder of hyperarousal which is manifested continuously(throughout the 24-hour cycle of the day) and not only during sleep.SS17.2.THE NEUROBIOLOGICAL SUBSTRATE OFHYPERSOMNIASW. SzelenbergerDepartment of Psychiatry, Medical University of Warsaw, PolandSleepiness is a physiological phenomenon after prolonged wakefulness,but it is defined as hypersomnia or excessive daytime sleepiness(EDS) if it occurs at inappropriate or undesirable times and is notrelieved by an adequate amount of sleep at night. In the majority ofepidemiological studies, the prevalence of EDS is in the range of 5%to 15%. The neurobiological substrates of EDS are incompletelyunderstood. Numerous brain areas, including brainstem reticular activatingsystem, locus coeruleus, dorsal raphe, hypothalamic loci, basalforebrain, thalamus, and cortex, and many neurotransmitters and peptidesare involved in the expression of alertness and sleep. The recentlydiscovered deficient hypocretin neurotransmission in the hypothalamusappears to have a crucial role in narcolepsy. Relatively less isknown about mechanisms by which EDS is produced in other disorders.EDS is a sign of sleep disorders, such as narcolepsy, idiopathichypersomnia, Kleine-Levin syndrome, sleep-related breathing disorder.It is also a symptom of atypical depression. Down-regulation ofhypothalamic-pituitary-adrenal axis and corticotropin releasing hormonedeficiency are proposed as an explanation for lethargy andhypersomnia in atypical depression. Further, there are a variety ofcauses leading to EDS, including neurodegenerative conditions, neuromusculardisorders, head trauma, metabolic disorders, substanceuse. Multiple tools have been proposed for assessing sleepiness, e.g.Stanford Sleepiness Scale, Epworth Sleepiness Scale, Multiple SleepLatency Test, Maintenance of Wakefulness Test, pupillography, andevent related potentials. Various treatment options are also identified.Current treatments for hypersomnia typically enhance dopaminergictransmission; however, it has been suggested that modafinil may acton hypocretin neurons in hypothalamus.SS17.3.NEUROBIOLOGICAL CORRELATES OFNIGHTMARESI.M. ZervasDepartment of Psychiatry, University of Athens, GreeceNightmares have always been an exception and a puzzlement indream research. As a psychological phenomenon they have not fittedneatly into psychoanalytic dream theory and their role in psychicequilibrium, if they have any, has never been clarified. Even a clearrelationship to general anxiety has not been established, contrary tolay thinking. On the other hand, post-traumatic stress disorder hasgiven us more insights about nightmares than any other clinical condition.In this presentation we shall try to bring together findings fromthe biological, pharmacological, and psychological literature onnightmares in an attempt to organize our current knowledge on thesubject as groundwork for further investigation.SS17.4.REM SLEEP BEHAVIOR DISORDERT. PaparrigopoulosDepartment of Psychiatry, University of Athens, GreeceRapid eye movement sleep (REM) behavior disorder (RBD) is a REMsleep parasomnia, which is characterized by abnormal behaviors, i.e.vigorous body movements, prominent limb or truncal jerking, vocalizations,and sometimes injurious behavior occurring during vividdreams. During the episodes, polysomnographic recordings are characterizedby the abnormal abolition of muscle atonia that occurs duringREM sleep in the absence of epileptic activity. RBD reportedly israther infrequent and mostly affects older male individuals. It can beeither idiopathic or associated with neurodegenerative diseases ofmultiple etiology, narcolepsy, and medication use or withdrawal; quiteoften it is a prodromal manifestation of a parkinsonian disorder. Theanimal model of RBD implicates the area of the brain stem, especiallythe pontine tegmentum, in the pathogenesis of the disorder; inhumans, the exact nature of the underlying neuroanatomic lesions andneurophysiologic mechanisms remains to be clarified. Clonazepam(0.5 –1.0 mg) at bedtime is the treatment of choice for RBD. Patientsfully respond to its administration and immediate relief is provided,although relapse following discontinuation of medication is frequent.Adjunctive or alternative treatments for RBD include tricyclic antidepressants,anticonvulsants (e.g. carbamazepine, gabapentin), clonidine,and carbidopa/L-dopa. Protective measures during sleep are alsowarranted.66 World Psychiatry 3:S1 - October 2004

SS18.TREATMENT RESEARCH ON EATING DISORDERS(Organized by the WPA Section on Eating Disorders)SS18.1.A RANDOMIZED TRIAL COMPARING TELEMEDICINEVS. IN-PERSON COGNITIVE BEHAVIORAL THERAPYFOR PATIENTS WITH BULIMIA NERVOSAJ. Mitchell, R. Crosby, T. Myers, L. Swan-Kremeier, S. Wonderlich,K. LancasterNeuropsychiatric Research Institute, University of North DakotaSchool of Medicine and Health Sciences, Fargo, USAThis research group has been conducting a randomized treatmentstudy comparing the effectiveness and acceptability of cognitivebehavioral therapy delivered via telemedicine vs. cognitive behavioraltherapy delivered as per routine practice in a face-to-face interviewsetting. The purpose of this study is to evaluate the efficacy andacceptability of a treatment via telemedicine, given the fact that studieshave shown that manual based psychotherapies for eating disorderpatients, and for many psychiatric patients in general, are frequentlynot available to patients in rural and underserved areas. Subjectsfor this trial are recruited in various rural settings in easternNorth Dakota and Northwestern Minnesota, and the upper Midwestof the United States. These are areas where the population density isquite low. Subjects then are randomly assigned to be treated by a psychologistwho travels to their area or to be treated via telemedicine.Thus far 125 subjects have been randomized in the study. To ourknowledge this is the first large scale study to examine the effectivenessand acceptability of a manual based form of psychotherapy foradult psychiatric patients. The results of the study will have implicationsfor possible new ways of disseminating psychotherapy to ruraland underserved areas.SS18.2.FAMILY-BASED OUTPATIENT TREATMENT FORADOLESCENT ANOREXIA NERVOSA: A CLINICALCASE SERIESD. le Grange 1 , K.L. Loeb 21 University of Chicago, IL; 2 Columbia University, New York, NY,USAThe first controlled studies of family-based treatment for anorexianervosa (AN) were conducted at the Maudsley Hospital in the UK.These studies have demonstrated that this unique outpatient interventionholds promise for adolescents with AN. There are, however,no published data on this treatment’s effectiveness or ease of disseminationin the US. The purpose of this study was to provide a descriptionof a clinical case series of adolescents with AN undergoing thistreatment in the US. Participants were recruited from two sites andcomprised of 50 adolescents with AN (mean age 14.91 years, andmean duration of illness 14.7 months) and their family members.Therapists adhered to the manualized Maudsley approach. The primaryoutcome measure was weight expressed as body mass index(BMI) and percent increase of body weight (IBW). Height and weightwere obtained at baseline and termination while weight was alsomeasured at every treatment session. Analyses were intent-to-treat.The mean number of treatment sessions was 14.9±10.79, while themean entry BMI was 17.2±2.18. At last visit or termination, the meanBMI was 19.3±2.71 (p=0.0001). Percent IBW also significantlyincreased over the course of treatment (83.0±9.12 vs. 93.7±11.87,p=0.0001). Of the 35 female patients who were amenorrheic at thestart of treatment, 24 (69%) experienced a resumption of menses atthe time of their last visit. Findings from this clinical series in the USare similar to results from the UK, suggesting that the Maudsley family-basedapproach is an effective and viable outpatient interventionfor adolescents with AN, and that this treatment can be disseminatedbeyond its place of origin.SS18.3.THE CONCEPTUALIZATION AND EFFECTIVENESSOF A STEPPED CARE APPROACH TO THETREATMENT OF EATING DISORDERSA. Kaplan, M. Olmsted, J. Carter, B. WoodsideProgram for Eating Disorders, Toronto General Hospital andUniversity of Toronto, CanadaThe Eating Disorder Program at the Toronto General Hospital providesa continuum of care to patients with anorexia nervosa (AN) andbulimia nervosa (BN) utilizing a stepped care approach. This modelprovides treatment in a group therapy format, with the least intensive,least expensive interventions given to the largest number of patients,reserving the most expensive, most intensive interventions for themost ill patients. The outpatient component of care consists of psychoeducation,followed by motivational enhancement therapy andthen cognitive behavioral symptom focused group therapy. The intensivecomponents of treatment consist of day hospital and inpatientprograms, followed by outpatient relapse prevention. In terms ofeffectiveness, psychoeducation, delivered in 6 weekly 1.5 hour groupsessions, proved to be ineffective for the treatment of AN, but is a usefulfirst step in reducing binge eating and vomiting for BN, with 11%of patients with full syndrome BN at pretreatment becoming abstinentat post-treatment. A five day a week day hospital was effectivefor AN, with a mean weight gain of 8 kg and with close to 80% ofpatients reaching a body mass index (BMI) of 18.5 or above at discharge.For BN, close to 50% of patients left treatment completelyabstinent from binge eating and vomiting. Inpatient treatment waseffective in normalizing weight for those AN patients who receivedmore than 4 weeks of treatment; mean weight gain for AN, restrictingtype was 14 kg and for AN, binge/purge type 9.5 kg. Close to 75% ofsuch AN patients left treatment with a BMI at or above 18.5. In conclusion,a stepped care approach to the treatment of eating disordersis both conceptually sound and therapeutically effective.SS18.4.COST EFFECTIVENESS MODELING OF ANOREXIANERVOSA TREATMENTS. Crow, J. NymanUniversity of Minnesota, Minneapolis, MN, USAAnorexia nervosa (AN) is an expensive-to-treat illness with high mortality.Some health care systems have limited the amount or intensityof treatment provided for AN despite the lack of clearly documentedefficacy for these low-intensity approaches. One method that caninform decisions about anorexia nervosa treatment is cost effectivenessanalysis. Cost-modeling analysis was used to estimate the incrementalcost effectiveness of AN treatment; modeling was chosengiven the lack of primary data on costs and outcomes in AN treatment.Data for age of onset, life expectancy, and disease-associatedmortality were taken from the literature. The costs of treatment usedin the analysis were those at the authors’ institution. A variety oftreatment scenarios and assumptions were examined using sensitivityanalyses. Assuming an approach consisting of inpatient weightrestoration followed by treatment of gradually diminishing intensity67

(partial hospitalization, then outpatient psychotherapy plus medicationmanagement), the costs of treatment were modeled. Incrementalcost-effectiveness ratios were calculated comparing to the limitedintensity, “usual care” model. These assumptions yielded a cost peryear of life saved of $30,180. Relative to many other types of medicalinterventions, the comprehensive treatment of anorexia nervosaappears quite cost effective in terms of cost per year of life saved.Such data may have an impact on payor decisions in health care systemswhich severely restrict treatment for anorexia nervosa, and alsoserves to underscore the serious nature of AN.SS18.5.SELF-HELP INTERVENTIONS FOR BULIMIANERVOSAB.T. Walsh, R. SyskoDepartment of Psychiatry, College of Physicians and Surgeons ofColumbia University, and New York State Psychiatric Institute,New York, NY, USAThe best established interventions for bulimia nervosa are cognitivebehavioral therapy (CBT) and the use of antidepressant medication.The time and expense required to deliver CBT and the relativeunavailability of well-trained and experienced CBT therapists hasprompted the development of self-help manuals based on the principlesof CBT. This presentation will examine the published informationon the efficacy of self-help programs in the treatment of bulimianervosa and review data from a recently concluded controlled studyof a self-help program and antidepressant medication in a primarycare setting. Ninety-one women with bulimia were randomly assignedto receive either fluoxetine or placebo and either guided self-helpcombined with medical management or medical management alone.Fluoxetine was superior to placebo in reducing symptoms of bulimia,but there was no evidence of benefit from guided self-help. Controlledstudies of self-help programs for bulimia have generallyemployed a waiting list control group, and found evidence of utilityfrom self-help. However, studies utilizing more active control groupshave not been as positive. This presentation will provide a criticalreview of the data regarding the utility of self-help programs forbulimia nervosa.SS19.PSYCHOPATHOLOGY AND TREATMENT (Organizedby the WPA Section on Clinical Psychopathology, incollaboration with the Section on Psychopathologyof the European Psychiatric Association, AEP)SS19.1.NEW PHENOTYPES AS A BASIS FOR TREATMENTS. OpjordsmoenDepartment of Psychiatry, Ullevaal University Hospital,University of Oslo, NorwayModern classificatory systems (ICD-10, DSM-IV) based on a categoricalapproach are relatively reliable, but they have shortcomings asregards validity. Many clinical characteristics are similar or overlapping,making it difficult to define boundaries between the differentdiagnostic categories, and the nosological entities do not have pathognomonicfeatures. The purpose of this overview is to point out newdirections for etiology and treatment of severe psychiatric disorders.As to cause, the major psychiatric disorders, i.e. schizophrenia andbipolar disorder, are now regarded as multifactorial, but with animportant genetic contribution. Search for genetic vulnerability factorshas resulted in worldwide interest for new phenotypes that may beeasily quantifiable, with enduring traits rather than being statedependent, and with clear neurobiology (intermediate phenotypes).The inherited phenotype may be subtle abnormalities of cortical functionresulting in neurocognitive dysfunctioning, or reduced/enhancedneurotransmission. Moreover, for a long while psychotic symptomshave been divided into positive (delusions, hallucinations), negative(poverty of speech, affective flattening, lack of initiative), and disorganized(formal thought disorder, inadequate affect, bizarre behaviour).Recently there has been a renewed interest in catatonia as a separateclinical entity based on genetic and clinical studies. Newendophenotypes in psychotic disorders, as mentioned here, are importantto define. They can be used in the search for genetic susceptibilityfor the development of psychosis. This is crucial in the study of pathophysiology,but has also clinical implications. Subsequently more targetedtreatment might be available for homogeneous patient groups.SS19.2.CATEGORICAL VERSUS DIMENSIONALDIAGNOSTIC APPROACHES AND TREATMENTM. MusalekAnton Proksch Institute, Vienna, AustriaThe main requirement of diagnostics is the improvement of communicationin daily practice on the one hand and the clinical relevance ofdiagnoses with respect to treatment and prognosis on the other hand.As classical classification systems, e.g. ICD-10 or DSM-IV, are not satisfyingwith regard to the second demand, it is necessary to change theparadigm in diagnostics in order to develop more effective pathogenesis-orientedtreatment strategies. A possible alternative to the classicalcategorical approaches might be dimensional approaches. Accordingto empirical studies carried out in the past decades, the pathogenesisof mental disorders has to be considered as a multidimensionalprocess in which various mental, physical and social variables act aspredisposing, triggering and disorder-maintaining factors. Dimensionaldiagnostics, therefore, has to be phenomenon-, process- and pathogenesis-oriented,taking into account all the multiple mental, physicaland social processes underlying the psychopathological phenomena.Such dimensional differential-diagnostic procedures may help toimprove the foundations for the development of more effective treatmentstrategies for our patients.SS19.3.UNDERSTANDING AND CAREG. StanghelliniDepartment of Mental Health and University of Florence, ItalyUnderstanding aspires at collecting a range of phenomena that pointto multiple facets of a potentially significant construct, forcing tacit,implicit and opaque phenomena and their meanings to the surface ofawareness. In this epistemological context, phenomena can only begathered by interactive (emotional) involvement, not by dispassionateobservation; concepts should not be used as labels of experience,but as expressions which function in an interpersonal, indexical context;the goal of inquiry should preferably be understanding, nothypothesis testing; meaningfulness, and not simply agreement withobservation, should validate psychological expression; and, finally,understanding should require a holistic approach which expandsrather than constricts the realm of relevant phenomena. The final aimof this meaning-oriented and contextually sensitive approach is care.68 World Psychiatry 3:S1 - October 2004

SS19.4.LIFE THEMES IN PSYCHOPATHOLOGICALCONDITIONSC. Mundt 1 , P. Hammelstein 1 , R. Berger 1 , M. Bürgy 1 , P. Fiedler 21 Psychiatric Hospital and 2 Psychological Institute, University ofHeidelberg, GermanyLife themes have been a topic of research in psychiatry and psychologysince Karl Jaspers. His formal descriptions of life themes as firstexperience, crisis or constituting world have been followed by thedescription of life themes by C. Bühler in the 1920s, which focused onthe content of experiences: tentative disposition of life themes in adolescence,restriction and working out themes in early adulthood,“work over person” in late adulthood, and conclusion in late life. Therenaissance of life theme research in the 1960s with H. Thomae stillkept the hermeneutic definition of life themes. The subsequentchange of paradigm to objective research stimulated screening studieson representative population samples to extract life themes from narratives,necessarily on a very high abstraction level. For psychotherapy,the content oriented research on narratives was more helpful.Grande et al. could demonstrate that the patient’s understanding ofthe conflictual impact of central life themes and taking responsibilityfor handling them was the most powerful predictor for the success ofpsychotherapy. Psychological research on life themes showed thatcoherence of life themes correlated positively, complexity negativelywith mood. Research on false memory effects and the over-generalisationof memory in depressives showed that establishing coherenceover different life episodes is a very forceful organiser of the autobiographicalmemory. It is supported by “anchors” of meaningfulnesswhich govern the selection of episode retrieval. The work of ourgroup started from the clinical observation that life themes frozen inschizophrenic delusion turned out to be a severe obstacle for rehabilitationbecause they neither could be developed nor let go. Weconstructed the “Interview for the Retrospective Exploration of LifeEvents” (IREL), which adopts the life chart method and an assessmentmodule for the affective valence of life themes over their course.Validation data of the instrument will be presented as well as the firstresults of a pilot study which compares life themes in depressives andhealthy controls. One major finding was that depressives show ahigher degree of so-called regressive courses of life themes from positiveto negative emotional valence compared to controls. Consequencesfor psychotherapy and perspectives for future research willbe discussed.SS20.CHILDHOOD SEXUAL ABUSE, PARAPHILIAS ANDSEX OFFENCE: ARE THEY RELATED? (Organized bythe WPA Section on Psychiatry and HumanSexuality)SS20.1.AN EXPERIMENTAL STUDY ON SEX OFFENDERASSESSMENTC. Simonelli 1 , F. Petruccelli 2 , I. Petruccelli 1 , L.T. Pedata 21 La Sapienza University and Institute of Clinical Sexuology,Rome; 2 University of Cassino and Centre of Forensic Psychology,Rome, ItalyThe present pilot study investigates 24 sex offenders, all males. 15have been interviewed in the Rebibbia Jail of Rome and 9 have beenassessed by experts of the Forensic Psychology Centre of Rome. Thefirst aim of this study is to point out the level of risk for recidivism inthe sample. Another aim is to find out any specific historical variables(individual, family, social or cultural factors) associated to sexoffence. Finally, we studied moral disengagement mechanisms. Weused a checklist developed by the Forensic Psychology Centre ofRome, the Static-99 for the assessment of recidivism risk and theMoral Disengagement Scale of Bandura. In line with recent literature,a low risk for recidivism has been found. No peculiar psychosocialcharacteristics were observed in the sample. More typical were thedata concerning the mechanisms of moral disengagement.SS20.2.STIGMA, PSYCHIATRY AND THE SADOMASOCHISM-FETISH POPULATIONR. KjaerPrivate practice, Oslo, NorwayThe prevailing attitudes and related myths in the Western societiesabout the sadomasochism-fetish are presented, and contemporarystigma theory is used to analyze the relationship between the mechanismsof stigmatization, stereotyping and discrimination and theseattitudes. Members of this population experience harassment, loss ofjobs and custody of their children and this is often legitimized by laypeople referring to the categorization of these three sexual orientationsas diseases in the ICD system. The ICD-10 diagnoses F-65.0(fetishism), 65.1 (fetishistic transvestism) and 65.5 (sadomasochism)give occasion for labeling as mentally ill a large population that doesnot meet the ordinary scientific criteria for psychiatric disorders. Possiblepsychiatric problems and disorders in this population that arepresented to the clinician can better be described as in any other populationby using the ordinary diagnoses that are not connected to specificsexual behavior. In contrast to the fight against stigma related toschizophrenia, the sadomasochism-fetish population as a minoritygroup faces stigmatization, to which our non-updated psychiatricprofession is contributing. The shortcomings of the present threediagnoses in the ICD-10 are discussed. The use of diagnoses based onmyths and not science also gives the psychiatric profession a bad reputation.A revision is suggested to reduce this double-stigma.SS20.3.LATE PSYCHIATRIC SEQUELAE OF CHILDHOODSEXUAL ABUSES.A. Azim, S.A. Ali, L. El-Raey, A. El-Bakrey, H.Y. SayedPsychiatry Department, Faculty of Medicine, University of Cairo,EgyptA relationship between experiencing sexual abuse as a child and thelevel of subsequent adult adjustment has been hypothesized duringthe last decade. Childhood sexual abuse (CSA) was particularlyhypothesized to have a marked impact on adult sexual functioningand adult adjustment. The prevalence of sexual abuse amongpatients attending psychiatric outpatient clinic of Cairo UniversityHospitals was studied. Of 1650 patients screened, 458 (27.75%) hada history of CSA (sexual abuse questionnaire and clinical interviews),of whom 69.2% were males and 30.8% were females. Tostudy the impact of childhood sexual abuse on adult psychologicalfunctioning, 60 patients with history of CSA were compared with acontrol group of patients without CSA. Patients were assessed by aclinical interview, the Short-Check List 90, the Ego Strength Scale,the Defense Style Questionnaire, a measure for adult sexual functions,and the Negative Appraisals of Sexual Abuse Questionnaire(NASA). Patients with CSA showed a higher prevalence of psychi-69

atric disorders, a lower age of onset of psychiatric illness, a lower frequencyof a family history of psychiatric illness, a high celibacy rate,an unsatisfactory adult sexual functioning, and a higher symptomseverity. The relationship with the perpetrator was correlated toadult psychological symptom severity, with intra-familial abuse beingassociated with more symptom severity.SS20.4.CHILDHOOD SEXUAL ABUSER. Hernandez-Serrano 1 , G. Lucatelli 21 Central University of Venezuela, Caracas, Venezuela; 2 Universityof Buenos Aires, ArgentinaDomestic violence is a highly prevalent social and psychiatric problemin Argentina and Venezuela. Childhood sexual abuse is perhapsthe most damaging one. The data of both countries shows that atleast 30% of our children are victims of some kind of sexual abuse.The black and silence data is and will be unknown. After a visit toCordoba, Argentina we developed with several collaborators aresearch protocol which is under way: a) a model of clinical historywith a special way to ask questions to a child victim, depending onage and clinical situation; b) a technique using video tape filming ofcases in order to avoid repetition; c) a diagnostic model which takesinto account the role of the family, the school and the society (morethan 80% of the cases occurred inside the family group); d) a treatmentscheme following Cohen’s experience in dealing with the mostcontroversial issues involved in each particular case; e) bringing tothe attention of law makers, local and national governments, schooldirectors and mass media the real situation involved in this pandemic,and formulating child adolescent protection laws; f) developing atreatment model and protocol for treatment of sex offenders. Wepresent the approach from Argentina and Venezuela to this very sensitiveproblem.SS20.5.FORENSIC SERVICES AND THE MANAGEMENTOF VIOLENT SEXUAL PREDATORSJ. Arboleda-FlorezDepartment of Psychiatry, Queen’s University, Ontario, CanadaA relationship has long been established between forensic psychiatryand institutions that house serious and violent criminals, includingsexual predators. Along with many other doctors, psychiatrists havemade it a point to work in these institutions where many of theircharges suffer from major mental conditions and require specializedtreatment either within the institutions or on temporary transfer tomental hospitals. A prominent group of inmates are incarcerated as aresult of major and, usually, bizarre sexual crimes; the type that createsa feeling of abhorrence in the population. Physicians and psychiatristsare also expected to look after their health needs. A problemoccurs, however, when these inmates are about to leave the institutionand, by virtue of treatment relationships, are expected to continuereceiving these services once released. Many correctional institutionshave adopted a policy of “gating”. Ordinarily, this means thatthe individual is immediately re-arrested and committed to a mentalinstitution. The impacts of these policies and the deleterious effectson staff morale, retention of personnel, and budgetary allotments willbe the subject of this presentation.SS21.LABOUR, LAW AND DISABILITY (Organized by theWPA Section on Forensic Psychiatry)SS21.1.CRIMINAL OFFENCES AND MENTAL ILLNESS:WHAT ARE THE PUBLIC PERCEPTIONS AND THEIRCONSEQUENCES?B. Schulze, W. RösslerPsychiatric University Hospital, Research Unit for Clinical andSocial Psychiatry, Zürich, SwitzerlandDespite increased efforts to reduce the stigma related to mental illness,public attitudes are still dominated by the perception that mentallyill people are generally violent and dangerous – which is unsupportedby empirical findings. The stereotype of dangerousness continuesto shape perceptions of people with a mental health problem,thus limiting patients’ life chances. At the same time, the heightenedpublic discussion on the role of mental illness in criminal behaviourhas been accompanied by an increase in the number of criminaloffenders who have been admitted for psychiatric treatment. In Germany,their number has doubled over the past 25 years. In addition tothe legal system, psychiatry appears increasingly to be considered asan adequate institution for dealing with criminal offenders. Thisinvolves both chances and risks: on the one hand, mentally ill offendersincreasingly have access to appropriate treatment rather thanmere incarceration – with potentially more positive outcomes andbetter public security. At the same time, the growing pressure onforensic care and the emotionally taxing kind of therapeutic contactputs staff at these facilities at a stronger risk for burnout – with negativeimpacts on quality of care and treatment outcomes. This may leadto reinforcing public doubts as to the effectiveness of forensic interventions.Measures to reduce mental health-related stigma andimprove the conditions for effective forensic care will be suggested,including: a) stress and burnout management programmes for forensicstaff; b) placing forensic care within the legal rather than medicalsystem, while offering psychiatric treatments; c) continuing publicrelation efforts, especially facilitating contact with people who have amental illness to dispell stereotypes of violence.SS21.2.PRISON PSYCHOSESN. KonradInstitute of Forensic Psychiatry, Charite Universitätsklinikum,Berlin, GermanyWith reference to mental illnesses with psychotic symptoms, a substantialproportion of German psychiatrists maintain the distinctionwhich originated in the last century between “true psychoses” and“prison psychoses”. The disorders regarded as “true psychoses” generallyfit into the category of schizophrenic illnesses, with psychopathologywhich may be coloured by prison conditions in aspectssuch as the contents of delusions, whereas “prison psychoses” arespecific reactions to imprisonment. “Prison psychoses” have notentered international classification systems (ICD-10, DSM-IV) as adistinct clinical entity. Attempts to differentiate them diagnosticallyfrom the early manifestations of “true” psychoses, especially schizophrenicillnesses for which imprisonment has to varying degrees beenidentified as an important trigger, make reference to the narrownessof the scope of paranoid beliefs in prison psychoses, with a tendencyfor delusions to be limited to the immediate environment but not torelate directly to fellow prisoners. Another differentiating factor70 World Psychiatry 3:S1 - October 2004

which has been identified as crucial is the termination of prison psychoticphenomena with the interruption or ending of imprisonment,even though there may be “remnants” in the form of “now affect-freeremains of delusions” or querulant or hypochondriac character traits.The research project deals with the question whether “prison psychoses”can be differentiated from schizophrenic disorders in prisonersand what special features are demonstrated by prisoners with thediagnostic label prison psychosis with regard to sociodemographic,clinical-psychopathological and forensic factors.SS21.3.ADDICTION TREATMENT AND JUSTICE SYSTEMS:EXPANDING LINKAGESN. el-GuebalyDepartment of Psychiatry, University of Calgary, CanadaThis presentation will review the recent North American attempts tobuild bridges between the substance abuse treatment network and thecriminal justice system. The conceptual bases for this rapprochementinclude the experiences of prohibition versus legislation as well as the“war on drugs” versus the “harm reduction” approaches. Other considerationsinclude the issue of responsibility for one’s behavior, thepromotion of the disease model, the constitutional right to medicalcare as well as the influence of demographic variables such as race,gender and class. The developing North American alliance betweenpolice and health systems, drug courts as well as rehabilitative measuresincluding therapeutic communities, substitution therapies suchas methadone maintenance in the jail and in the community will beoutlined along with implications for the future.SS21.4.STIGMA AND EMPLOYMENT INEQUITYH. StuartQueen’s University, Kingston, CanadaNo single activity conveys a sense of self more so than work. It influenceshow and where an individual lives, it creates opportunities forsocial contacts and social support, it gives a title and a social role, andit confers social identity. To be excluded from the workforce not onlycreates material deprivation, it erodes self-confidence, and results inisolation, alienation, and despair. Unemployment is a key risk factorfor mental health problems ranging from mild psychosocial stress, toserious depression and suicide. The converse is also true. Mentalhealth problems also predict unemployment, and the resulting socialand economic hardships undermine quality of life, community participation,and recovery. Employment inequity occurs when one’schances of finding or keeping a job are hampered by prejudicial attitudes.It is the result of discriminatory employment practices, includinghiring, firing, and workplace management of those with a mentalillness. Disability legislation, enacted in many countries, requiresemployers to make reasonable accommodations for those with physicaland psychiatric disabilities. Despite a willingness and capacity towork, those with mental health problems continue to be significantlyunderrepresented in the workforce. This paper synthesizes currentknowledge on stigma and work, and how stigma functions throughvarious forms of employment inequity to create and reinforce socialdisadvantage, poverty, and psychiatric disability.SS22.EUROPEAN PSYCHIATRY FROM 1800 TO 2004:INSTITUTIONS, CONCEPTS AND POLICIES(Organized by the WPA Section on History ofPsychiatry)SS22.1.CONCEPTS OF MENTAL DISORDERS IN THE 19THAND 20TH CENTURY: WHY DO THEY MATTER FORPRESENT-DAY PSYCHIATRY?P. HoffDepartment of Psychiatry, University of Zurich, SwitzerlandThe concept which is applied by the individual psychiatrist in thetreatment of his or her individual patient is not only a theoreticalissue. It has a lot to do with practical questions like doctor-patientrelationship, patient’s autonomy and long-term therapy planning.This paper discusses three major approaches to the concept of mentaldisorders since the late 18th century: the realistic, nominalistic andbiographical approach. This framework is still in use nowadays. Theimplications of each concept for practical issues in psychiatric therapyand research are discussed.SS22.2.MADNESS IN THE HOME. FAMILY CARE,PSYCHIATRY AND WELFARE POLICIES FORTHE MENTALLY ILL IN THE 19TH AND 20THCENTURIES IN FLORENCEP. GuarnieriUniversity of Florence, ItalyThe view that the asylum is the only place for the care of the mentallyill is a prejudice. And it is necessary to promote family care. Thisrepresented the main advice that well-known psychiatrists such asLombroso and Tamburini offered at the time that the first Italian lawon insanity was being drafted. Why did this 1904 law, which insistedon the dangerousness of patients in psychiatric hospitals, brush asidethe original advice of the experts? The model that they intended toextend to the national level was clearly in force in Florence, wherefamily care began early (in 1866) and assumed important and lastingdimensions. In some cases the psychiatric patients were sent to a farmfamily on contract (according to a similar model for looking afterabandoned children). But most often the patients were officiallyassigned in custody to their own families and subsidized by the government(contrary to the idea that it was the poor who wished to disembarrassthemselves of their mentally ill relatives). The study of thisexperience, on the basis of archival sources of the asylum and theprovincial government, permits an understanding, more scholarlythan activistic, of a law that lasted too long, from 1904 to 1978, untilthe so-called Basaglia law. And the confrontation of evidence andself-interest - on the part of the municipality doctors, the psychiatrists,the police, the neighbors and in addition a lady who was a militantadvocate of “aiding the working class”- gives us a rich group narrativeof attitudes and behaviors concerning the mentally ill, importantfor the history of psychiatry as well as for the history of the familyand of society.71

SS22.3.JURISDICTIONS OF PSYCHIATRIC PRACTICE:ON THE EMERGENCE OF UNIVERSITY CLINICSIN GERMANYE. EngstromMax-Planck-Institute for Psychiatry, Munich, GermanyThe paper explores the emergence of university psychiatric clinicsand their impact on professional development in late-nineteenth centuryGermany. It argues that these clinics represented a fundamentalredistribution of expert labor insofar as academic practitionersacquired jurisdiction over the work of laboratory and bedsideresearch, professional training, and hygienic prophylaxis. Focusingmainly on Wilhelm Griesinger’s reform project at the Charite hospitalin Berlin, it explores the professional politics of competing jurisdictionalclaims to control psychiatric practice - claims that pitted academicians,alienists, and representatives of other medical specialtiesagainst one another. The paper situates these jurisdictional disputeswithin the context of institutional priorities, administrative strictures,regional systems of psychiatric care, and growing public scrutiny ofthe profession in Imperial Germany. It illustrates how the organizationof contemporary psychiatric practice is prefigured in debates thatare nearly 150 years old.SS23.PSYCHIATRY, LAW AND ETHICS (Organized by theWPA Section on Psychiatry, Law and Ethics)SS23.1.EDUCATIONAL PROGRAMS IN ETHICS INPSYCHIATRYA. CarmiInternational Center for Health, Law and Ethics, Haifa, IsraelThe student specializing in psychiatry during the course of his studiesand the graduate psychiatrist during his clinical activities are both besetwith more recurrent ethical problems than face any other health carer.Surveys of the educational syllabuses of the world’s medical schoolsindicate a woeful lack of instructors and teaching aids in ethics. Thedearth of instructors is evidenced by the fact that courses in ethics, ifthey exist at all, are given to students by staff members who have noqualifications in ethics. As for the lack of teaching aids, it derives fromthe fact that current syllabuses are not updated to accord with modernscientific progress and are not structured methodically. A contributionto the teaching of ethics by the WPA and by its Standing Committee onEthics and the Section on Psychiatry, Law and Ethics in particular, willundoubtedly be of tremendous importance to the world’s populationsrequiring treatment. The United Nations Educational, Scientific andCultural Organization (UNESCO) became aware of the failure of ethicaleducation at medical schools in most countries as a result of twosurveys made at 150 medical schools of all the world’s continents in1995 and 2001. The Organization rightly attributed this defect to thephenomenon of the deterioration of relationships between health carersand their patients. UNESCO, entrusted by the United Nations withresponsibility for worldwide progress in education as well as science,decided that it must play its part in redressing the situation by providingfor the efficient training of the teachers and for ethical teachingaids. These can be achieved by the compilation of a professional curriculumof studies in ethics, followed by national and internationalseminars at which personnel can be trained to teach ethics as methodizedin the new curriculum.SS23.2.ETHICS AND MENTAL HEALTH LEGISLATIONJ. Arboleda-FlorezDepartment of Psychiatry, Queen’s University, Ontario, CanadaFor the past several decades a wave of reform has been felt in manycountries in regard to general health services and, most specifically,mental health services. Many of these reform proposals or legislativechanges have impacted or have the potential to impact negatively onthe entitlements to access to health services. The negative impactshave many facets and range from lack of parity issues or constraintson access to diagnostic or therapeutic modalities to outright discriminationbased on inability to pay for health services. Unfortunately,this last challenge to access affects mostly disenfranchised minorities.In mental health, the challenges go past the familiar stigmatizing anddiscriminating policies of long-term hospitalizations in institutionsdeprived of basic quality benchmarks and abuses to the dignity andcivil rights of patients and onto issues brought about by deinstitutionalizationincluding lack of jobs and discriminatory housing policies.This paper will review issues on mental health policies that perpetuateunethical and discriminatory practices against mental patientsand their families.SS23.3.MENTAL DISEASES IN THE JEWISH DIVORCE LAWS. WolfmanFaculty of Jewish Studies and Humanities, University of Tel Aviv,IsraelThere are quite numerous references, already written about 2000years ago in the Mishna and Talmud, to the mentally ill person, as onewho is disconnected from reality and, therefore, is unable to take careof his own matters. Such a person, who is termed, in the Halacha literature,as Shote’, is defined in Chagiga as having bizarre manners,such as sleeping in cemeteries and tearing his clothes. Obviously,such person’s discretion is defected and accordingly, his legal competence,in matters where such discretion is a precondition to the validityof legal acts. The act of divorce in Jewish law, in particular the handoveror servicing the Get, the divorce certificate, is preconditionedwith absolutely free will of the Get server, the husband. After RabenuGershom’s ordinance, the wife’s consent as well is a precondition tothe divorce. Consequently, it is difficult for the Rabbinical courts tovalidate divorce when one of the parties is dissociated from realityand cannot use the discretion needed for the free will of the husband,or the needed consent of the wife, to receive her Get. The question ofthe competence of the mentally ill patient to divorce has attracted alot of debates during all centuries. The debates are rather in the areaof divorce enforcement on the mentally ill husband while he is inremission from his psychotic state and is able both to understand thesurrounding reality as well as to use discretion. The presentation willdeal with the mental diseases in divorce law, as reflected in theresponsa literature and in rabbinical courts ruling in Israel.72 World Psychiatry 3:S1 - October 2004

SS24.INTERVENTIONS IN DISASTERS (Organized by theWPA Section on Military and Disaster Psychiatry)SS24.1.CHILDREN, FAMILIES, VIOLENCE AND DISASTERSC.R. Collazo 1 , M. Benyakar 2 , J.L. Pérez-Iñigo 31 El Salvador University, Buenos Aires, Argentina; 2 University ofBuenos Aires, Argentina; 3 Complutense University, Madrid, SpainMillions of children worldwide are victims of, or witnesses to, violencein the home, community or school. Intra-familial abuse anddomestic battering account for the majority of physical and emotionalviolence suffered by children in the world. In homes where nophysical or emotional violence is present, children are still bathed inviolent images; the average child spends more than three hours a daywatching television. Television, videogames, music and film havebecome increasingly violent. For thousands of children, school is notsafe. The more common forms of school violence are intimidation,threat and simple assault. Much of this is youth on youth violence.When the child perceives threat (e.g., anticipating an assault on self orloved one), his/her brain will orchestrate a total-body mobilization toadapt to the challenge. His emotional, behavioral, cognitive, socialand physiological functioning will change. Different coping strategieswill be developed to face the danger. Children and the adults whocare for them can become further stressed and feel unsupported whena disaster cause rifts in communities and families. Lifelong consequencesand early intervention strategies will be discussed.SS24.2.NEW DEVELOPMENTS IN THE DIAGNOSIS ANDTREATMENT OF POST-TRAUMATIC STRESSDISORDERJ.L. Medina Amor, J.L. Pérez-Iñigo, J. Gomez-Trigo, A. Rodríguez-PalancaComplutense University, Madrid, SpainThe recent application of new neuroimaging techniques may be helpfulin the development of new strategies for the diagnosis and treatmentof post-traumatic stress disorder (PTSD). A revision of the diagnosticcriteria for this disorder appears necessary, in order to makethem more objective. We review recent research findings, includingthose by our group, obtained by magnetic resonance imaging, singlephoton emission tomography, electroencephalography and positronemission tomography. Future research lines are outlined. Treatmentof PTSD is also reviewed. Several drugs have been studied and seemto be effective. Some antidepressants are actually used in clinicalpractice with positive results. Other drugs are still under investigation.There is no consensus at the moment about pharmacologicalstrategies to be adopted in this disorder. We provide here some basicguidelines.SS24.3.THE ROLE OF THE MEDIAL. WeysaethUniversity of Oslo, NorwayThe rhetoric of the mass media, particularly in their tabloid form,polarizes, simplifies, personifies, problematisizes, concretizes, brutalizesand vulgarizes traumatic events. The so-called “11 on top” criteriafor the press are 1) the news, 2) the consequence, 3) the conflict, 4) thedrama, 5) the rarity, 6) trendy, 7) personal focus, 8) “good news”, 9)exclusivity, 10) “journalist knows a journalist”, 11) nearness in geography.The above aspects of modern media and the work situation ofjournalists ought to be known by professionals in the rescue serviceand in the medical preparedness organization for accidents and disasters.The media have important societal responsibilities in connectionwith traumatic events and may for that reason be of invaluable help inthe disaster work. But the media stress may in itself represent a considerablestress on the actors. The experience demonstrates that mediastrategies ought to be open, honest, engaged, warm and self-critical. Ifyou appear as infallible, inaccessible, critical and cold “you ask for it”.A media strategy presumes that there is contingency planning, a presscenter, a spokesman with clear authorization, media knowledge, mandateto take initiatives, for example to hold press conferences, thatthere is an understanding of the media’s professional background andtheir resources, that the 24-hour cycle of the media is known, thatthere is collaboration, that leaders are willing to expose themselves forthe media if necessary. Good risk communication, i.e. situations wherethere is a need to calm, but not to deny/belittle, demands that thecommunicator 1) is perceived as competent, 2) has a reputation forbeing open and honest and 3) has a capacity for empathic communication.Division of responsibility for disseminating information whenthe main rescue center/ local rescue center are involved in large transportaccidents is as follows: 1) The transport company may confirmthe event/facts related to the event, may take care of the interest of theinjured, diseased and their next of kin, may/should inform about thebackground for the accident, inform about the transport company’simplemented support services, about the consequences for continuedtransport activities (“business in the crisis”), prepare for interview withsurvivors/witnesses. 2) The rescue service is responsible for all informationabout the rescue operation, about injured/diseased and survivors,may make identities of deceased known and inform next of kinabout the deceased or missing (coordination). 3) The hospitals areresponsible for informing the next of kin of the injured, may give permissionfor journalists to interview with injured and may inform themedia about physical injuries. 4) When it comes to foreign citizens, itis that nation’s embassy that is entitled to disseminate informationabout the involved citizens and consequences for their activity, maydisseminate name of injured and deceased and inform about otheractions.SS24.4.DISASTERS AND SPECIAL GROUPS: CHILDRENAND ELDERLYJ.L. Pérez-Iñigo 1 , M. Benyakar 2 , C.R. Collazo 31 Complutense University, Madrid, Spain; 2 University of BuenosAires, Argentina; 3 El Salvador University, Buenos Aires,ArgentinaSeveral authors report a very high prevalence of post-traumatic stressdisorder (PTSD) among children who are exposed to a disaster.Detection of mental health problems and early intervention in thesechildren are extremely important. We review some strategies developedin order to work with children in disaster situations, includingpsychological and pharmacological interventions. The elderly representanother high risk group. Few studies have been carried out inthis group. Risk factors for mental health problems in a disaster situationare probably different among the elderly compared with thegeneral population. The incidence of PTSD among the elderly whoare exposed to a disaster is not clear. Recent studies show a specialvulnerability among elderly with dementia. We review preventivemeasures to be adopted by both specialists and caregivers.73

thought disorder, disturbance of consciousness, treatment resistance,and cognitive decline, indicative of a dementing process, possibly asuperimposed or inherent part of this schizophrenia subtype.SS26.2.PSYCHOPHYSIOLOGICAL ABNORMALITIESIN CHILDREN WITH DYSLEXIA:THERAPEUTIC IMPLICATIONSG.A. Chiarenza 1 , S. Casarotto 21 Department of Child and Adolescent Neuropsychiatry,G. Salvini Hospital , Rho, Milan; 2 Department of BiomedicalEngineering, Polytechnic University, Milan, ItalyThis study is intended to investigate the cerebral mechanismsinvolved in reading through the analysis of event-related potentials(ERPs) recorded from normal children and from children affected bydevelopmental dyslexia. ERPs were recorded during four readingrelatedtasks: the stimuli consisted of visually presented letters andnon-alphabetic symbols. In the first two tasks, subjects were asked topassively watch at symbols and letters, respectively, without makingany effort in reading or silently articulating them. In the other twotasks, subjects were asked to read aloud the letters that appeared onthe screen after the technician or the subjects themselves respectivelypressed a button. On the basis of the muscular activity of the lips duringreading aloud and of the forearm flexor muscles during buttonpress, the ERP components were divided into four periods. The premotorperiod occurs while the subject is preparing to read and precedesthe stimulus onset. The pre-lexical period (

sidering the time span of psychotic states. Further, the neural mechanismunderlying psychotic symptoms is discussed on the basis of theconcept of abnormal neural plasticity. One can classify epileptic psychoticstates as follows: postictal psychotic state, petit mal status,temporal lobe status, cerebral organic or toxic psychotic state, episodicpsychotic or dysthymic state, interictal neurotic state, interictal psychoticstate. In epilepsy psychiatric symptoms or states are temporallydescribed as ictal, episodic and continuous. The time span of thesymptoms or states may relate to the neural mechanisms underlyingthe events. Most psychotic symptoms or states of epilepsy appearafter a somewhat long period since the first seizure. A neuronal mechanismof abnormal plasticity develops with the repetition of seizureactivity, underlying psychotic symptoms or states. Additionally, psychologicalcircumstances influence the patient’s mental state andworsen psychopathological symptoms or states.SS27.ACCESS TO CARE IMPEDIMENTS: AFRICAN,AMERICAN AND EUROPEAN EXPERIENCES(Organized by the WPA Sections on ConflictManagement and Resolution; on Women’s MentalHealth; on Psychiatry, Medicine and Primary Care;and on Occupational Psychiatry)SS27.1.ACCESS TO CARE IMPEDIMENTS: THE EXAMPLEOF TUNISIAS. Douki, S. Ben Zineb, F. NacefHopital Razi, La Manousa, TunisiaUp until recently, mental health was afforded low priority in Tunisiaas in other developing countries faced with major health concernssuch as epidemic diseases or infant mortality. Consequently, despitesteady advances, psychiatric care did not share the progress of the restof medicine and remains greatly underdeveloped. Thus, today, theaccess to mental health care is significantly hampered by a crucialshortage of resources (one bed/10,000) and manpower (one psychiatrist/75,000)facing a huge growing request of care. Furthermore, theexpressed needs are far below the potential needs, as shown by someepidemiological data. As an example, less than 10% of patients withmajor depressive disorder and only 50% of individuals with schizophreniaare seeking professional help and benefit from specific treatments.In fact, many cultural constraints still stand in the way of mentalhealth care seeking and access, such as the strong belief in a varietyof supernatural causes of mental illnesses, the cultural-bound“somatoform symptomatology”, and above all the stigmatisation ofmental disorders and psychiatric care. Last but not least, health careis becoming increasingly expensive and low-income people cannotbenefit from the new but costly therapeutic opportunities that canoptimise the compliance and minimize the risk of relapse. Informationand sensitisation are the best tools to enhance mental health careaccess in countries where psychiatric care hasn’t always been fully inharmony with the prevailing cultural norms in the community.SS27.2.ACCESS TO CARE IMPEDIMENTS:SCANDINAVIAN PERSPECTIVESM. KastrupCentre of Transcultural Psychiatry, Rigshospitalet, Copenhagen,DenmarkFree and equal access to health services, including mental health,irrespective of sex, race, age, ethnic group or social class, is a basicassumption of the health systems in the Scandinavian countries. Anincreasing number of patients entering mental health care come fromother cultures and till now insufficient focus has been directedtowards investigating special needs and demands of psychiatric illimmigrants. About 8-10% of patients treated in Danish psychiatricinstitutions have a non-Danish background with large geographicalvariations. No mental health policy is directed towards immigrantsand no special public services provided. In order to elucidate the particularproblems related to the immigrant population, a questionnairewas sent to all Danish psychiatric institutions to assemble informationabout local services/projects involving immigrants. Based uponthis regional focus, group interviews were carried out with the localliaison officers. The paper will concentrate on issues of concern relatedto: delineation of the population treated at psychiatric institutions,available psychiatric services, staff competence and treatment. Recommendationsfor strategies to overcome care impediments andenhance the cultural competence of psychiatric staff will be outlined.SS27.3.MEDICAL NECESSITY: ITS USE AND MISUSEIN THE AMERICAN MANAGED CARE SYSTEME. SorelGeorge Washington University, Washington, DC, USAMedical necessity has become the fulcrum upon which criteria forapproval or denial of health care have evolved in the context of managedcare in the United States in the last two decades. Initial lack ofprofessional societies’ involvement in defining the terms and reachinga consensus regarding “medical necessity” combined with the misuseand abuse of the term by managed care companies contributed to significantimpediments to mental health care, in general, and in-patientcare, in particular. Furthermore, the virtual autonomy that physicianshad, in the last century, to determine what was medically necessary,has been significantly eroded. The author presents data of a UnitedStates study on medical necessity that he stimulated as chairman ofthe Partnership for Parity Working Group of the Washington PsychiatricSociety and as a consultant to the project. The study data indicatethat American health insurers increasingly reserve the contractualauthority to make medical necessity decisions that depart from scientificevidence regarding what is appropriate treatment for psychiatricdisorders. Common procedural problems and challenges to“medical necessity” will be presented, as well as the important role ofprofessional organizations, advocacy and advocacy alliances networksin stemming and possibly reversing such misuses and abuses of“medical necessity”.76 World Psychiatry 3:S1 - October 2004

SS28.MILITARY PSYCHIATRY (Organized by the WPASection on Military and Disaster Psychiatry)SS28.1.THE PSYCHIC STATE OF THE HUNGARIANSOLDIERS BEFORE AND AFTER PEACEKEEPERMISSIONSG. KovacsCentral Military Hospital, Budapest, HungaryThe aim of our study was to evaluate the psychic state of “healthy”soldiers before and after the peacekeeper operations and to comparethe psychological effects of different stressful missions. We used twoscales to measure psychological functions: the Short Check List-90(SCL-90) and the State-Trait Anxiety Scale. The study was carried outin the soldiers deployed to the SFOR-KFOR Task Force and to Iraq.Anonymity was allowed but the soldiers could give their name for thefollow-up. The state and trait anxiety level of the SFOR-KFOR soldierswas lower after the deployment. The factors of the SCL-90 weredecreased after the mission. We could compare the results of thegroups of soldiers deployed to the Balkans and to Iraq. The pathologicaleffects of different deployments can be recognized only by personalexamination and/or follow-up.SS28.2.COPING WITH STRESS DURING IRAQ DEPLOYMENTL. WeysaethUniversity of Oslo, NorwayDuring their last week of service in southern Iraq, 84% of the firstNorwegian contingent responded to a 25 page questionnaire for thestudy “Perception of risks, threats, and a meaningful service”. Thethree most frequently mentioned positive aspects of the service wereteamwork, excitement and carrying out a job one was prepared to do.While half of the soldiers judged the Norwegian force contribution inIraq as highly successful, two thirds saw their own contribution in asimilar light. Separation from family, the physical conditions and themedia coverage were the most negative aspects. Improvised explosivedevices (IEDs), extreme heat and hostile public crowds were reportedas the most significant risks. Some 80% had experienced stonethrowing from crowds, about 25% had been exposed to small armsfire, 16% had been involved in severe danger situations. One out offour stated that the service was a strain on the relationship to partner.Telephone was a more important communication channel to familythan e-mail. 75% reported that phone contact was of vital importance.The fear arousing effect upon the families at home by thetabloid media coverage, and its consequences for the family supportto the soldier appears to be a major concern. However, 68% felt theyhad been able to correct the family’s exaggerated worries based uponmass media reports. Twenty percent stated that skewed media reportsabout what they had accomplished reduced the meaningfulness oftheir service. The study sheds some light on the effects of the formerregime lojalists’ strategy of inflicting losses in the force in order toarouse family and public concern in home country.SS28.3.MILITARY PSYCHIATRY: CURRENT ISSUESP. McAllisterDuchess of Kent’s Psychiatric Hospital, Catterick, UKThe recent conflict in the Arab Gulf saw the large-scale deploymentof field mental health teams (FMHT), in support of one UK divisionand its constituent brigades. This presentation describes the goals,activities and findings from a FMHT deployed alongside a generalsupport medical regiment covering the rear divisional area. The rateof psychiatric casualties was much lower than anticipated, but theexpected bias towards less experienced personnel and reservists willbe demonstrated. We will cover all stages of the operation, from predeploymenttraining to reception, staging and onward integration,operations, redeployment and homecoming, describing the coreactivities of the FMHT at each stage. The presentation will expandupon the team’s publication in the Journal of the Royal Army MedicalCorps in June 2004 and present data on personnel who were returnedfrom active duty on mental health grounds.SS28.4.WAR SYNDROMES: A HISTORICAL PERSPECTIVEJ.L. Perez-Iñigo, J.L. Medina Amor, J. Gomez Trigo, A. Rodríguez-PalancaComplutense University, Madrid, SpainWar syndromes have been described for more than two hundredyears, with different names. All of them consist of a group of symptoms,affecting several organs. They have many symptoms in common,wherever they have been described. Also, it seems there is nospecific expression depending on the different cultures. Even whenthey have been initially studied as somatic affections, they have beenfinally found to have a psychological etiology. In recent conflicts, varioussyndromes (e.g., the Gulf syndrome, the Balkan syndrome) havebeen described. Comparing them with the other previously describedsyndromes, we find a very significant similarity in their expression. Itseems that we are talking about a unitary syndrome, related to stressand psychological factors, that appears in every war situation, withno important differences.SS28.5.MILITARY PSYCHIATRY: FUTURE TASKSP.W. JepsenMilitary Psychiatrist, DenmarkWritten just after the Korean War, that of classical military psychiatrywas the story of a success. The story was that, if the proper treatmentwas provided, 80% or more of mass casualties suffering from a combatrelated mental breakdown could be cured within a few days. Thiswas just the news needed in a cold war with few if any reserves inmanpower on the Western side. The cured mental casualties were thepotential reserve in manpower. Fortunately the cold war neverbecame hot. So we will never know if the story was true. But lookingback, what were the facts behind the story? Late in the First WorldWar, Salmon introduced the concept of forward psychiatry. However,we know very little about possible effects of this intervention. Salmonalso introduced the concept of ‘preventive psychiatry’, meaning predeploymentselection of personnel by psychometric measures withthe purpose to deselect future mental breakdowns. Used for the firsttime in large scale in the beginning of the Second World War, preventivepsychiatry turned out to be a failure and for this reason the AlliedArmies reintroduced forward psychiatry. Although there was certain-77

ly a tendency that the number of mental and physical mass casualtiesvaried with the roughness of combat, there was only limited evidencefor the effect of acute psychiatric intervention. We have only limiteddata from the Korean War and as of the Vietnam War data are inconclusive.However, the conclusion might very well be that the story ofclassical military psychiatry was too good to be true. But there isanother story. In modern Western warfare there is a limited number ofcasualties and no mass casualty situations. A significant fraction ofveterans, however, develops post-deployment syndromes, the natureof which remains at least partially obscure. These disorders give riseto significant morbidity. The so-called Gulf War syndrome is an example.It seems that every major war has produced a similar syndrome ofits own. Most of these veterans do not fulfil the diagnostic criteria forpost-traumatic stress disorder and it remains to be proved that thesedisorders are long-term consequences of combat stress or cumulatedstress. These veterans claim to have a psychical disease rather than amental one and typically they relate their disease to environmentalcombat factors rather than to stress. It is the challenge of future militarypsychiatry to address these complicated questions. The main taskof future military psychiatry may no longer be to handle mass casualtysituations during combat but to diagnose and offer treatment toveterans with post-deployment disorders.SS29.QUALITY IMPROVEMENT: PRACTICEGUIDELINES AND SUICIDE PREVENTION(Organized by the WPA Section onQuality Assurance in Psychiatry)SS29.1.TREATMENT GUIDELINES IN SCHIZOPHRENIAW. Gaebel, S. WeinmannDepartment of Psychiatry and Psychotherapy, Heinrich-HeineUniversity, Dusseldorf, GermanyMental disorders pose an increasing burden on societies all over theworld. At the same time, treatment variations within and betweencountries are prevalent. Reasons for this have to be investigated inorder to improve care for people with mental disorders. The WorldPsychiatric Association (WPA), Section on Schizophrenia (W.Gaebel), Section on Quality Assurance (J. McIntyre), and N. Sartorius;the World Health Organization (WHO) Regional Office forEurope (W. Rutz); and the German Society of Psychiatry, Psychotherapyand Nervous Diseases (DGPPN), Section on Quality Assuranceand Guidelines (W. Gaebel), have set up a program on TreatmentGuidelines in Psychiatry. The program is coordinated by the UniversityDepartment of Psychiatry, Dusseldorf, Germany. The aim of theprogram is: a) to collect existing treatment guidelines worldwide, b) toevaluate these guidelines according to predefined criteria, c) to comparethem with respect to key recommendations, d) to investigateregional, cultural and other specific characteristics, and e) to estimatethe impact on psychiatric care in different countries. National scientificsocieties and other national institutions concerned with mentalhealth care have been addressed using a specifically developed questionnaire.Results of this survey will be presented.SS29.2.THE AMERICAN PSYCHIATRIC ASSOCIATIONPRACTICE GUIDELINE PROJECT: STATUSAND CHALLENGESJ. McIntyreDepartment of Psychiatry and Behavioral Health, Unity HealthSystem, Rochester, NY, USAThe American Psychiatric Association has published 12 practice guidelinesover the past decade. Most of the guidelines are Axis-I disorderbased, but the most recently published guidelines are on suicidalbehaviours, and last year the first guidelines for a personality disorder(borderline personality disorder) were published. The guidelines arebeing increasingly used in the United States, and some of them havebeen translated into 9 languages. A number of derivative products havebeen developed, including quick reference guides to increase the use ofthe guidelines by psychiatrists in their day-to-day clinical work. In furtherincreasing the use of the guidelines a number of challenges remain.These will be discussed in this presentation and include increasing theexposure to the guidelines in residency programs, developing otherderivative products including pocket cards and personal digital assistant(PDA) versions, being used by managed care organizations andother systems of care. Issues concerning the development of internalguidelines will be highlighted.SS29.3.QUALITY IMPROVEMENT EFFORTS ANDPRACTICE GUIDELINES: WHOSE GUIDELINES?J. Arboleda-FlorezDepartment of Psychiatry, Queen’s University, Kingston, CanadaOver the past several years, and in an attempt at improving the qualityof medical intervention, there has been a proliferation of practiceguidelines and other methods against which to measure whether aparticular intervention meets standards for evidence-based medicine.Whether practice guidelines are a good method to improve quality ofcare or a hindrance and a threat to independent medical decisionmakingdepends on many factors, not the least the originators of theguidelines or those who have commissioned their compilation. Practiceguidelines like evidence-based medicine itself cannot be taken aspanaceas for quality improvement. Many times they are not what theylook to be in the surface, so they require a critical review and a scepticalapproach before they can be fully accepted and implemented.This presentation will review some pitfalls of practice guidelines withinthe general contexts of evidence-based medicine.SS29.4.A NATIONWIDE PREVENTION PROGRAMOF DEPRESSION AND SUICIDE IN ICELANDH. Oskarsson, S.P. Palsson, O. Gudmundsson, W. Nordfjord,T. Magnussson, A. Ingvadottir, O. Thoregeirsson, S. Bjarnadottir,S. GudmundssonNational Prevention Against Depression, Directorate of Health,Reykjavik, IcelandOur program is shaped after a German model, tested in at least onesite in Germany and which is currently being organized/launched inseveral European sites. This project works simultaneously at the levelof primary health care, important multipliers or keyholders (teacherand school consultants, social services workers, policeman, priests,media), high-risk groups and the general public. It consists of trainingworkshops, public information, pamphlets, videotapes, posters and78 World Psychiatry 3:S1 - October 2004

other means. Outcome evaluation in based on impact of training,changes in suicide and suicide attempts rates, changes in antidepressantprescription patterns and public attitude towards depression.The programme was launched in the spring of 2003. Initial assessmentof public knowledge showed a reasonably sophisticated level ofknowledge of depression and little prejudice. The training workshopsconcluded so far have received a highly favourable rating by all participants.Baseline measures are available for all parameters and willbe repeated annually for the next three years. No conclusions on theimpact can be drawn as yet. We will discuss some of the obstacles metin launching a program nationwide and the difficulties in measuringchanges in a small population such as resides in Iceland.SS30.NEW PERSPECTIVES ON NEUROIMAGING INSCHIZOPHRENIA (Organized by the Sectionon Neuroimaging in Psychiatry)SS30.1.CORTICAL AND SUBCORTICAL BRAIN VOLUMESIN DEFICIT AND NONDEFICIT SCHIZOPHRENIA:A MULTICENTER MRI STUDYA. Vita 1 , S. Galderisi 2 , U. Volpe 2 , M. Quarantelli 3 , G.B. Cassano 4 ,A. Rossi 5 , A. Mucci 2 , B. Alfano 3 , M. Maj 21 Department of Mental Health, S. Maria delle Stelle Hospital,Melzo, Milan; 2 Department of Psychiatry, University of NaplesSUN, Naples; 3 National Council of Research, Institute ofBiostructure and Bioimaging, Naples; 4 Department of Psychiatry,Neurobiology, Pharmacology and Biotechnology, University ofPisa; 5 Department of Experimental Medicine, University ofL’Aquila, ItalyStructural brain imaging studies comparing patients with deficitschizophrenia (DS) with patients with nondeficit schizophrenia(NDS) have yelded inconsistent findings. In a multicenter study,sixty-five patients with a DSM-IV diagnosis of schizophrenia (34 DSand 31 NDS) and 27 healthy controls were enrolled. Each subjectunderwent a conventional spin echo magnetic resonance imaging(MRI) examination and both cortical and subcortical gray matter volumeswere analyzed. Gray matter volumes were decreased in frontaland temporal lobes in the whole patient group, when compared tocontrols. All the evaluated subcortical structures, with the exceptionof the left caudate, showed an increased volume in the patient group,which was statistically significant for the pallidum and thalamus.Thalamic and lateral ventricles volumes were increased in the NDSgroup, with respect to healthy controls. The volume of right thalamuswas larger in NDS than in DS patients. The relationships betweenantipsychotic treatment and the volume of subcortical structures werethen investigated. Fifteen patients were treated with standard antipsychotics,38 with novel antipsychotics and 7 with both types of drugs.ANCOVA analyses revealed that the volumetric abnormalities foundin DS vs. NDS patients were not related to the dose or type of antipsychotictreatment or to the illness duration. Brain morphological differencesbetween DS and NDS lend support to the hypothesis thatthe two syndromes may have different etiopathogenetic mechanisms.At least in chronic and stabilized patients with schizophrenia, volumeincrease in subcortical structures seems to be independent of antipsychotictreatment.SS30.2.PHARMACOGENOMICS OF ANTIPSYCHOTICSIN SCHIZOPHRENIA: A ROLE FOR FUNCTIONALNEUROIMAGING?A. Bertolino 1,2,3 , G. Caforio 1 , G. Blasi 1,2 , M. De Candia 1 ,V. Latorre 1 , V. Petruzzella 4 , M. Altamura 1,2 , G. Nappi 1 , S. Papa 4 ,J.H. Callicott 2 , V.S. Mattay 2 , A. Bellomo 5 , T. Scarabino 3 ,D.R. Weinberger 2 , M. Nardini 11 Department of Psychiatric and Neurological Sciences,University of Bari, Italy; 2 Clinical Brain Disorders Branch,National Institute of Mental Health, National Institutes ofHealth, Bethesda, MD, USA; 3 Department of Neuroradiology,Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia,Italy; 4 Department of Medical Biochemistry and Medical Biology,University of Bari, Italy; 5 Institute of Psychiatry and ClinicalPsychology, Department of Medical Sciences, University ofFoggia, ItalyMolecular genetic approaches provide a novel method of dissectingthe heterogeneity of psychotropic drug response. These pharmacogeneticstrategies offer the prospect of identifying biological predictorsof psychotropic drug response and could provide the means of determiningthe molecular substrates of drug efficacy and drug-inducedadverse events. In this sense, choosing the right phenotype is a keyissue. We are pursuing use of intermediate phenotypes to try andunravel the complexity of genetic susceptibility to schizophrenia andthe heterogeneity of response to treatment with antipsychotics. Forexample, deficits in working memory (WM) and in prefrontal corticalphysiology are important outcome measures in schizophrenia andboth have been associated with dopamine dysregulation and with afunctional polymorphism (Val108/158 Met) in the catechol-O-methyltransferase (COMT) gene that affects dopamine inactivation in prefrontalcortex. We performed a study in patients with schizophreniato evaluate the effect of COMT genotype on variation in symptomatology,WM performance, and prefrontal cortical physiology inresponse to treatment with an atypical antipsychotic drug. 30 acuteuntreated patients with schizophrenia were clinically evaluated withthe Positive and Negative Syndrome Scale (PANSS), were genotypedfor COMT val/met, and entered a prospective study of eight weeks oftreatment with olanzapine. Twenty patients completed two functionalmagnetic resonance imaging (fMRI) experiments, at four and ateight weeks, using a 3T magnet and the N-back task. There was a significantinteraction of COMT genotype and the effects of olanzapineon prefrontal cortical function. Met allele load predicted improvementin WM performance and prefrontal physiology after eight weeksof treatment. A similar effect was found also for negative symptomsassessed with the PANSS. These results suggest that a geneticallydetermined variation in prefrontal catabolism of dopamine impactson the therapeutic profile of olanzapine. Furthermore, use of intermediatephenotypes seems to be promising to contribute clarificationsto the heterogeneity of response to treatment with antipsychotics.79

SS30.3.IMAGING THE FRONTO-STRIATO-THALAMICCIRCUIT IN SCHIZOPHRENIAM.S. Buchsbaum 1 , W. Byne 1 , B.T. Christian 2 , D.S. Lehrer 2 ,E. Hazlett 1 , E. Kemether 1 , S. Mitelman 1 , R. Prikyrl 3 ,L. Shihabuddin 1 , A. Brickman 11 Mount Sinai School of Medicine, Department of Psychiatry,New York, NY, USA; 2 Wallace-Kettering Neuroscience Institute,Dayton, OH, USA; 3 Psychiatry Department of Faculty Hospital,Brno, Czech RepublicIn a series of imaging studies we examined the components of thefronto-striato-thalamic circuit. High-resolution magnetic resonance(MR) and diffusion tensor images were acquired in patients withschizophrenia (n=106) and normal comparison subjects (n=42) and asubset of 101 subjects had the medial dorsal and pulvinar tracedby fluorine 18-fluorodeoxyglucose positron emission tomography(FDG-PET) while off medication. In a separate cohort of 13 normalsand 12 never previously medicated patients, PET scans with D2/D3ligand 18F-fallypride and with FDG were obtained. Patients withschizophrenia had smaller medial dorsal nuclei, and showed reducedrelative metabolic rates in both previously medicated and never-medicatedsamples. 18F-fallypride binding potential was reduced in theregion of the medial dorsal nucleus and this was confirmed both withsignificance probability mapping and with traced nuclei. Putamenswere bigger in patients with schizophrenia who had previouslyreceived neuroleptic treatment. The frontal lobe was reduced in sizein patients with schizophrenia and showed relatively less FDGuptake in never-previously medicated patients. The anterior limb ofthe internal capsule where thalamocortical fibers linking the medialdorsal and other thalamic nuclei pass on their way to the prefrontalregion was of smaller size in patients with schizophrenia. Takentogether, these studies indicate the importance of the fronto-striatothalamiccircuit in schizophrenia and suggest that the thalamusand/or striato-thalamic interaction may be a more important anatomicalsubstrates of drug action than previously appreciated.SS30.4. SCHIZOPHRENIA P50 SENSORY GATINGDEFICIT: CLINICAL AND NEUROCOGNITIVECORRELATESJ.M. Canive 1,2 , R.J. Thoma 1,2 , F.M. Hanlon 3 , M. Huang 4 ,G.A. Miller 51 Psychiatry Service, New Mexico VA Health Care System,Albuquerque; 2 Department of Psychiatry, University of NewMexico Health Sciences Center, Albuquerque; 3 Department ofPsychology, University of New Mexico, Albuquerque;4 Department of Radiology, University of New Mexico HealthSciences Center, Albuquerque; 5 Department of Psychology andBeckman Institute, University of Illinois at Urbana-Champaign,USAInadequate inhibition of redundant sensory information, measuredas a deficit in auditory sensory gating, is thought to underlie reportsof sensory overload and attentional dysfunction in patients withschizophrenia. EEG studies have documented abnormal modulationof sensory information, assessed by P50 amplitude in an auditorypaired-click paradigm. Since P50 has traditionally been measuredusing EEG at one central electrode (Cz), little information is availableabout hemispheric differences in sensory gating among controlsand patients. Unlike standard EEG signal processing, magnetoencephalography(MEG) permits independent left and right hemisphereM50 source strength measurements. In addition to the issue of laterality,the relationship of the P50 gating deficit to clinical phenomenahas not been fully explicated. Event-related EEG and MEG weresimultaneously recorded from 20 patients with schizophrenia and 15controls in an auditory sensory gating paradigm. EEG and MEG gatingratios were calculated as P50/M50 amplitude following the secondstimulus divided by that for the first stimulus (S2/S1). The Positiveand Negative Syndrome Scale (PANSS), the Scale for the Assessmentof Negative Symptoms (SANS) and a neuropsychological testbattery were administered. M50 dipoles localizing to superior temporalgyrus demonstrated gating similar to that of P50. As expected,patients demonstrated less P50 gating than did controls. Left- but notright-hemisphere M50 gating correlated with EEG gating, differentiatedpatients and controls, and correlated with symptom ratings andwith neuropsychological measures of sustained attention and workingmemory. Converging evidence from EEG and MEG sensory gatingmeasures, psychopathology ratings and neuropsychological measuresstrongly suggests a left-hemisphere dysfunction in schizophreniathat is strongly related to the well established sensory gating deficit.SS31.WELL-BEING AND QUALITY OF LIFE IN THE 21STCENTURY (Organized by the WPA Section on MassMedia and Mental Health)SS31.1.WELL-BEING AND QUALITY OF LIFE IN THE 21STCENTURYM.A. MaterazziFoundation for Interdisciplinary Investigation of Communication,Buenos Aires, ArgentinaWell-being and quality of life are parameters supported by both theeducation and culture of societies. For the time being, however, theyare strongly hindered by violence, discrimination, and a certainbanalité that, at times, bursts out violently and, at other times, seemsto be subtly in disguise. It is thus absolutely necessary that the structureand means of education are firmly sustained, and we proposethat such support be created on the basis of a mix between the teachingsof the brillant pedagogists from the 20th century Iván Ilich andPablo Freire, who keep being in full force in our century.SS31.2.MIGRATION AND MENTAL HEALTH: THE ROLE OFTHE MASS MEDIAM. De BerardinisLocal Health Unit, Florence, ItalyWithin the frame of the globalization effects that are characteristic ofthe beginning of this new century, we comment on the impact onmental health of the migration process which took place from Albaniato the Florence area of Mugello. Our study examined in particularthe role of the mass media in the above mentioned phenomenon aswell as in the integration of these Albanian migrants with the localculture.80 World Psychiatry 3:S1 - October 2004

SS31.3.THE RELATIONSHIP WITH THE MEDICAL STAFFAND QUALITY OF LIFE IN ONCOLOGYP.M. FurlanMental Health Department, San Luigi Gonzaga Hospital,University of Turin, ItalyWe have developed a brief instrument, the Patient Alliance Index(PAI), to measure the patients’ perception of the alliance with themedical staff and its correlation with the modifications of their qualityof life (QoL) during advanced oncological illness. In all theadvanced stages of illness, where the patient and his/her relatives areincreasingly involved in the care provision, QoL becomes one of themain factors conditioning the treatment. To guarantee success, the“quality of the relationship” that has been established between thepatient, his/her relatives and the staff is crucial. In fact, all the eventsof the oncological treatment take place within a relational field thatdefines the impact and the significance of the whole course of events.A functioning relationship with the staff may help patients to “contain”difficult emotions, to face the ongoing reality and even to bettertolerate the side effects of treatment. On the contrary, if the relationshipwith the staff is too “technical”, the patient feels himself/herselfin the hands of an illness that is progressively worsening, increasingthe experience of fear, desperation and loss of control. Since thesymptoms are the link with the medical staff, the patient may beinduced, more or less consciously, to give expression to his/her emotionalneeds through the language of physical symptoms. Our studysuggests that the PAI can be regarded as an easy to use and relevantinstrument characterised by a validity evaluated by an expert teamand by patients. From a psychometric viewpoint, it is mono-factorialand characterised by a high self-consistency. A reduced psychologicaldistress was associated with an improvement in the alliance with thestaff. A reduced alliance was associated with the worsening in theoccurrence of symptoms such as pain, appetite loss and constipation.SS32.ECOLOGICAL CHANGES AND MENTAL DISTRESS:THERAPEUTIC PERSPECTIVES (Organized by theWPA Sections on Ecology, Psychiatry and MentalHealth, and on Mass Media and Mental Health)SS32.1.THE MASS MEDIA, THEIR ENVIRONMENTPERCEPTION, AND CONSEQUENCES THEREOFON MENTAL HEALTHM.A. Materazzi, I.-J. PuigFaculty of Medicine, University of Buenos Aires, ArgentinaCurrently, it could be said that the mass media are eager to replace theAthens Academy by just manipulating information so that anabsolute dominion is generated upon the communities they want tosubdue by any spurious means at hand. Hence, a mix between IvanIlich’s proposal, and Pablo Freire’s proposal, i.e. de-schooling on theone hand and increasing the public awareness of the communities onthe other hand could be a good possibility to intercept the schemingof the Power, even though we are aware that this is to be an unevenstruggle for the time being. Struggle, however, could be strengthenedgradually so that George Orwell’s 1984 forecast would not come true.To the contrary, the “Book Men” Ray Bradbury created in Fahrenheit451 could be in a position to targeting this aim.SS32.2.ECOLOGY AND MENTAL HEALTH IN DEVELOPINGCOUNTRIES: AN EGYPTIAN PERSPECTIVET.A. OkashaInstitute of Psychiatry, Ain Shams University, Cairo, EgyptAfrica is a large continent, prone to strife, especially south of theSahara. Most of its countries are characterized by low incomes, highprevalence of communicable diseases and malnutrition, low lifeexpectancy and poorly staffed services. Mental health issues oftencome last on the list of priorities for policy makers. Where mortality isstill mostly the result of infectious diseases and malnutrition, the morbidityand disablement due to mental illness receive very little attentionfrom the government. Health in general is still a poorly funded area ofsocial services in most African countries and, compared to other areasof health, mental health services are poorly developed. This talk willdiscuss the effect of ecology on psychiatry and mental health in developingcountries, taking Egypt, a North African country, as an example.SS32.3.ECOLOGICAL PSYCHIATRY: BIOLOGICALAND PSYCHOLOGICAL ASPECTSV. KrasnovMoscow Research Institute of Psychiatry, Moscow, RussiaEcological psychiatry, which developed at the end of the last century,had different background, basic thesis, and focuses of attention inWestern and Eastern Europe. Among different ecological (outward)factors which influence individuals’ and groups’ health, WesternEurope researchers focused on micro social environment. In Russiaand other countries of Eastern Europe, the ecological branch of psychiatryfocused on technogenic accidents’ consequences and unfavorablephysical and chemical industrial factors, as well as particularclimatic and geographic conditions. Psychological factors were consideredsecondary. The revealed disorders mostly corresponded toexogenous reaction type to outward influences. Nevertheless, longtermexamination and treatment of patients with ecology related disordersmakes us regard these states as the reflection of a whole consistingof biological and psychological factors. Cognitive, affectiveand asthenic disorders of psychorganic type provoke repeated psychologicalproblems in families, prevent professional activity andcomplicate or limit social contacts. Polymorphic symptomatology ofdisorders is sometimes complicated by neurosis-like disorders andpersonality deviations. In addition, alcohol abuse quite often createsnew psychosocial problems. Modern trends of development in ecologicalpsychiatry include studying of both biological and psychologicalaspects of pathological states. Treatment of disorders caused orprovoked by ecological unfavorable factors include pharmacotherapy,psychotherapeutic and psychosocial methods, as well as provisionof social support. Family and closest social environment play a significantrole in patient’s social adaptation.SS32.4.SOCIO-CULTURAL CHANGES AND TREATMENTOPTIONS FOR PSYCHIATRIC DISORDERS INDEVELOPED COUNTRIESL. Janiri 1 , M. Nardini 21 Institute of Psychiatry, Catholic University, Rome;2 Chair of Psychiatry, University of Bari, ItalyChanges of human environment, in its social and cultural aspects,influence the approach to the psychiatric disorders, which are in turn81

modified by these changes. The rapid and dramatic increase in mood,anxiety, impulse control, substance use and eating disorders in thelast decades reflects broad phenomena of developed countries suchas population turnover, worsening of relationships, media perception,evolution of people’s life style and way of thinking. For instance,panic attacks and post-traumatic stress disorder are syndromes thatuntil a few years ago were not recognized or underestimated and noware in need of adequate integrated treatments. It could be said that“new” psychopathological entities represent reactive and copingmodalities rather than ordinary forms of illness according to the medicalmodel. Likewise, behavioral disturbances and personality disorderstake place instead of more functional and organized adjustmentattempts. In line with a process which could be defined as “psychopathomorphosis”,treatment options in psychiatry are changing:self-help groups, non-conventional groups and communities, dayhospital settings are increasingly available among the therapeuticresources. More eclectic and resilient attitudes are requested from thetherapists’ educational track so that they are enabled to face suchemerging situations. The complexity of treatment programs is growingand is shared by both territorial and hospital services.SS33.TOPICS OF PREVENTION: EVIDENCE ANDRESEARCH (Organized by the WPA Section onPreventive Psychiatry)SS33.1.WHAT WORKS IN MENTAL DISORDERPREVENTION: A REVIEW OF INTERNATIONALEVIDENCES. Saxena 1 , C. Hosman 2 , E. Jane-Llopis 21 World Health Organization, Geneva, Switzerland;2 University of Nijmegen, The NetherlandsPrevention of mental disorders is a public health priority in view ofthe enormous burden these disorders cause and the limitations ofexisting methods of treatment. However, the attention and resourcesearmarked for prevention have been rather scarce so far. Increasingevidence on effectiveness of prevention can lead to more widespreadutilization of these interventions all over the world and especially inlow and middle income countries where the need is the greatest.Effective preventive interventions include macro-strategies (e.g.improving nutrition, housing, access to education, reducing economicinsecurity, strengthening community networks and reducing use ofaddictive substances). Meso- and micro- level strategies can reducestressors and enhance resilience; these include home-based and preschoolinterventions in early years of life, reducing child abuse andneglect, managing parental mental illnesses for benefits to children,school-based programmes to reduce risks and to enhance resilience,prevention of family disruption, interventions at workplace and thosetargeted to the elderly, chronically ill and other vulnerable groups. Inaddition, a number of strategies are available to prevent specific mentalconditions like conduct disorders, depressive, anxiety and eatingdisorders, substance use disorders, psychotic disorders and suicides.Wider utilization of these strategies requires integration of scientificknowledge into policy and programmes and developing effectivelinks with other sectors.SS33.2.CONTRIBUTION OF THE HELLENIC PSYCHIATRICASSOCIATION TO PSYCHIATRIC PREVENTIONIN GREECEG.N. Christodoulou, V. Alevizos, V. Kontaxakis,D. AnagnostopoulosHellenic Psychiatric Association, Athens, GreeceNational associations can play an important role in activities aimingat psychiatric prevention. The Hellenic Psychiatric Association hasestablished a special program to advance this scope on the basis ofthe following: mental health promotion addressed to the general public;seminars for general practitioners; the Athens Mental Health PromotionProgram, organized jointly with the Athens UniversityDepartment of Psychiatry, the Section of Preventive Psychiatry of theWPA and other agents; special seminars for priests of higher education.There are plans for expansion of this program especially towardsmore extensive use of the media.SS33.3.PROMOTING WELL-BEING AND HEALTH INRURAL AND REMOTELY BASED POPULATIONSS. RajkumarUniversity of Newcastle, Bloomfield Hospital, Orange, AustraliaThe paper outlines conceptual issues on health and well-being inrural and remote populations. Drawing lessons from Australian ruralexperience, mental health promotion programmes that are effectiveare discussed. Rural settings have difficulties in retention and recruitmentof mental health workers and doctors. Given these restraintsand the geographical isolation, the quality of care needs to be managedby community health workers, primary care doctors and thenurses in general. Effective programmes need to keep a life spanapproach in implementing a spectrum of interventions. A comparisonis made of rural and remote areas. Mental health promotion in relationto farming communities, vulnerable families, ageing in the countryare covered. Promoting well-being and health in aboriginal peoplein remote areas is explored. Concepts of well-being, health promotionstrategies and factors causing mortality, morbidity, suicide, and incarcerationin institutions are further elaborated. Efficacy and effectivenessof mental health promotion programmes in rural settings arecritically reviewed and suggestions offered on developing moreappropriate prevention and promotion activities.SS33.4.WHAT CAN WE LEARN FOR PREVENTION ANDTREATMENT FROM PROTECTIVE HEALTHRESOURCES REPORTED BY MENTAL PATIENTS?M. SchmolkeDynamic Psychiatric Hospital Menterschwaige, Munich, GermanyThe paper outlines the concept of psychological (personal) and external(social) resources and their protective functions in diseaseprocesses and health care. The concept of resources needs to beembedded into a broadly conceptualized prevention frameworkwhich includes a positive health orientation. This would involve ahealth promotion and salutogenesis orientation complementing apathogenetic orientation which focuses on diseases, deficits and riskavoidance. Recent research results on protective health resources inschizophrenic patients (such as self help, coping, regulatory activitiesand social support networks) are presented and their clinical valuefor prevention and treatment is discussed.82 World Psychiatry 3:S1 - October 2004

SS33.5.BURNOUT SYNDROME AMONG PRIMARYCARE PHYSICIANS: A NEED FOR PREVENTIOND. Lecic-Tosevski 1 , S. Dimic 1 , B. Pejuskovic 1 ,E. Tanovic-Mikulec 2 , B.O. Hoftvedt 31 Institute of Mental Health, School of Medicine, University ofBelgrade, Serbia and Montenegro; 2 Institute of Public Health,Sarajevo, Bosnia and Herzegovina; 3 Committee for HumanRights, Norwegian Medical Association, Oslo, NorwayThe burnout syndrome has been claimed to affect a great percentageof human service professionals. Its etiology is multidimensional andincludes a variety of organizational, environmental and individualfactors. Our study aimed to assess the level of burnout among primarycare physicians. The sample consisted of 111 general practitioners (31from Sarajevo, 41 from Oslo and 39 from Belgrade), who were examinedby the Maslach Burnout Inventory, measuring the three dimensionsof exhaustion, depersonalization and inefficacy. The inventorywas administered during training seminars on mental health in primarycare. The highest burnout scores were found in Belgrade physicians,followed by the Sarajevo and Oslo samples. The emotionalexhaustion was correlated with the female gender as well as with thedaily number of patients. Since burnout affects personal well-beingand professional performance, it is important to undertake preventivemeasures against its development, such as strategies focused on individualand organization.SS34.UPDATING SUICIDOLOGY (Organized by the WPASection on Suicidology)SS34.1.VIOLENCE AND SUICIDALITY – A MODERN ISSUE?J.P. SoubrierWPA Section on SuicidologyThe discussion is based on the link between suicide and violence.Definitions are different: suicide, as a crime against oneself, an act ofdespair; violence, as a criminal act against others. Prevention hasbeen organized differently. In 2002, the World Health Organization(WHO) Report on Violence – A Planetary Challenge included suicidefor the first time, proposing three categories of violence. Psychoanalyticalapproaches will be described as well as modern suicidologicalapproaches. Cultural and biological information will also be given.An up-to-date socio-political report (France) will be presented. Allthis confirms the research made by Van Praag on violence and suicidality.SS34.2.GLOBAL PERSPECTIVES IN SUICIDAL BEHAVIOURJ.M. BertoloteWorld Health Organization, Geneva, SwitzerlandAlthough the impact of mortality associated with suicide is knownfrom general mortality data banks (such as the one maintained andupdated by the World Health Organization, WHO), there is no systematiccollection of data related to morbidity (including disability),associated with a variety of suicidal behaviours, particularly suicideattempts. In the absence of population data on that, measures of suicidalideation and planning have been proposed as indirect indicatorsof the potential burden of suicidal behaviours in general. Data from arecent WHO study conducted in representative general populationsamples from ten countries will be presented and discussed. Thesedata refer to suicidal ideation, planning and attempts, and their eventualensuing contacts (or not) with health care services.SS34.3.THE RELEVANCE OF CHILD TRAUMA TO THEPSYCHOPATHOLOGY OF SUICIDAL BEHAVIOURSM. Sarchiapone, G. Camardese, V. Carli, C. Cuomo, R. Lacerenza,P. Madia, S. De RisioInstitute of Psychiatry, Catholic University, Rome, ItalySuicidal behaviours are characterized by a phenomenology whoseetiology consists of a constellation of components that act together,which vary from one individual to another. Risk factors, from an epidemiologicalperspective, can be organized in a framework that differentiatebetween predisposing factors and potentiating factors. Toexamine psychopathological predisposing risk factors for suicidalbehaviour in depressed patients we interviewed 70 patients and completedthe Childhood Trauma Questionnaire (CTQ) and Eysenck PersonalityQuestionnaire (EPQ). We will present data showing the relevanceof psychopathological variables and childhood trauma to suicideattempts of depressed patients.SS34.4.TEACHING SUICIDAL CRISIS INTERVENTIONTO HEALTH CARE PERSONNEL AND MEDICALSTUDENTSJ.P. KahnDepartment of Psychiatry and Clinical Psychology,CHU de Nancy, FranceSuicide prevention has been considered as one of the major publichealth priorities by the National Health Conference in France since1999. In this context the Department of Health (Ministère de laSanté) launched several programs, among which a National ConsensusConference on «Detecting and taking care of a suicidal crisis»(October 2000) and a nationwide program aiming at teaching practicalintervention skills to medical staff, nurses, social workers, andother primary care personnel. This program and how it was set up inLorraine will be presented and its advantages and drawbacks discussed.SS34.5.SUICIDE IN BORDERLINE PERSONALITYDISORDERR. TatarelliDepartment of Psychiatry, Sant’Andrea Hospital, La SapienzaUniversity, Rome, ItalyEstimates of the lifetime risk of death by suicide among patients withborderline personality disorder (BPD) range from 3% to 9.5%.Patients with BPD represent 9% to 33% of all suicides. According tosome studies, patients with chronic suicidality who made 4 or morevisits in a year to a psychiatric emergency often meet criteria for BPD.A high incidence of BPD in the adolescents and young adults aged 15to 24 years who engage in suicidal behavior has also been reported.Those at higher risk appeared to be young, ranging from adolescenceinto the third decade, which likely reflects a decrease in symptomsseverity later in adulthood for most patients. The high rates of suicidalbehavior in patients with BPD are reflected by the inclusion of83

ecurrent suicidal behavior, gestures, threats, or self-mutilating behavioras diagnostic criteria in the DSM-IV. A history of suicidal behavioris found in 55% to 70% of individuals with a personality disorderand in 60% to 78% of individuals with BPD. Suicides by individualswith BPD may carry an extra burden for survivors. Putative risk factorsfor attempted or completed suicide in BPD, derived from clinicalreports and longitudinal follow-up studies, include: a) comorbiditywith affective disorder; b) alcohol and substance abuse; c) impulsivity,aggression, and hostility; d) repeated attempts; e) antisocial traits;and f) severity of the disorder. Borderline patients who attempted suicidehave more substance abuse than control subjects. Various studiesfound that the suicide attempters suffering from BPD had experiencedmore adverse life events recently, particularly in the area ofstressful events at home, with the family, or financially. Our metaanalysisshows that suicide among patients with BPD is more frequentthan in the general population. All studies except two reportedthat patients with BPD committed suicide more often than theircounterparts in the general population.SS34.6.DEPRESSION AND SUICIDE BEHAVIOUR IN THEELDERLY IN ROMANIAN. TataruAmbulatory Psychiatric Clinic, Oradea, RomaniaThe aging of population is becoming a reality in developed and lessdeveloped countries. As aging is a period of decline, to understandbetter the needs of the elderly, we must analyse the significant lossesof late life, which contribute directly or indirectly to the high prevalenceof depression and other psychiatric disorders. Multiple losses inold age are important in decreasing the quality of life and increasingmental health problems in the elderly. Suicide and attempted suicideare one of the major health problems in the world. In all countries oldpeople are the most vulnerable of all groups in human life span. Thereare very few studies on suicide and attempted suicide in Romania. Inthe traditional Romanian society, the elderly usually enjoyed muchrespect and care. The social and cultural changes, with an increase inurban life style and a decrease in the three generation family support,are now a dwindling of our traditional family life and also a challenge.This study presents an analysis of suicidal behaviour in a 50 year andover group from Bihor county, Romania. The aim of this study was toassess any risk factors for parasuicide and completed suicide in a fiveyearfollow-up of a sample of elderly suicide attempters. We made acomparison of people who committed or attempted suicide with controlsmatched for age, gender, ethnicity, profession and community ofresidence. To find predictors of suicide in old age is an urgent task forprevention. Caring of the elderly requires an understanding of biologicalchanges in late life and of the specificity of elderly mental disorders.It also requires the recognition of the medical comorbidity in theelderly and the high prevalence of depression. We believe that mentaldisorders in the elderly are underrecognized and undertreated. Thesedisorders could be more recognizable and better treated if we used aneducational prevention program for primary care and a combinationtreatment including psychopharmacotherapy and community care.SS35.PSYCHOIMMUNOLOGY: EVIDENCE ANDPERSPECTIVES (Organized by the WPA Sectionon Immunology and Psychiatry)SS35.1.IMMUNOLOGY: CURRENT CONCEPTS INPSYCHIATRIC DISORDERSM. AckenheilPsychiatric Hospital of the University of Munich, GermanyAlterations of the immune system (IS) are described in various psychiatricdisorders. Considering abnormalities of brain functions (BF),especially at the level of neurotransmitters and the endocrine system(ES), and with regard to our current knowledge of cross talksbetween these three systems, it is easy to understand that the IS itselfmust be involved in the etiopathogenesis of psychiatric disorders.Nowadays it is widely accepted that psychological stress and psychiatricillnesses may interfere with immune functions. Vice versa,altered immune functions due to somatic illnesses like HIV infection,neurodegenerative disorders and autoimmune diseases interfere withbrain activities leading to abnormal behaviours. An outline of ourknowledge of interactions between IS, ES and brain functionsexplains possible abnormalities in relation to psychiatric disorderslike schizophrenia, depression, Alzheimer’s disease and functionalsomatic symptoms (e.g. fibromyalgia, chronic fatigue syndrome). Themost abnormal clinical findings so far are reported in schizophrenia,a subgroup of which most probably is caused by immune disturbances.In affective disorders, either immune abnormalities inducebehavioural symptoms or the concomitant stress causes abnormalitiesof the IS. Other complex interactive models are discussed for anxietydisorders and organic brain diseases. Current research activitiesshould not be restricted to one single system but must connect thethree systems in a comprehensive way.SS35.2.IMMUNOLOGICAL RESEARCH IN NEUROLOGICALAND PSYCHIATRIC DISORDERSM. Clerici 1 , D. Trabattoni 1 , C.L. Cazzullo 21 Chair of Immunology, University of Milan; 2 Association forResearch on Schizophrenia, Milan, ItalySeveral lines of evidence suggest a role for the immune system in themultifactorial pathogenesis of schizophrenia and other psychiatricand neurodegenerative diseases. We report the results of our researchon cytokines in different groups of psychiatric and neurologicalpatients. We observed a predominant type 1 cytokine profile in acutemultiple sclerosis patients, while IL-10 production predominated instable multiple sclerosis individuals. The modifications of cytokineprofiles observed in schizophrenic patients suggest that clinicalimprovement is associated with a reduction in the inflammatory-likesituation present in those not currently under treatment. Our data onAlzheimer’s disease (AD) support the role of the inflammatoryprocess in the pathogenesis of AD and reinforce the hypothesis thatthe neurodegenerative processes in the AD patients are associatedwith an abnormal antigen-specific immune response. The activationof immune system mechanisms observed in obsessive-compulsive disordercould be due to the combination of endogenous (hormonalalterations associated to the modifications in the hypothalamic-pituitary-adrenalaxis) and exogenous (viral or bacterial infection) factors.84 World Psychiatry 3:S1 - October 2004

SS35.3.GENE POLYMORPHISMS INNEURODEGENERATION: INFLAMMATORY ASPECTSB. Arosio 1 , D. Trabattoni 2 , L. Galimberti 1 , G. Annoni 3 ,M. Clerici 2 , C.L. Cazzullo 4 , C. Vergani 11 Chair of Gerontology and Geriatrics, Department of InternalMedicine, University of Milan; 2 Chair of Immunology, Universityof Milan; 3 Department of Clinical Medicine, Prevention andMedical Biotechnology, University of Milan-Bicocca;4 Association for Research on Schizophrenia, Milan, ItalyAn inflammatory process seems to be involved in the pathogenesisof Alzheimer’s disease (AD). A “cytokine cycle” has been proposedin the neurodegeneration mechanisms, where the anti-inflammatoryinterleukins (the best characterised is IL-10) control the betaamyloid-inducedmicroglial/macrophage response inhibiting theproinflammatory cytokine production (i.e. IL-6). The promoterregion of both cytokine genes possesses single nucleotide polymorphisms(SNPs) that correlate with their production (IL-10: –1082G/A; IL-6: –174 G/C). However, it is not known whether this productionrepresents a late or an early step or precedes the diagnosisitself. We analysed these SNPs in 34 patients with mild cognitiveimpairment (MCI), a preclinical state of AD, 120 with establishedAD and 100 healthy controls (HC). The percentage of IL-10 –1082Alow-producer allele was significantly higher in AD and MCIpatients than HC (66.2%, 64.7% and 55.1% respectively; p=0.06).As expected, the G/G high-producer genotype was lower in AD andMCI than HC (9.8 and 5.9% vs. 20.3%; p

Dove model exemplifies deeply canalized neuromentalities entirelycompatible with both the basic and clinical science germane tomanic-depression and psychosis, the occurrence of which are renderedeven more robustly adaptive when epidemiological calculationsare corrected for suicide. Moreover, a number of studies linkgenes expressive of bipolar phenotypy to a variety of traits germane toDarwinian selection, including social dominance, scientific genius,religiosity, artistic creativity and suicide. First reviewed are studies ofwell-known artists and their family psychiatric histories that associatebipolarity in general and mood cycling in particular with artisticgenius and productivity. Then considered is how treatment may beoptimized to balance symptom control with creativity and otheradaptive features. The paper closes with a discussion of psychotherapeuticand ethical considerations made more pressing amid progressin molecular genomics of psychopathology.SS36.2.BIPOLAR TEMPERAMENTS, SUICIDALITYAND ADAPTATION: A DATA-BASED REVIEWH.S. AkiskalUniversity of California at San Diego, CA, USAProspective and retrospective data-bases are analyzed to betterunderstand the precursor and intermorbid behavior of individualssuffering bipolar psychopathology and suicidality. Interim analysis ofempirical clinical data strongly conforms with evolutionary etiologicalmodels. The author submits that the affective temperaments representthe most prevalent phenotypic expression of the genes underlyingbipolar disorder and that the disorder itself is an aberration, andexists simply because the genes themselves, likely to conform to oligogenictransmission, are useful for evolutionary ends. Depressivetraits subserve sensitivity to the suffering of other conspecifics. Generalizedanxiety temperamentally subserves altruistic worries thatenhance kin survival and, by proxy, that of one’s own genome.Cyclothymic traits render the subject more difficult to attain for lovemakingand sexual selection, thereby attracting more robust spousesfor enhanced survival of offspring. Hyperthymic traits lend distinctadvantages in exploration, territory, leadership and mating. In linewith this Darwinian formulation, new data from the author’s internationalresearch team has shown that both cyclothymic (.35) andhyperthymic (.34) traits are positively and the depressive (-.10) andanxious (-.14) negatively correlated with Temperament and CharacterInventory’s novelty seeking. By contrast, harm avoidance is positivelycorrelated with the depressive (.58) and the anxious (.48), butinterestingly also with the cyclothymic (.49), and negatively with thehyperthymic (-.53). These data are of clinical relevance, particularlytoward the abatement of morbidity and mortality risks.SS36.3.PSYCHOSIS, SUICIDALITY AND ADAPTATION:A DATA-BASED REVIEWJ.S. PriceOdinture Place, Plumpton, UKMacLean’s conceptual platform essentially describes two opposingarchetypal neuromental circuitries at three levels upon which oursociality is based. The first level is the brain stem, midbrain, and partof forebrain. MacLean called this the R(reptilian)-complex, insofar asit became fully instantiated in the reptilian line ancestral to humans.The second comprises a more recent assemblage abutting the earlierR-complex, viz, the limbic system (or paleo [old]mammalian complex)arisen with transitional mammals about 300 million years ago.It facilitates nursing of infants, parent-infant bonding, and continuousinteractive, reciprocal ‘warm-blooded’ social life and the emergenceof play – reciprocal and convivial social interation - amongmammals. The third level, the neocortex (or neomammalian complex)extends increasingly sophisticated and often domain-specificfunctions such as language, abstract reasoning, and a greatly extendedreciprocally interactive social life, including self-consciousness.Prospective and retrospective data-bases are analyzed to betterunderstand the precursor and intermorbid behavior of individualssuffering psychotic psychopathology. Interim analysis of empiricalclinical data strongly conforms with evolutionary etiological models.These data are of clinical relevance, particularly toward the abatementof morbidity and mortality risks.SS36.4.SUICIDE, ACHIEVEMENT AND CREATIVITYA. PretiUniversity of Cagliari, ItalyData concerning suicide, psychosis and creativity are analysed withrespect to history of obstetric complications as well as psychiatricgenetics. Risk of suicide in schizophrenia appears to correlate withpersistence of relevant epigenes in excess of population genetic models.This excess is in part due to phenomenologically greater creativitywithin lineages with psychotic diatheses. That is, suicidality in psychosisis best understood as an example of kinship selection as it islinked to greater creativity which more than compensates for theadded mortality of suicide. These data are of clinical relevance, particularlytoward the abatement of morbidity and mortality risks.SS37.INTERVENTION STRATEGIES FOR MENTALRETARDATION: AN INTEGRATIVE APPROACH(Organized by the WPA Section on MentalRetardation)SS37.1.THE INTEGRATIVE APPROACH: A NEWCONCEPTUAL CARE MODEL AND ITSAPPLICATION TO MENTAL RETARDATIONL. Salvador-CarullaDepartment of Psychiatry, University of Cadiz, SpainIn 2001, the US National Research Council released a document thatidentifies a broad domain of questions at the interface of social,behavioural, and biomedical science for improving the health of thepopulation. This conceptual model provides a new paradigm of carefor chronic conditions such as mental retardation, where the traditionalbio-psychosocial approach failed to provide an adequateframework for care planning and intervention. It defines ten priorityareas of social, psychological and biomedical integration: prediseasepathways, positive health, gene expression, personal ties, healthycommunities, inequality, population health, interventions (effectiveness),methodology and infrastructure. The importance of the keyissues in each of these areas with regard to mental retardation isreviewed. The integrative model opens a new and comprehensiveapproach to care in the mental retardation field.86 World Psychiatry 3:S1 - October 2004

SS37.2.A NEW INSTRUMENT FOR THE DIAGNOSIS OFPERVASIVE DEVELOPMENTAL DISORDERSM. Bertelli 1 , G. La Malfa 2 , S. Lassi 3 , D. Scuticchio 31 World Psychiatric Association – Mental Retardation Section;2 Italian Society for the Study of Mental Retardation;3 Department of Neurological and Psychiatric Sciences,University of Florence, ItalySPAID is the Italian acronym for Psychiatric Instrument for the IntellectuallyDisabled Adult. This is a system of diagnostic instruments.The aim of the present study was to evaluate the psychometric propertiesof the subscale for pervasive developmental disorders (PDD;SPAID – DGS). A sample of 40 people with intellectual disability wasrandomly recruited to be assessed using the SPAID – DGS, the Italianadaptation of the Matson’s Diagnostic Assessment for the SeverelyHandicapped (DASH) and the Kraijer’s Scale of Pervasive DevelopmentalDisorder in Mentally Retarded Persons (PDD-MRS). Most ofsubjects were resident in specialised institutes. Around 25% of thesample was found to present a cluster of symptoms consistent with adiagnosis of PDD. The correlation of scores between SPAID and theother two instrument (DASH and PDD-MRS) resulted to be higherthan 60%. The internal consistency and inter-rater reliability of theSPAID also resulted to be high.SS37.3.APPLICATION OF PHARMACOGENOMICS TOMENTAL RETARDATIONP. Tejedor-RealDepartment of Pharmacology, Puerto Real Hospital. Universityof Cadiz, SpainThe fundamental understanding of the genetic processes and theirpotential application as research tools and therapeutic approaches inmany disease areas are increasing rapidly and mental disorders arenot exception. Genetic mental retardation is a clinical manifestationof the variable phenotype of a group of diseases (Angelman syndrome,Prader-Willi syndrome, fragile X syndrome, Williams-Beurensyndrome...) involving specific genetic and epigenetic abnormalities.Different molecular mechanisms have been identified in affectedpatients, including microdelections, intragenic mutations, uniparentaldisomy, and imprinting centre defects. In contrast to singlegene diseases, psychiatric disorders involving mental retardation aregenetically complex and involve the expression of a multitude ofgenes in extremely complex temporal patterns. The heterogeneity ofthe clinical phenotype hampers the application of a pharmacologicaltreatment. Moreover, a given genetic predisposition may confer a lessfavourable response to drugs. Pharmacogenomics is the use of geneticinformation (the influence of the DNA-sequence variation on theeffect of a drug) to guide pharmacotherapy and improve outcome byproviding individualised and science-based treatment decisions. Drugefficacy and safety could be improved in patients with mental retardationby using pharmacogenomics. Most of new drugs will be likelyderived through molecular genetic approaches in the years to come.SS37.4.COMMUNITY INTEGRATION OF PERSONSWITH MENTAL RETARDATION: RIGHTS ANDRESPONSIBILITIESL.S. SzymanskiChildren’s Hospital and Harvard Medical School, Boston,MA, USAAs the result of the normalization movement, it has been widelyaccepted that persons with mental retardation (MR) have the right tobe included in the community and to obtain there integrated habilitationand medical (including mental health) services. However, it wasoften forgotten that integration into the community requires a transactional,interactive accommodation between the society and theindividuals. Often the persons with MR are poorly prepared to makeinformed and appropriate decisions in order to accept medical andother services, as well as to conform their behavior to the society’sstandards. Conversely, the services provided by the society may notmeet their needs for guidance and support. A related issue is the needto assess the results of the measures to integrate persons with MR intothe community. This need led to the concept of quality of life anddevelopment of instruments to measure it. Another important issue ishow one can assess a person’s ability or competence to makeinformed decisions concerning exercising the rights while fulfillingthe responsibilities. The past view that persons with MR are by definitionnot competent is clearly inappropriate. Currently many jurisdictionsuse the concept of partial competence that may exist for certaindecisions but not for others. We will present data from a cohortof 23 adults with MR who lived in the community and who got into avariety of legal and personal difficulties.SS38.THE USE OF PSYCHOANALYSIS IN TODAY’SURBAN MENTAL HEALTH SETTINGS(Organized by the WPA Sections on Urban MentalHealth and on Psychoanalysis in Psychiatry)SS38.1.FROM DSM-IV CULTURAL FORMULATION TOPSYCHODYNAMIC UNDERSTANDING INCULTURALLY DIVERSE URBAN POPULATIONSG. CaracciUniversity of Medicine and Dentistry of New Jersey, Newark,NJ, USAUrban populations are growing increasingly diverse. Migratory wavesfrom rural areas and other countries account for the expanding multiculturalismof urban areas. The DSM-IV cultural formulation outlineuses a subjective and narrative approach to understanding theimpact of cultural factors on mental illness and its treatment. Usingthis outline the author explores the multiple layers of interactionbetween the patient and its cultural environment and demonstrateshow this may provide a useful “point of entry” into the psychodynamicunderstanding of the patient. The cultural perspective providesa useful prism from which to view the patient’s symptoms, psychosocialfunctioning and interpersonal relations. This enhanced understandingmay considerably contribute to greater effectiveness of therapeuticapproaches. Illustrative cases will be presented for each of theheadings and subheadings of cultural formulation.87

SS38.2.WHAT CAN PSYCHOANALYSIS DO FORHOMELESS’ MENTAL HEALTH?M. BotbolClinique Dupré, Sceaux, FranceExclusion and insecurity are becoming major issues in our postmodernurban settings. They increasingly tend to challenge the efficiencyof social and health systems in big cities. This applies particularly tomental health of homeless people, which asks for an integratedapproach involving many different organizations. Faced with thisproblem, each public organization tends to ascribe its failure toanother, claiming for a drastic and urgent change of the functioning ofthe latter. In this frame we are facing a double risk: a) to deny thesocial and political dimension of the problem; b) to neglect how thissocial condition affects the subjectivity of these persons and how itrelates with their psychopathological organization. We advocate thenecessity to keep the psychopathological eye open and to build networkprograms taking into account what this eye can see.SS38.3.PSYCHOANALYSIS AND MENTAL HEALTHS.-D. Kipman7, rue de Montparnasse, Paris, FrancePsychoanalysis is more than a hundred years old, and has currently ascientific status. As a science, it may be applied to various fields. Oneof the more important questions in psychoanalysis is the link betweenindividual and collective moves. The majority of world populationlives in big cities, in big urban zones, with a strong human density. Forpsychoanalysts, each person must be envisaged in a complete integrity,including biological, psychological and social aspects. Mentalhealth is a important parameter in big cities. The French organisationof mental health care is based on “secteurs”. Through psychoanalysiswe can introduce the notion of “secteur d’appartenance”, belongingto a group by affective and historical ways, including street life, communitylife, social life, but also family life.SS38.4.THE DOCTOR-PATIENT RELATIONSHIP ANDPSYCHOTHERAPEUTIC APPROACHES INMEDICATION MANAGEMENTA. TasmanDepartment of Psychiatry and Behavioral Sciences, University ofLouisville, KY, USAIt is well known that adherence to recommended treatment isimproved in the context of an ongoing and trusting doctor-patientrelationship. This is particularly true when the primary treatment ispharmacologic, as occurs in many community mental health centers.Unfortunately, the clinical approaches advocated within many privateand government reimbursement programs, as well as other economicand workforce issues, have led to decreased attention to thisimportant aspect of our clinical encounters. This presentation willreview a variety of aspects of the doctor-patient relationship from theperspective of both the patient and the physician. Increased attentionto these aspects of patient care in both office and hospital settingimproves patient adherence with recommended treatment, thus providinghigher quality care and greater patient satisfaction.SS39.VIOLENCE AGAINST WOMEN ACROSS CULTURES(Organized by the WPA Section on Women’sMental Health)SS39.1.VIOLENCE AGAINST WOMEN IN NORTH AMERICAD.E. StewartUniversity Health Network, University of Toronto, CanadaDespite the public perception of women’s autonomy and power inNorth America, many women live with violence, abuse, and discrimination.Domestic violence, particularly wife abuse, remains a hiddensocial problem with physical and mental health sequelae. Even lessrecognized is violence toward marginalized women – the homeless,addicted, incarcerated and mentally ill. Mail-order brides, exoticdancers, sex trade workers, illegal immigrants and impoverishedwomen may live in violent environments with little opportunity toescape. Increasing globalization and poverty in South East Asia, EasternEurope and Latin America brings many women to North Americain search of a new and better life. Instead, some find themselvestrapped in violent spirals and slip into demoralization and depression.The role of mental health professionals in assisting these womento disclose their situations, seek appropriate services from legal,social, medical and mental health services, and combat institutionalizedsexism will be addressed. The principles and examples of mentalhealth treatment for women living in violent environments will be thefocus of this presentation.SS39.2.RESPONSES TO GENDER BASED VIOLENCE INLATIN AMERICAM.B. RondonUniversidad Peruana Cayetano Heredia and Hospital NacionalEdgardo Rebagliati Martins, Lima, PeruViolence against women has long been recognized as a public healthand human rights issue. In spite of the efforts of multilateral organizations,states and the organized civil society, violence continuesbeing the cause of several mental and physical health problems (anxiety,depression, suicide attempts, substance abuse, chronic pelvicpain). Under-reporting leads to difficulties in recognition of the problemat decision-taking levels. Deep cultural roots of violence giveraise to high social tolerance which combines with demographic factorssuch as limited education, and individual ones, like alcohol useand exposure to violence as a child, to account for very high rates ofviolence against women in Latin America. A system of services whichprovide safety, minimize distress and offer adequate referrals to affectedwomen is under construction. The needed changes in health policyand in health care providers’ attitudes and knowledge have notoccurred yet. However, several countries (Mexico, Chile, Venezuela,Bolivia) have been able to design programs that in the short term provideservices for victims and punish perpetrators and in the long termwill address the social determinants of violence. The strategies usedinclude the development of culture sensitive learning material, buildingthe capacity of the staff and educating the community, providingpublic space for exploration of communal ideas and values, advocacyat the public health, professional sector and community leadershiplevels and some types of local activism with establishment of networks.These model programs and available outcomes will be discussedin the presentation.88 World Psychiatry 3:S1 - October 2004

SS39.3.VIOLENCE AGAINST WOMEN IN ARAB ANDISLAMIC COUNTRIESS. Douki, F. Nacef, S. Ben ZinebService de Psychiatrie, Hospital Razi, La Manousa, TunisiaIn Arab and Islamic countries, domestic violence is not yet considereda major concern, despite its increasing frequency and seriousconsequences. Surveys in Egypt, Palestine and Tunisia show that atleast one out of three women is beaten by her husband. The indifferenceto this type of violence stems from attitudes that wife abuse is aprivate matter and, usually, a justifiable response to misbehaviour onthe part of the wife. Selective excerpts from the Koran are used toprove that men who beat their wives are following God’s commandments.These religious justifications, plus the importance of preservingthe marital links and the honour of the family lead abusers, victims,police, justice and health professionals to join in a conspiracy ofsilence rather than disclosing these offences. We shall present theresults of a recent survey carried out in Tunisia among a sample of 424married women which confirms the same observations. We shall thendemonstrate that a fair reading of the holy texts in Islam shows thatwife abuse, like “genital mutilation” or “honour killings”, are a resultof culture rather than religion. Mental health providers can play acritical role in preventing violence against women, in addition totreating its consequences, by beginning to address the cultural as wellas psychological conditions that create and support this kind of violencein our societies.SS39.4.ASPECTS OF SOUTH ASIAN CULTURECONCERNING VIOLENCE AGAINST WOMENU. NiazPsychiatric Clinic and Stress Research Centre, Karachi, PakistanCultural factors are resilient to overcome and this is the main reasonwhy violence against women presents in different more ghastly forms:acid throwing, dowry deaths, cutting a woman’s nose for suspicion ofadultery, or karo kari (both the man and the woman are murdered foradultery by the local Jirga System, parallel legal system in the tribalareas). In South Asia women are under the tremendous burden toabide by the cultural traditions. Women have struggled over the yearsto declare these heinous crimes against them. Different prevailingforms of violence against women will be discussed, and the progressmade by women activists will be described.SS39.5.PSYCHODYNAMIC TRAINING ON SEXUALVIOLENCE EFFECTS IN ADDIS ABABA, ETHIOPIA:A TRANSCULTURAL EXPERIENCEA. OrlandiniDepartment of Psychology, Bicocca University, Milan, ItalyIn this paper I will describe my experience in the establishment of thefirst rape center in Ethiopia (Addis Ababa) and in providing a psychodynamictraining to the staff (psychologists and social workers) of thecenter. The increasing attention given to sexual abuse and its psychologicalconsequences is strictly related to the recent cultural changesthat have spread in Ethiopia. Psychodynamic training has been a challengingwork because Ethiopian psychologists have no psychopathologicalor psychotherapeutic knowledge, and belong to a social andcultural background different from the Western one. Therefore, one ofthe major problems was the selection of the contents to be transmitted,and also of the technical issues. Teaching and supervising clinicalcases has been very stimulating for the unexpected problems that haveoccurred but also for the unexpected solutions that have been found.The results of the encounter between an African environment and psychodynamicknowledge will be presented.SS40.GENETICS AND PSYCHOPATHOLOGY OFSUICIDAL BEHAVIOURS (Organized by the WPASection on Suicidology)SS40.1.NEW DATA ON GENETICS OF SUICIDEA. Roy, Z. Zhou, X. Hu, D. GoldmanNational Institute on Alcohol Abuse and Alcoholism, NationalInstitutes of Health, Bethesda, MD, USANew data will be presented showing an interaction between the serotonintransporter genotype and childhood trauma and suicideattempts in psychiatric patients. New data will also be presentedabout the trypytophan hydroxylase (TPH) genotype and suicideattempts. Genetic variants of TPH 2 are associated with suicideattempts in psychiatric patients and also with high scores on the BarrattImpulsivity Scale.SS40.2.THE GENETIC BASIS OF SUICIDAL BEHAVIOURSJ. BobesArea of Psychiatry, Faculty of Medicine, University of Oviedo,SpainSuicide is a multidetermined act. The importance of psychiatric,social and biological factors as determinants of suicide is now wellestablished. The results from family, twin, and adoption studies supportthe hypothesis of a genetic contribution in the expression of suicidalbehaviour. Numerous abnormalities have been found in theserotonergic system in suicide attempters and completers. Thehypothesis of a serotonin deficiency in suicidal behaviour has beenproposed. A great deal of progress has been seen in scientific investigationof human and molecular genetics as it relates to the transmissionand expression of disease. Many of the genes potentiallyinvolved in the control of serotonin metabolism, such as those fortryptophan hydroxylase (TPH), serotonin receptors and transporters,have been cloned. Some (but not all) molecular genetic studies havereported an association between suicidal behaviour and a number ofserotonin gene polymorphisms. Further replications of serotonin andother molecular genetic findings are needed in order to determine therole that polymorphisms in serotonin and in other neurotransmittersystems may play in the multi-determined act of suicide. On the otherhand, genetic factors related to suicide may largely represent a geneticpredisposition for psychiatric disorders associated with suicide,particularly affective disorders. Furthermore, there is some evidencefor an independent genetic component for suicide, possibly related tothe control of impulsive behaviour. Future approaches should examinethis, not yet well established, relationship.89

SS40.3.DISENTANGLING GENOTYPIC AND PHENOTYPICHETEROGENEITY OF SUICIDAL BEHAVIORF. Slama 1 , F. Bellivier 1 , A. Malafosse 2 , P. Courtet 3 , M. Leboyer 11 Psychiatry Department and INSERM U 513, CHU Creteil,France; 2 Psychiatry Department, University of Geneva,Switzerland; 3 Psychiatry Department, University of Montpellier,FranceSuicidal behaviors are inherited independently of transmission ofassociated major psychiatric disorders. Genes encoding proteinsinvolved in serotoninergic metabolism are major candidate genes insuicidal behavior. In particular, the tryptophan hydroxylase (TPH)gene and the serotonin transporter (5-HTTP) gene have been found tobe associated with suicidal behavior independently of the primary psychiatricdiagnosis. We present data of a meta-analysis on the interactionbetween these two genes in suicidal behavior and preliminarydata showing associations between specific clinical characteristics andvulnerability factors. We performed a meta-analysis on nine associationstudies (n=1061 Caucasian suicidal patients), taking into accountheterogeneity between studies, and confirmed the association betweenthe A allele of TPH (TPH A 218C) gene with both suicide and the subgroupof violent suicide. In parallel, Anguelova et al. performed ameta-analysis with 5-HTTP and also confirmed the associationbetween the “s” allele of the promoter of the 5-HTTP and suicidalbehavior. We explored the interaction between TPH and 5-HTTPgenes in suicidal behavior. We will present data showing that, in a sampleof 960 suicidal patients and 436 controls, there was no interactionbetween TPH and 5HTTP candidate genes for suicidal behavior. Thesedata also suggest that different subgroups of suicidal patients are associatedwith either TPH or 5-HTTP alleles and/or with environmentalfactors. In order to further explore this hypothesis we present data ondimensional characteristics evaluated by the Buss and Durkee HostilityInventory, the Barratt Impulsivity Scale and the Spielberger AngerScale and on the impact of early events assessed by the ChildhoodTrauma Questionnaire associated with either 5-HTTP or TPH allelesin a large population of suicidal patients.SS40.4.GENETIC ANALYSIS OF SUICIDAL BEHAVIOURS:CLUSTER ANALYSIS OF SUICIDE ATTEMPTERSAND THEIR PARENTSD. Wasserman, M. Telega, T. Geijer, J. WassermanSwedish National Centre for Suicide Research and Preventionof Mental Ill-Health, Stockholm, SwedenTwin studies, adoption studies, and family studies indicate the role ofgenetic factors in suicidal behaviours. Psychobiological hypothesesregarding suicidal behaviours involve neurotransmitters such as serotonin,norepinephrine, dopamine, and their correlation to psychologicalfunctions. In our study comprising 244 triplets (244 suicideattempters, and 488 parents), we performed a cluster analysis concerningthe presence of different personality variables measured bythe Neo-Personality Inventory - revised version (NEO-PI-R), theWorld Health Organization (WHO) Well-Being Scale, Beck’s DepressionInventory and Trait Anger Scale. Three clusters were found forthe suicide attempters and parents with a history of suicide attempt: adepressive cluster, a borderline cluster with pronounced angry andhostility characteristics, and a “normal cluster” (in comparison to theNEO-PI-R variables in the total population). Parents without suicideattempt constitute two clusters: a depressive cluster and a “normalcluster” which in turn can be split into two groups with normal andlow anger and hostility values. The borderline cluster was missing.Heredity for suicidality was overrepresented in “normal” and borderline(angry/hostility) clusters. In our previous genetic analysis westudied tyrosine hydroxylase (TH) polymorphism in the group ofpatients with diagnosis of adjustment disorder (AD). AD predominatesin “normal clusters” in the present material. TH is a key enzymein norepinephrine and dopamine biosynthesis. Our future strategy forgenetic analysis will be discussed.SS40.5.GENES, LIFE EVENTS AND SOCIAL NETWORKIN THE DEVELOPMENT OF THE RISK OF SUICIDALBEHAVIOUR IN SLOVENIAA. MarusicInstitute of Public Health of the Republic of Slovenia,Ljubljana, SloveniaSuicidal behaviour is attributable to many causes. A comprehensivemethod for identifying risk factors for suicide is to consider that theyare composed of genetic and environmental influences and theirinteractions. High suicide rate in Slovenia is thus a consequence ofgenetic and environmental factors. Being lonely, divorced, widowedand living in stress are the most important among environmental factors,while history of suicide behaviour in the family stands for geneticvulnerability. At higher risk for suicide are single, widowed andolder people, people with mental disorders and lower education. Particularlyat risk are people with depression, alcohol dependency, peoplewith more pronounced impulsive and aggressive personality featuresand persons with previous suicide attempts. Suicide riskincreases dramatically when factors which are usually independentinteract. The present study focuses on risk factors in the general populationand in particular in vulnerable groups (depressives, alcoholics,impulsive/aggressive persons, persons with previous suicideattempts). This is a rather novel approach in the field of suicideresearch as we have been including genetic, life events and social networkvariables. We have been using the DNA analysis to determinegenetic risk factors, and psychological autopsy or cognitive tests todetermine psychological factors. As for the social risk factors, wehave been relying on mathematically and statistically supportedanalysis of social support and social networks of an individual. Theend result of our investigation will be a mathematical multifactormodel of risk to develop the suicidal behaviour.SS41.THE MIND CLINICAL IMAGING CONSORTIUM:A MULTIMODALITY COLLABORATIVE STUDYOF SCHIZOPHRENIA (Organized by the WPASection on Neuroimaging in Psychiatry)SS41.1.TRAINING AND CALIBRATION FOR STRUCTUREDINTERVIEW TOOLS USED BY THE MIND CLINICALIMAGING CONSORTIUM PROTOCOLF. FlemingDepartment of Psychiatry, University of Iowa, Iowa City, IA, USAThe clinical assessments of the MIND collaborative study are beingmade using established structured interview tools to measure psychotic,disorganized and negative symptoms and depression in patients withschizophrenia. The Scale for the Assessment of Negative Symptoms(SANS), the Scale for the Assessment of Positive Symptoms (SAPS) and90 World Psychiatry 3:S1 - October 2004

the Calgary scale are currently used at each site, allowing for training tobe carried out with a series of patient interviews on videotape and a setof “gold standard” ratings prepared such that individual raters mayreview ratings and discuss any differences. To monitor individual sitedifferences we will ask sites to tape the interviews and jointly establish“gold standard” ratings via telecom. Medication side effect scales(Abnormal Involuntary Movement Scale, Simpson-Angus Scale, andBarnes Scale) will be administered upon completion of a training module.The threads that weave these cross-sectional assessments togetherare the Comprehensive Assessment of Symptoms and History - On Follow-Up(CASH-UP) and the Psychosocial Status You Currently Have -On Follow-up (PSYCH-UP). These instruments have been utilized atIowa University for the last 18 years to collect longitudinal data at sixmonth intervals for analysis. These interviews record psychosocial functioning,treatment (nonsomatic, electroconvulsive therapy, drug therapy,compliance and subjective evaluation), lifetime diagnosis, duration andcourse of the disorder. To establish inter-rater reliability, a series of tapedinterviews have been presented and rated by experienced raters at IowaUniversity. These videos were then shown in group settings to new raterswho applied the instruments to the interviews and filled out the forms.Initially the forms were filled out in a large group setting to facilitate discussionand questions. The final phase of training was done on an individuallevel. Ratings were tabulated and outliers received additionaltraining based on specific areas of need.SS41.2.A PROTOTYPE TABLET-PC APPLICATION FORTHE COLLECTION OF CLINICAL ANDNEUROPSYCHOLOGICAL ASSESSMENTS ANDSOCIO-DEMOGRAPHIC HUMAN SUBJECT DATAH. Bockholt 1 , J. Ling 1 , K. Shingler 1 , R. Lenroot 2 , F. Fleming 3 ,T. White 4 , N.C. Andreasen 1,2,31 MIND Institute, Albuquerque, NM; 2 University of New Mexico,Albuquerque, NM; 3 University of Iowa, Iowa City, IA; 4 Universityof Minnesota, Minneapolis, MN, USAPaper-based data recording has historically been used for the collectionof clinical and neuropsychological assessments, socio-demographic,and other data collected on human subjects for neuroscienceresearch. Research data is only useful within an electronic form.There are a number of problems with manually recording data topaper forms: missing, ambiguous, conflicting, and extraneous data.Technological solutions have been developed to assist researchers inconverting paper sources into usable electronic data, such as usingOCR and TELEFORMS. Most of these solutions, however, permitmistakes that must be manually reviewed and corrected. Since thepersons that data enter paper forms typically are not those who ratedthe subject and recorded the data, there are often delays or mistakes.Due to their size and awkwardness, desktop and laptop computersare typically not compatible with the clinical assessment environment.Personal digital assistant (PDA) devices typically suffer fromsmall screen size and low amounts of storage space. We propose usinga Tablet-PC that combines the advantages and avoids the disadvantagesof the laptop and PDA. The Tablet-PC utilizes a stylus that interactswith the screen like a PDA but on a full letter-sized page. Theprototype Tablet-PC application developed provides ease of navigationacross multiple-page assessments, intelligent entry, and annotation.The application provides the rater with feedback about missingor conflicting data, allowing the resulting data to be exported andarchived. The Tablet-PC application eliminates the need for researchersto record data onto paper and provides an efficient way of collectingreliable research data in a clinical environment.SS41.3.MULTI-SITE FUNCTIONAL MAGNETICRESONANCE IMAGING STUDIES: APPROACHESTO THE ASSESSMENT AND REDUCTION OFSCANNER DIFFERENCESL. Friedman 1 , V. Magnotta 21 MIND Institute, University of New Mexico, Albuquerque, NM;2 Department of Radiology , University of Iowa, Iowa City,IA, USAMulti-site functional magnetic resonance imaging (fMRI) studies arebecoming popular because they allow for the creation of datasets withlarger numbers of subjects, including psychiatric patients. Theincreased statistical power that multi-site studies promise may be particularlyimportant for psychiatric research, where the effects areoften small and many studies are not replicated. The ability to mergefunctional imaging results across sites would be a major step forwardbut scanners can differ in field strength, manufacturer, gradients andhardware. Software differences in pulse sequence design (e.g., EPIversus Spiral, single versus double echo, etc.) and the reconstructionalgorithm can also impede the merging of multi-site data. Our workfocuses on assessing these differences and their impact on the functionalactivation maps. We are also trying to develop post-processingschemes to minimize site-to-site differences. Finally, statisticalapproaches to analyzing multi-site data are also being explored. Thisline of investigation will help clarify the technical challenges to multisitecollaborative fMRI research and begin to address these challenges.This will be of interest in our own research on schizophreniabut will also have wider implications for other research efforts wheremulti-site studies are necessary. For example, fMRI studies of rare diseaseswill greatly benefit. Also, multi-site fMRI studies of the effects oftreatments may be helpful in documenting the generality of treatmenteffects.SS41.4.MULTI-SITE COLLABORATIVE FUNCTIONALMAGNETIC RESONANCE IMAGING STUDIESOF AUDITORY TARGET DETECTION INSCHIZOPHRENIAV. ClarkDepartment of Psychology, University of New Mexico,Albuquerque, NM, USAAlterations of the P3 event-related potential (ERP) and its sub-componentsevoked by the oddball task are highly sensitive markers forschizophrenia. However, similar P3 alterations have been found inother psychiatric disorders, due in part to the limited anatomical resolutionof ERPs, and thus cannot be used to obtain specific diagnoses.Functional magnetic resonance imaging (fMRI) may offerimproved detection of altered neural activity specific to schizophrenia,due in part to its superior anatomical resolution. In order to pursuethis line of research, we have dealt with a variety of methodologicaldifficulties, including the development of methods for using theoddball task with fMRI, increasing the sensitivity of fMRI data analysis,and dealing with the variability of fMRI measures obtained fromdifferent MRI systems at different field strengths. This last issue wasexamined by obtaining fMRI data using the auditory novelty oddballtask from ten healthy subjects in two sessions at each of the fourMIND Consortium sites, including two 3 Tesla systems (at the Universityof Minnesota and Massachusetts General Hospital) and two1.5 Tesla systems (at the University of Iowa and the University of NewMexico). Generally good replication was found across sites, with91

some effects of field strength, MRI vendor and session order. Dataobtained from schizophrenic patients and a variety of other clinicalpopulations (including traumatic brain injury, attention deficit disorder,addictive and antisocial disorders, among others) using the oddballtask are providing new information on the neural and cognitivebases of these disorders.SS41.5.WHITE MATTER INVOLVEMENT IN SCHIZOPHRENIAK. LimDepartment of Psychiatry, University of Minnesota, Minneapolis,MN, USAPostmortem studies examining cellular morphology and gene expressionhave found abnormalities in white matter in patients with schizophrenia.Magnetic resonance methods including conventional imaging,diffusion tensor imaging, magnetization transfer and T2 relaxographycan provide complementary, in vivo information about whitematter. These methods have been applied to the study of schizophreniaand have revealed subtle abnormalities in the white matter. Thispresentation will provide an introduction to these imaging methodsand how they are being applied to the study of schizophrenia.SS41.6.MAGNETIC RESONANCE SPECTROSCOPY ANDTHE PATHOPHYSIOLOGY OF SCHIZOPHRENIA:STUDIES OF GLUTAMATE FUNCTION INPEDIATRIC AND ADULT POPULATIONSR. Lenroot 1 , J. Lauriello 1 , P. Mullins 2 , L. Rowland 3 , R. Jung 1 ,W. Brooks 4 , N.C. Andreasen 1,2,5 , J. Bustillo 11 University of New Mexico, Albuquerque, NM; 2 MIND Institute,Albuquerque, NM; 3 Maryland Psychiatric Research Center,Catonsville, MD; 4 University of Kansas Hoaglund Brain ImagingCenter, Kansas City, KS; 5 University of Iowa, Iowa City, IA, USANeuroimaging methods are contributing essential information regardingabnormalities in brain structure and function in individuals withschizophrenia. While significant evidence supports a neurodevelopmentalcomponent in the pathogenesis of schizophrenia, the role of aneurodegenerative process is still controversial. Better characterizationis necessary to guide preventative measures in pharmacologictreatment and public health policy. The presence of abnormal glutamatefunction in schizophrenia, which may lead to neuronal damage,is becoming increasingly well-recognized. Early trials of therapeuticagents aimed at modulation of glutamatergic function are currentlyunderway in adults with schizophrenia. Magnetic resonance spectroscopy(MRS) is a technique by which selected brain metabolitessuch as glutamate may be measured in vivo. This allows the explorationof pathophysiological processes which may be related to thedecreased brain volumes found in schizophrenia. Metabolites ofinterest include N-acetyl aspartate (NAA), a measure of neuronalintegrity; glutamate; and glutamine, which may be a more accurateindex of glutamatergic activity associated with neurotransmission. Weare currently using 1H-MRS to study different patient populationswith schizophrenia, including children and adolescents, first-episodeadult patients, and chronically ill patients, using both clinical andhigh field (4-Tesla) MR scanners. This presentation will discuss ourfindings and their potential relevance to the pathophysiology ofschizophrenia.SS42.REHABILITATION OF TORTURE VICTIMS ANDTHE PROBLEMS OF THESE VICTIMS FROM THEPSYCHIATRIST’S VIEWPOINT (Organized bythe WPA Section on Psychological Consequencesof Torture and Persecution)SS42.1.TREATMENT OF TORTURE SURVIVORS:SPECIFIC PROBLEMS IN RELATION TO GENDERM. KastrupRehabilitation Center for Torture Victims, Copenhagen, DenmarkThere is no indication that men and women have different lifetimeprevalence of exposure to traumatic events. But women have a lifetimeprevalence of post-traumatic stress disorder (PTSD) that is twiceas high as men. Women exposed to a given trauma are four times aslikely to develop PTSD, and the course of disorder tends to becomemore chronic. Findings of gender differences in PTSD among personsexposed to torture are inconsistent and surprisingly little attentionhas been paid to female torture survivors and the specific problemsthey encounter as refugees. Treatment of women with a history ofmanmade violations including torture comprises consideration of thecomplexity of the social context in which they live. Women areproviders of emotional support, and exposure to further trauma mayoverload the woman‘s capacity to cope. Female torture survivors in amental health setting often share common traits and may experiencedis-empowerment, fear for safety of themselves and their children,and continuous harassment. In order to empower such women, thetherapist and the patient have to look for common ground and agreeon goals for treatment in recognition of cultural incongruities. Thepresentation will outline ways to optimize the fulfillment of the needfor treatment of female torture survivors with a particular focus on therights of these women.SS42.2.NEW ASPECTS OF TREATING TORTURESURVIVORS WITH VERBAL AND NON-VERBALTHERAPEUTIC GROUP METHODSL. HárdiCORDELIA Foundation for the Rehabilitation of Torture Victims,Budapest, HungaryThe author summarizes the verbal and non-verbal individual andgroup methods used in Hungary in the process of treatment of therehabilitation of refugees, survivors of torture. She describes the circumstancesin which the therapies are carried out and the backgroundof the rehabilitation process (the therapeutic team and the coworkers,the connection with the local staff etc.). The history of the“animation group” therapy goes back to the years of the Bosnian crisis.The group of patients was stimulated to use more artistic tools inthe group sessions. More active elements and special psychodramaelementscharacterize the “station group” therapeutic model elaboratedduring the war period in Kosowo. The ancient culture shiningthrough the therapy of our clients from Afghanistan, Iraq and Iranstimulated the elaboration of the “symbol group” therapy, using universaland characteristic symbols in the therapeutic process of ourclients.Supported by the MIND Institute and by NAMI of Dane Countythrough the NARSAD Research Partners Program92 World Psychiatry 3:S1 - October 2004

nized and under-treated. This paper will illustrate methods for reducingthe association between cardiac surgery and depression utilizingpharmacotherapy, psychotherapy, exercise and social support.SS43.3.DEPRESSION IN CARDIAC POST-INFARCT:OUR EXPERIENCER. FahrerDepartment of Mental Health, University Hospital, School ofMedicine, Buenos Aires, ArgentinaCardiovascular diseases and depression are among the most commondiseases. 17% of the population with cardiovascular disease hasmajor depression, and if we include dysthymia the rate goes up to25%. In the USA, mortality of cardiovascular diseased patients isaround 45%, and 54% of those deaths is due to coronary disease.Depression is a high risk factor and contributes to cardiovascularmorbidity and mortality. This paper will deal with depression insomatic illness, diagnostic criteria for depression in medicine, depressionand cardiovascular diseases. I will present a study carried out atthe Department of Mental Health of the University Hospital ofBuenos Aires, showing that the progression of mood symptoms 6months after an acute coronary event is associated with an impairmentof autonomic control of the heart in elderly people.SS43.4.THE PATIENT ADMITTED TO A MEDICAL WARDWITH COMORBID DEPRESSION AND SELFHARM BEHAVIOUR RISKM. Rigatelli, G. Palmieri, S. FerrariConsultation-Liaison Psychiatry Service, Department ofPsychiatry and Mental Health, University of Modena andReggio Emilia, Modena, ItalySelf-harm behaviours in medical inpatients are important reasons forreferral to a consultation-liaison psychiatry service in the general hospital.This group of patients usually includes those admitted after suicideattempts and the chronically medically ill with comorbid depression,especially in cases of severe pain, transient confusion, poorprognosis, or after recent adverse news. Physical disease is an independentrisk factor present in a high proportion of people who commitsuicide or parasuicide. At Modena University Hospital, in a fouryeartime, 1070 patients were referred for psychiatric consultationafter attempting suicide (n=142, 4.39% of total referred patients) orbecause of self harm behaviour risk (n=928, 28.67%). Analysing thedata from our local experience, we developed an integrated pathwayfor both categories of patients. The fundamental steps of the integratedpathway include: stabilization of medical conditions; rapid referralto our service by medical staff previously trained in the recognition ofthe suicidal risk; psychiatric assessment within a hour with riskassessment; analysis of the therapeutic-caring strategies. The latterconsist of pharmacologic treatment, daily follow-up psychiatric consultations,liaison with community mental health team, general practitionersand social services when needed, special monitoring of thepatient by the ward staff, environmental restraints, up to the rarenecessity for admission to the psychiatric ward.SS44.TRANSCULTURAL PSYCHIATRY IN EUROPE:SOMETHING IS GOING ON (Organized by the WPASection on Transcultural Psychiatry)SS44.1.MENTAL HEALTH SERVICES FOR IMMIGRANTS INDENMARK: PROBLEMS AND CHALLENGESM. Kastrup, U.J. Povlsen, M. ØsterskovCentre for Transcultural Psychiatry, Psychiatric Department,Rigshospitalet, Copenhagen, DenmarkImmigrants comprise today about 7% of the Danish population.About 10 % of patients treated in Danish psychiatric institutions havea non-Danish background, with large geographical variation, as someareas of Copenhagen have up to 25% of their patients with a non-Danish background. In certain services, e.g. forensic psychiatry, up to50% of the patients have a non-Danish background. This study comprisesthe transcultural patient population that received treatment in2004 at the regional outpatient clinic of the psychiatric department,serving an area densely populated with immigrants. Information wascollected on sociodemographic background, diagnoses, severity ofdisorder as well as treatment offered. The paper will provide a comparativeanalysis of this population and the Danish population at thesame outpatient clinic, with particular reference to possible limitationsof the present services from a cultural perspective and ways toovercome them.SS44.2.THE ITALIAN APPROACH TO MENTAL HEALTHCARE OF IMMIGRANTSM. Ascoli 1 , V. Iannibelli 21 Italian Institute of Transcultural Mental Health; 2 La SapienzaUniversity, Rome, ItalyMigration in Italy can still be considered a relatively recent phenomenon,compared to other European countries. On the other hand, asshown by official figures, the presence of foreigners, immigrants,refugees and asylum-seekers in Italy is an increasingly important phenomenonat a social and cultural level. In some catchment areas thehigh presence of immigrants is sufficient in itself to pose a mentalhealth problem. Nevertheless, an official policy on immigrants’ mentalhealth has not been structured yet, there are no public mentalhealth services for immigrants in Italy and the organization of publicmental health services in order to face the peculiar needs of foreignusers, both in terms of service planning and mental health professionals’training, is still lacking. Another aspect to be considered isthe existence of alternative health care systems to provide medicalassistance to legal and illegal immigrants in Italy. These organizations,the most famous of which is Caritas, are often of a religiouskind. They divert the immigrants’ health care request towards themselves,rather than towards the national health system, and this is particularlytrue for those immigrants whose illegal status makes themreluctant against the contact with any official Italian institution. At ascientific level, in Italy the amount of empirical research on the immigrants’mental health and mental health care is extremely poor, mostof all if compared to that produced in other European countries andto the importance immigration has recently gained at the social andpolitical level. In this article, possible reasons for these peculiar Italianphenomena are discussed.94 World Psychiatry 3:S1 - October 2004

SS44.3.THE PROVISION OF SERVICES IN EAST LONDOND. ClaassenEast London and the City Mental Health Trust, London, UKIn order to know why the provision of services in East London meansalso in large part the psychiatric treatment of ethnic minorities, onehas to appreciate the sociodemographic characteristics of this area.The borough of Newham is presented as an example. Here, 68% ofthe population belong to “ethnic minorities”, namely Indian andAfro-Caribbean, making it the most culturally diverse borough in thewhole UK. Mental health services in Newham comprise a newly builthospital with 4 adult wards and a psychiatric intensive care unit, communitymental health teams, an assertive outreach team, a alcoholand drug service, a rehabilitation and continuing care team with residentialcare homes and supported living, the day opportunities servicewith a broad spectrum of activities and groups, and the more psychotherapeuticallyoriented services like the psychological therapyservice and the psychotrauma clinic. In addition, there are also voluntaryservices and charities offering social support, occupationaltherapy and vocational training. Furthermore, there are voluntaryservices for ethnic minorities. A lot has been achieved over the last 7-8 years. However, the service is still some distance away from racialand ethnic equality. Rather than the creation of separate services, wewill pursue the aim to raise knowledge, skills and transcultural awarenessof the whole workforce regarding ethnic minorities and theirneeds.SS44.4.FORTY YEARS ON THE IMMIGRANTS’ SIDE: THEACTIVITY OF THE MINKOWSKA CENTER IN PARISR. Bennegadi 1 , J.C. Olivier 1 , R. Rechtman 21 Minkowska Center; 2 MSH Paris Nord, Paris, FranceThe Minkowska Center is a medical, psychological and social institution,based in Paris and working with refugees and migrants sincemore than 40 years. The Center is involved in a community healthapproach where the main goal is to answer in the most appropriatemanner to important and complex needs coming from the migrantpopulation in Paris and suburbs. The main concern is to facilitateaccess to medical, mental and social care in a medical, clinical andanthropological setting allowing therapeutical approaches such aspsychoanalysis, ethnopsychiatry, cognitive and systemic psychotherapy.The linguistic issue is solved either because the therapists speakthe language of the patient or by the help of linguistic and culturaltranslators. The clinical sessions have the characteristic of being freeof charge. Epidemiological data will illustrate different aspects of theneeds, of the psychiatric morbidity and of the peculiarities in the populationconsulting the centre.SS45.POSITIVE AND NEGATIVE IMPACT OF NEWTECHNOLOGIES IN PSYCHIATRIC SCIENCES(Organized by the WPA Section on Informaticsand Telecommunications in Psychiatry)SS45.1.USER PERSPECTIVES ON THE IMPACT OF ANONLINE PEER SUPPORT GROUPJ. Freedman 1 , R.C. Hsiung 21 UCLA Neuropsychiatric Institute, Los Angeles, CA;2 University of Chicago, IL, USAPsycho-Babble (http://www.dr-bob.org/babble) is a website that consistsof a number of message boards. Members of the communityreceive support and education from each other, and a mental healthprofessional maintains a supportive milieu. Group members postunder names of their own choosing. All posts are public. There is nocharge to participate. In early 2004, members were asked what impactthey thought the site had on: a) how empowered and knowledgeablethey felt, b) their treatment and their relationship with their treatmentprovider, and c) the larger mental health community. They were alsoasked how much they used the site and for some information abouttheir illness and treatment course. In this paper, we present theirresponses. These findings are not intended to be generalizable. Groupmembers were self-selected in that they had Internet access, the motivationto seek out the site, the cognitive and technical ability to use it,and some degree of comfort with text communication. Also, the siteitself may be atypical in terms of longevity (it was started in June1998), activity level (there were >360 posts/day in February 2004),and efforts made to maintain a supportive milieu.SS45.2.TELEPSYCHIATRY IN PSYCHIATRIC CLINICSI. ModaiShaar Menashe Mental Health Center, Hadera, IsraelA videoconference system was set up in two distant satellite clinics(Or Akiva and Hadera) of the Eiron Outpatient Clinic of ShaarMenashe Mental Health Center. 51 patients were treated using thissystem for the first time in Israel. Nine months results are encouraging.The number of days of hospitalization has declined (179 inpatientdays in the nine months following implementation of the systemas compared to 231 in the same time period prior to implementation).Rate of compliance increased from 76% to 87.8%. The Brief PsychiatricRating Scale (BPRS) total score decreased from 31.8 to 26.52,whereas the Clinical Global Impression (CGI) score remained stable(4.3 pre vs. 4.2 post). Satisfaction for both patients and psychiatristsincreased. Evaluation of costs revealed savings of 5,829 NIS forpatients, 3,780 NIS for therapists, 32,920 NIS in medications, whereasinstitutional costs remained the same (188,952 pre, 189,932 post).The patients get dressed up for the videoconference meetings andreport that they feel good about the sessions, and do not feel anychange in their relationship with the psychiatrist. Routine use oftelepsychiatry can be economically effective in the public service byreducing the need for physical accommodations in the clinics, and bymanaging the patients’ and physicians’ time more efficiently. Thismethod can be also implemented for initial consultations with familyphysicians, which may reduce referrals to psychiatric clinics.95

SS45.3.THE PSYCHOLOGICAL AND PSYCHIATRIC IMPACTOF NEW COMMUNICATION TECHNOLOGIESP.M. FurlanMental Health Department, San Luigi Gonzaga Hospital,University of Turin, ItalyThe extent and the nature of the changes in communication technologyhave gone far beyond any of the predictions made twenty yearsago. Instantaneous free or cheap communication throughout the dayall over the world, multiple participant open access, limited identificationwith little or no data protection, together with an increasingdesire or even need to chat, have added new dimensions to the formationand structure of communities. The use and choice of languageis being rapidly transformed and not always according to the standardgrammatical norms; not only the creation of neologisms and a newlexicon, but also a change in the logical patterns governing thethought processes is occurring. The phenomenon not only includesthe writing of e-mails and chatting in discussion groups, but alsoshort messages and the taking and transmission of instantaneous picturesand/or recording. On the one hand short messages lead to concision;on the other this very concision can lead to misunderstandingsor even an invasion of personal space and/or privacy. With the newtechnologies, millions of people can receive unsolicited and unauthorizedshort messages, have their presence and movements immediatelydetected and be themselves detected and their own messages bememorised and stored. All that implies strong changes in individualpsychology and thus in the psychiatric approach, bearing also inmind that communication technology is more and more present inthe daily medical practice.SS45.4.IMPACT OF NEW TECHNOLOGIES IN PSYCHIATRY:A PERSPECTIVE FROM DEVELOPING COUNTRIEST.A. OkashaInstitute of Psychiatry, Ain Shams University, Cairo, EgyptAfrica is a large continent, prone to strife, especially south of theSahara. Most of its countries are characterized by low incomes, highprevalence of communicable diseases and malnutrition, low lifeexpectancy and poorly staffed services. The lack of mental healthresources, whether human resources, mental health professionals,inpatient or outpatient facilities and even community care, is becominga problem that is in need of an immediate solution. In remoteareas of developing countries transport is difficult and the centralizationof services exists only in big cities, so that the next revolution inpromoting mental health services in developing countries becomesthe use of new technologies mainly through telecommunication, toreach the remote areas giving advice about diagnosis, managementand reassurance to primary care physicians or mental health professionals.An evaluation of the impact of new technologies in psychiatryand mental health in developing countries will be presented.SS45.5.INTERACTIVE AUDIOCONFERENCES:THE NEW FRONTIER OF SCIENTIFICCOMMUNICATION IN PSYCHIATRYF. BollorinoNeuroscience Department, University of Genoa, Italypeople with different knowledge will work side by side in constructingnew paradigms and new protocols. Technology and contents arethe milestones to start from: a technology which is easy to use andcontents which are certified and constantly updated, following thenature of the web, where all is in movement and in constant development.The WPA can be the center of international projects aimed todevelop a common background for all psychiatric professionalsworldwide, with no colonialistic intent and no will to impose a particularview against another.SS46.THE HIDDEN BURDEN OF MENTAL RETARDATION(Organized by the WPA Sections on Mental HealthEconomics and on Mental Retardation)SS46.1.THE MAGNITUDE AND BURDEN OF MENTALRETARDATIONJ.M. BertoloteWorld Health Organization, Geneva, SwitzerlandMental retardation (MR) is a meta-syndromic descriptor that encapsulatesa variety of clinical conditions (some of which described at asyndromic level). The nature of these specific clinical conditionsrange from nutritional (e.g. iodine deficiency), genetic (e.g. Downsyndrome), infectious (e.g. intrauterine rubella), metabolic (e.g.phenylketonuria) to toxic (e.g. fetal alcohol syndrome and heavymetal intoxications). While the prevalence of MR in developed countriesvaries between 0.5% and 2.5%, in some developed countries itcan be up to twice as high. There are, however, important variationsin the severity of MR, with has major implications for determining thedegree of disability caused by MR. Level of disability is crucial for theassessment of the burden of disease. Methodological and conceptualproblems for estimating the economic burden of all forms of mentalretardation will be presented.SS46.2.CONSUMPTION AND OUTCOMES OF MENTALHEALTH SERVICES FOR PEOPLE WITH MENTALRETARDATIONN. Bouras, H. Costello, M. Spiller, A. Cowley, G. Holt, E.Tsakanikos, A. BokszanskaInstitute of Psychiatry, London, UKSignificant differences in service consumption and outcomes werefound in referral patterns over a period of time in people with mentalretardation. These related to ethnicity, residence, psychiatric diagnosis,the level of mental retardation and psychiatric admissions. Anincreased presence of psychopathology was associated with olderage, mild mental retardation, admission to an inpatient unit, referralfrom generic mental health services and detention under currentmental health legislation. Regression models relating to specific psychiatricdiagnoses generally accounted for a limited amount of variation.No significant differences were observed in the use of differentaspects of mental health provision in relation to diagnostic groups.Characteristics of “heavy” service users were identified. Clear servicearrangements are essential for individuals with mild mental retardationwho have a high incidence of psychiatric disorders.The worldwide accessibility of the web will allow in the future toorganize and standardize new forms of medical education, in which96 World Psychiatry 3:S1 - October 2004

SS46.3.INTERNATIONAL RESEARCH ON MENTALHEALTHCARE SYSTEMS FOR PEOPLE WITHINTELLECTUAL DISABILITIES IN EUROPE:BRIDGING THE GAPS WITH CARE POLICYL. Salvador-CarullaUniversity of Cadiz, SpainIn the recent years a considerable effort has been put forward to gathersystematic information on services and care systems for peoplewith intellectual disabilities (PWID) and mental health needs inEurope. Three European Union (EU) funded networks have producedrelevant information and experience. The MEROPE networkbrought together the expertise of 5 countries (England, Austria,Greece, Spain and Ireland) in order to share information in relationto the mental health of PWID. The project considered four keyaspects of dual diagnosis: service provision, assessment and diagnosis,improving awareness of mental health needs, and the developmentof a European database. It had significant implications for theuse of clinical assessment tools in Europe and the development ofdual diagnosis services. The Intellectual Disability Research Network(IDRESNET) project involved seven countries (Belgium, England,Germany, Greece, The Netherlands, Spain and Sweden) and focusedon: a) deinstitutionalisation and the development of community care,b) legal aspects, c) the use of direct payments or personal budgets,and d) the development of person-centred planning. A series of commonmethods for care system assessment were suggested. ThePOMONA project, carried out in 13 EU member states, was aimed atdeveloping health indicators useful for health monitoring and policyplanning in Europe. A considerable effort has been made towardsbetter understanding of care systems for PWID in Europe. However,this effort has not been translated into international health policies. Itmay be necessary to promote further links between existing networks,to achieve consensus on service research methods and to buildbridges between researchers and policy planners.SS47.PSYCHOSIS: MEANING, MECHANISM ANDINTERPERSONAL CONSEQUENCES (Workshoporganized by the WPA Section on Psychoanalysisin Psychiatry, in collaboration with the InternationalSociety for the Psychological Treatment ofSchizophrenia and other Psychoses, ISPS)SS47.1.PSYCHOSIS: MEANING, MECHANISM ANDINTERPERSONAL CONSEQUENCESA.-L. Silver 1,2,3 , B. Martindale 1,21 WPA Psychoanalysis in Psychiatry (PIP) Section; 2 InternationalSociety for the Psychological Treatment of Schizophrenia andother Psychoses (ISPS); 3 Department of Psychiatry, UniformedServices University of Health Sciences (USUHS), Bethesda, MD,USAIncreased understandings of unconscious psychological mechanismsand of disturbances in symbol formation allow scientific explorationfrom these perspectives of both the form and content of psychoses.These discoveries/understanding are needed to complement researchthat focuses on the biological underpinnings of psychoses. Biologicalresearch looks for what is common to those with certain psychoses.Psychoanalytic investigations are more likely to focus on what is particularto an individual in terms of the personal and developmentalhistory and personal psychology in coping or not coping with mentalpain. In terms of treatment, recognising the personal psychology willlead to establishing recovery goals that are personally relevant. Closedefinition is needed of the specific personal, relationship and environmentalfactors and the affects that could not be managed prior tothe psychosis. We discuss case material to demonstrate and discusswith the participants unconscious meanings and mechanisms in psychoses.We also discuss the interpersonal manifestations of these phenomenaduring the course of a psychotherapeutic relationship in psychoticcases.SS48.THE RELEVANCE OFNEUROPSYCHOPHYSIOLOGICAL RESEARCH TOPSYCHIATRIC TREATMENT (Organized by the WPASection on Psychophysiology)SS48.1.THE RELEVANCE OF NEUROPHYSIOLOGICALRESEARCH TO THE TREATMENT OFSCHIZOPHRENIAW. Strik, D. Hubl, T.J. Mueller, H. Horn, A. Federspiel, T. DierksUniversity Hospital of Clinical Psychiatry, Berne, SwitzerlandNeurophysiological research in schizophrenia is primarily aimed tounderstand the pathophysiology of the disorder and, more recently, ofspecific symptoms. Like in other basic research areas, the relevance toclinical practice (i.e. to prognosis, diagnosis and treatment) is an indirectgoal and may be missed or turn out to be a hardly predictable byproduct.The presentation will show time-honored and new examplesof neurophysiological contributions with importance to the treatmentof schizophrenia. Among these are electroencephalographic diagnosticprocedures, the meaning of cognitive evoked potentials in prognosisand therapy planning, the contribution of functional imaging andof transcranial magnetic stimulation. It is concluded that neurophysiologicalresearch has a great potential to improve the clinical handlingof schizophrenia, although in many of the promising cases,unfortunately, the last necessary step of independent clinical validationhas been left undone.SS48.2.PSYCHOPHYSIOLOGY OFOBSESSIVE-COMPULSIVE DISORDERL. LeocaniDepartment of Neurology and Clinical Neurophysiology,Scientific Institute San Raffaele Hospital, Milan, ItalyConverging neuropsychological and neuroimaging evidence suggeststhe presence of frontal lobe overactivity in obsessive-compulsive disorder(OCD). Event-related potentials (ERPs) may be used to investigatethe speed of cognitive processes and may be recorded duringtests designed to assess frontal functions, such as the Stroop test.Frontal lobes also play an important role in the control of voluntarymovement, particularly in motor planning and execution. These circuitriesmay be investigated using event-related desynchronization(ERD) analysis. ERD of the sensorimotor EEG rhythms evaluates thetemporal course of cortical activation during movement preparationand execution; event-related synchronization (ERS) of the samerhythms, occurring after movement termination, is considered a cor-97

elate of cortical idling or inhibition. We will present findings on theapplication of ERPs and reaction times to the Stroop test and ofmovement-related ERD/ERS in patients with OCD. All findings areconsistent with the hypothesis of a frontal lobe dysfunction in thisdisorder.SS48.3.THE RELEVANCE OFNEUROPSYCHOPHYSIOLOGICAL RESEARCHTO TREATMENT OF DEMENTIAT. DierksDepartment of Psychiatric Neurophysiology, University Hospitalof Clinical Psychiatry, Bern, SwitzerlandElectroencephalography (EEG) reflects the spontaneous neuronalactivity. Hans Berger demonstrated EEG alterations in patients sufferingfrom cognitive deficits already 60 years ago. Since then manyinvestigations aimed at demonstrating the clinical usefulness of EEGand its value in the elucidation of pathophysiological aspects of thecerebral processes underlying cognitive deficits. In Alzheimer’s disease(AD), in general a slowing of the EEG has been described, whichcorrelated in some frequency bands with the severity of the cognitivedeficits. Alpha and theta activity seemed more to be a state marker ofcognitive function in AD, whereas beta activity was seen as a traitmarker. Topographical changes of EEG in AD reflected alterations ofcerebral glucose metabolism and results indicated that topographicalparameters might predict AD in a preclinical stage. The prediction ofAD converters in subjects with mild cognitive impairment would providean indication of which subjects would be suitable for a pharmacologicaltreatment at an early point. Additionally EEG, complementaryto behavioral measures, provides important information aboutthe individual pharmacological treatment course on a neuronal level.In addition, the effect of non-pharmacological treatment strategiescan be monitored by neurophysiological techniques. Complementaryto the electrophysiological methods, neurophysiological tools likefunctional magnetic resonance imaging can potentiate the insightsinto the neuronal mechanisms of brain function in cognitive disorders.Together these neurophysiological tools will probably allow inthe future both a better evaluation of medications and a better planningand monitoring of treatment strategies in individual patients.SS48.4.EMOTIONAL PROCESSING IN SUBJECTS WITHPANIC DISORDERS. Galderisi, A. Mucci, U. Volpe, P. Bucci, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalyAdvances in both pharmacological and psychoterapeutic interventionshave contributed to ameliorate the outcome of panic disorder(PD), although etiopathogenetic mechanisms underlying the disorderremain unclear. We have recently explored the hypothesis that a dysfunctionof temporo-limbic regions, in particular those of the righthemisphere, plays a crucial role in the pathogenesis of PD and mayunderlie key psychological features described in these subjects, i.e.alexithymia, the tendency to interpret ambiguous stimuli as threateningand an attentional bias toward threat-related cues. In 22 drug-freepatients with DSM-IV PD and matched healthy controls (HC), alexithymiawas evaluated by the Toronto Alexithymia Scale, and EEGbasedbrain imaging was carried out by using the low resolution electromagnetictomography (LORETA) on event-related potentials(ERPs) recorded during a visual target detection task in which stimuliwith different emotional valence were used. Alexithymia was morefrequent in PD subjects than in HC. Different activation patternswere observed in HC and PD subjects. For erotic stimuli, an activationof the anterior cingulate, insula and medial frontal areas wasobserved in HC, while a hypoactivation of the right parieto-temporalregions was found in PD subjects. For threat-related stimuli, no activationpatterns were found in HC, while a hypoactivation of righttemporal regions was observed in PD subjects. The results confirmthe hypothesis that a dysfunction of temporo-limbic regions, in particularthose of the right hemisphere, is involved in the disorder andsuggest that subjects with PD may benefit from psychotherapeuticinterventions addressing difficulties in emotional processing.SS49.ATTENTION-DEFICIT/HYPERACTIVITY DISORDERIN PRIMARY CARE (Organized by the WPA Sectionon Psychiatry, Medicine and Primary Care)SS49.1.ADHD: BEYOND DIAGNOSISE. BelfortCentral University of Venezuela, Caracas, VenezuelaAccording to recent epidemiological studies on attentiondeficit/hyperactivity disorder (ADHD), approximately 3 to 7% ofschool age children suffer from this disorder. In most cases, the disorderproduces not only academic dysfunction, but also social andfamilial malfunctioning, hindering more adequate adaptationprocesses, and developing in a high percentage into the adult life ofthose patients. This is a lifetime syndrome which not only affects thepatients’ cognitive or behavioral areas, but also impacts on their emotionaland functional life. Although information is accumulating onthe involvement of dopaminergic or noradrenergic pathways associatedwith the control of impulsivity or attention, the possible linkbetween inattention and the control of inhibitory mechanisms, andthe difficulties in the inhibition response that may lead to secondaryexecution deficit, further research is needed in order to perceive whatis basic or fundamental for these children, improve their functioningand ensure a less stigmatizing life, beyond just diagnosis.SS49.2. IMPULSIVITY AND INATTENTION INADULTS: DIFFERENTIAL DIAGNOSIS ANDTREATMENT CONSIDERATIONS FOR PRIMARYCARE PHYSICIANSD. BaronDepartment of Psychiatry, Temple University, Philadelphia,PA, USARarely will adult patients present to their primary care physicianwith complaints of making careless mistakes or boredom at work,difficulty maintaining attention or concentration, misplacing thingsfrequently, being easily distracted or problems remembering appointmentsor obligations. Similarly, adults will not offer a chief complaintof feeling restless or fidgety, compelled to always be active, talkingtoo much, frequently interrupting others or having no patience whenforced to wait in lines. However, these classic symptoms of impulsivityand inattention result in significant life impairment for patientswho experience them on a regular basis. The problem of not identifyingthese important symptoms is the result of physicians not askingand patients not providing this information to their doctor. Mostpatients see these symptoms as life problems, and not appropriate to98 World Psychiatry 3:S1 - October 2004

discuss with their family doctor. As is the case in all areas of clinicalmedical practice, symptoms unidentified and untreated usuallyresult in progressive impairment and difficulty in achieving successfulsymptom relief when the diagnosis is delayed. The differentialdiagnosis of impulsivity and inattention in adults begins with askingthe appropriate questions and includes a lengthy list of possible diagnoses.Psychiatric syndromes which can present with symptoms ofimpulsivity and inattention include major depression, bipolar disorder,anxiety disorders, learning disorders, psychotic disorders, substanceuse disorders and attention-deficit/hyperactivity disorder. Anumber of neurologic and cognitive disorders may also present withsimilar symptoms. This presentation will offer guidelines in assistingthe primary care provider in making an accurate diagnosis and suggesteffective treatment strategies for each of the potential diagnoses.Recommendations will be based on the current clinical research literature.SS49.3.TRAINING OF THE PRIMARY CARE PHYSICIANIN ADHD: AN EDUCATIONAL PROGRAMR. FahrerDepartment of Mental Health, University Hospital Schoolof Medicine, Buenos Aires, ArgentinaAttention deficit/hyperactivity disorder (ADHD) is a chronic neuropsychiatricdisorder that produces severe functional impairment. Inapproximately 65% of the children with ADHD, the symptoms willpersist into adulthood. There are estimations showing that 85% ofadult patients with ADHD are not diagnosed. The syndrome goesunnoticed for years, and by adulthood people with high intellectualquotient have developed effective compensatory abilities. There is novalidated procedure or tool to detect and diagnose ADHD in adults.The diagnosis is commonly missed by primary care physicians. Wewill present an educational program to train the primary care physician,who is the first point of contact with the patient, to early detectionof this disorder.SS50.VIOLENCE: A MAN MADE DISASTER (Organizedby the WPA Section on PsychologicalConsequences of Torture and Persecution)SS50.1.STRATEGIES FOR PREVENTIVE MEASURESAGAINST TORTUREI. GenefkeInternational Rehabilitation Council for Torture Victims,Copenhagen, DenmarkIn several European countries, estimates and studies have shownthat, amongst refugees, the percentage of torture victims is 20-30%. Inthe US, medical doctors in the rehabilitation centres estimate that,amongst refugees, there are 400,000 torture victims. In other parts ofthe world it is difficult to estimate the exact number, but knowing thathalf of the population in the world, 3 billion people, are living incountries where the authorities only can keep the power because theyare torturing their own citizens, the number of torture victims isfreightening. Disaster is known as a destructive event that causes adiscrepancy between the number of casualties and the treatmentcapacity. Working against the man-made disaster represented by torture,the prevention model, which has been implemented during our30 years of medical work against torture, will be presented. Primaryprevention aims at eradicating torture before it occurs: identify thecauses of torture, the possible agents of torture, the systems that permit,organise and spread torture, and the ”high risk for torture”groups in each specific country of intervention. Secondary preventionis to limit the occurrence and consequences of torture, through educationand training of health professionals and other professionalgroups, specifically law enforcement personnel. Tertiary preventionaims to lessen the effects of torture. It is person-related and providessupport and treatment to the individual torture victim. A detaileddescription of the three prevention strategies will be provided. Thisapproach is a reflection of a medical conceptualization of preventionthat we have found to be extremely useful. The special role of the psychiatristin primary, secondary and tertiary prevention will be discussed.SS50.2.MENTAL HEALTH CONSEQUENCES OF STATEPERPETRATED VIOLENCEM. KastrupCentre for Transcultural Psychiatry, Copenhagen, DenmarkAccording to the United Nations Convention of 1984 against Tortureand Other Cruel, Inhuman or Degrading Treatment or Punishment,states having signed the Convention shall ensure that education andinformation regarding the prohibition of torture are included in thetraining of medical personnel who may be involved in the custody ortreatment of individuals deprived of their liberty. Unfortunately, fewcountries enforce this, implying that few psychiatrists receive anysuch education and thus have appropriate knowledge on the issue oftorture. Knowledge about the mental health consequences of stateperpetrated violence, including torture, is of clear clinical relevancefor psychiatrists worldwide, as a significant proportion of refugeesand migrants have experiences of war, strife, persecution and tortureand a large proportion of the world population live in countries thatcondone torture. The paper will outline the psychiatric symptomatologyfollowing exposure to state perpetrated violence, prevailing therapeuticmodels, preventive considerations as well as educationalneeds for the psychiatric profession.SS50.3.WAR TIME EXPOSURE, HELP-SEEKING ANDPOST-TRAUMATIC STRESS DISORDER IN WARVICTIMS FROM BOSNIA-HERZEGOVINAT. Wenzel 1 , V. Redzic 1 , L. Linzmayer 1 , M. Krautgartner 2 ,A. Karkin-Tais 31 WPA Section on Psychological Consequences of Tortureand Persecution; 2 Department of Psychiatry, University of Vienna,Austria; 3 Hope Treatment Centre for War Victims, Sarajevo,Bosnia and HerzegovinaThe fate of Bosnia-Herzegovina (BH) and specifically that of Sarajevohas become a symbol of war exposure in a civilian population.Sarajevo became emblematic in the early 1990s for the suffering of thecivil population. Prosecution of those responsible is ongoing in animportant step to justice and prevention in the Den Haag court. Theeffect caused by crimes against humanity and war must be seen aslong-term, though it is presently overshadowed by war reconstructionin Iraq and Afghanistan. Psychological sequels are part of the aftereffects that should be taken into account and could be argued to beeligible to recompensation, based on research and individual findings.Long-term health care programmes are often based on the99

expectation that symptom presentation and help-seeking might influenceprevalence data that are the base of long-term health care planning.We evaluated treatment and non-treatment seeking war survivors(n= 30 for both groups) using the Harvard Trauma Questionnaire(HTQ) and the Impact of Events scale in Bosnian language. Thequestionnaire evaluated general war related events, general and sexualtorture, rates of intrusive and avoidance cluster symptoms, andsymptoms of general and complex post-traumatic stress disorder(PTSD). Key findings of relevance include a high rate of PTSD symptomseven 6 years after the war. High age and torture appear to bemajor risk factors for PTSD, while patients who had suffered rape ascrime of war had lower rates of general PTSD symptoms, but highrates of complex PTSD on the HTQ. While PTSD symptoms werehigh mainly in the help-seeking group, and usually low in the nontreatmentgroup, the different cut-off scores in the literature and especiallythe application of the DSM-IV criteria did greatly influence thePTSD rate.SS51.SUBSTANCE ABUSE AND THE FAMILY (Organizedby the WPA Section on Addiction Psychiatry)SS51.1.FAMILY THERAPY AND SUBSTANCE ABUSE:A RESEARCH OVERVIEWN. el-GuebalyFoothills Hospital Addiction Centre, University of Calgary,CanadaAspects of family life and relationships have long been connected tothe initiation, exacerbation and relapse of the spectrum of substanceuse disorders. Examples include that poor parent-adolescent relationshipsconsistently predict adolescent drug use across cultures andtime; negative communications and poor coping strategies within amarriage may initiate and perpetuate drug use, while close relationshipwith healthy families-of-origin may buffer the abuser fromrelapse. Based on the above, family-based interventions have beenidentified as “promising”, but until recently not “definitive” as a treatmentmodality, due to the relative dearth of empirical support. Morerigorous investigation of the impact of these interventions is now possible,spurred by the presence of several manualized family-basedapproaches. Particularly, among adolescent populations, cost-effectivefamily-based treatment approaches are now shown to significantlyreduce drug use, achieve better retention rates, reduce comorbidexternalizing problems, improve school and performance as well asoverall family function. The evidence for family interventions withadult abusers is more limited. A notable exception has been a series ofstudies involving behavioral couples therapy (BCT). This growingempirical evidence is however overwhelmingly rooted in a Westernand particularly North American family perspective. It is thereforetimely to compare the experience of family interventions in other culturalcontexts, including structure, power division, attitude towardsdrugs and the role of self-help.SS51.2. BEHAVIORAL COUPLE THERAPY (BCT):INDIVIDUAL AND GROUP INTERVENTIONSN. el-Guebaly, R. RichardFoothills Hospital Addiction Centre, University of Calgary,CanadaIn the context of the predominantly nuclear family structure, behavioralcouple therapy (BCT) has gained prominence for enlisting thefamily’s help after the alcohol or drug-dependent person has soughttreatment. Recent research has demonstrated its utility with a range ofaddictions, gender and social classes, citing enhanced cost-effectivenessand benefit to children. This intervention aims to build supportfor abstinence and to improve relationship functioning. This paperdescribes the process of selecting and preparing couples for treatmentalong with the use of behavioral contracts to promote abstinence andthe complementary relationship enhancement and communicationskill training. The optional use of prophylactic medication to supportabstinence is also reviewed. Although this program was originallydesigned to be delivered to groups, most of the 17 published outcomestudies have focused on individual marital therapy. We also focus onour pilot group marital therapy program, based on the experiencewith 35 couples so far. The pros and cons of group versus individualintervention are reviewed, as well as clinical insights gained from successesand failures.SS51.3.THE FAMILY: A SITE FOR CONTROL AND CAREOF ALCOHOL ABUSEF. PoldrugoSchool of Medicine, University of Trieste, ItalyWhile cultural norms that influence drinking behavior have beenwidely explored, the importance of sociocultural factors in shapingfamily attitudes toward drinking and the drinker have been rarelyaddressed. However, it has been recognized that some family-centeredEuropean cultures (like the Italian, Portuguese and Spanish),exerting familiar informal social control with regard to drinking, aremost successful in preventing alcohol abuse. In the same countries,families act as the primary groups for alcohol-related problem intervention.We present the results of an Italian experience where anearly active inclusion of families in the recovery process, in the contextof a community-based rehabilitative program for the treatment ofalcoholism, proved to be the main ingredient leading to success. Itfollows that more culturally informed strategies of interventionshould be a future aim.SS51.4.EXPRESSED EMOTION AND SUBSTANCE-RELATEDDISORDERS IN OUTPATIENT AND RESIDENTIALTREATMENT: A CASE CONTROL STUDYG. Carrà 1 , M. Clerici 21 Department of Applied Health and Behavioural Sciences,Section of Psychiatry, University of Pavia; 2 Department ofPsychiatry, San Paolo Hospital Medical School, University ofMilan, ItalyLittle is known about expressed emotion (EE) as a predictor ofrelapse for substance related disorders, and there have been few publishedclinical trials evaluating family psychoeducation in these disorders.We compared high-EE status rates between families ofpatients with substance related disorders in outpatient and residentialtreatment and of schizophrenic patients in standard outpatient100 World Psychiatry 3:S1 - October 2004

care. Seventy-one relatives of addicted patients, in outpatient andresidential treatment, and 45 relatives of schizophrenic patients werecompared as regards EE status. High-EE status is more frequent inthe substance related group, particularly in residential treatment,than in the schizophrenic group. The benefit of family interventionand the predictive power of EE in schizophrenia emphasize the needof controlled trials of family psychoeducation interventions for substancerelated disorders.SS51.5.CULTURAL ISSUES AND FAMILY TREATMENTOF SUBSTANCE ABUSEA.H. GhodseDepatment of Psychiatry of Addictive Behaviour, Universityof London, UKEach family has its own culture and its own dynamic and, when substanceabuse occurs, the response of different family members is notnecessarily uniform. For example, the family may split into rejectingand rescuing factions, thus leading to family conflict. Wider culturalfactors undoubtedly also affect the family’s response to substanceabuse. In traditional societies, accustomed to folk methods of confrontingdifficulties and problem-solving, a professional therapist maymeet considerable resistance, which can be alleviated if the positionof an older person in supervising treatment is recognised andacknowledged. To understand the experience of a family from a verydifferent culture requires a mind that can be open to new constructionsof the pattern of family life, both internally and externally and interms of custom and expectation. For example, respected kinship andauthority structures in Asian and African extended families are strikinglydifferent to those in Western families and, in countries where thefamily is the nucleus of society, it often plays a significant role inbringing the abuser to treatment. Certainly, substance abusers themselvesperceive family support as most important for remaining intreatment. All of these examples demonstrate the importance ofunderstanding the impact of culture on family life and also its effectson treatment interventions. Studies of substance abuse in differentparts of the world demonstrate that people in different countries aredoing very different and sometimes quite contradictory things to helpsubstance abuser and this presumably reflects markedly differentviews about the nature of the disorder being treated and of the helpingprocesses. Case studies will demonstrate the influence of culturein different forms of family treatments and the important role whichfamily does play in recovery or otherwise.SS52.SETTINGS AND TECHNIQUES OF INTERVENTIONIN EMERGENCY PSYCHIATRY: A COMPARISONOF DIFFERENT MODELS (Organized by the WPASection on Emergency Psychiatry)SS52.1.PSYCHODYNAMIC CRISIS INTERVENTION FORBORDERLINE PATIENTS WITH A SUICIDE ATTEMPTA. Andreoli, Y. Burnand, M.F. Cochennec, L. Cailhol, R. PirrottaHôpitaux Universitaires, Geneva, Switzerlandself-damaging behaviour, new research should be aimed to developbetter acute treatment for these subjects. To address this issue, we furtherdeveloped a well studied crisis intervention program in order toprovide cost-effective ambulatory therapy to borderline patientsreferred to emergency room for a suicide attempt. We present here afirst prospective evaluation of this program. Inclusion criteria werethe following: consenting subjects, with an age range between 20 and65 years, referred to emergency room with self-poisoning, majordepression and borderline personality disorder, and requiring psychiatrichospitalisation. Psychotic disorders, bipolar disorder, severesubstance dependence, mental retardation were exclusion criteria.After emergency treatment (up to 5 days), consecutive subjects meetingcriteria were assigned to comprehensive outpatient crisis interventionincluding standard clinical management with selective serotoninreuptake inhibitor (SSRI) medication, suicidal risk case managementand psychodynamic psychotherapy (2 session per week). At3 month follow-up we found substantial symptom improvement, fairto good global functioning, negligible rates and severity of self-damagingbehaviour. In addition, most patients exhibited remarkableadherence to treatment within crisis intervention and after dischargefrom the program.SS52.2. PSYCHIATRIC EMERGENCIES:FROM DIAGNOSTIC EVALUATION TOINTERVENTION IN A PSYCHIATRIC EMERGENCYSERVICEG. Invernizzi, C. Bressi, M. PorcellanaPsychiatric Clinic, State University, Milan, ItalyPsychiatric emergencies are characterized by the acute subjective sufferingwhich accompanies mood, thought and behavioral disorders.The subjective feeling expressed by the patient that his/her emotionalbalance has broken down requires that he/she receives immediatehelp and a specific treatment. In order to decide which interventionwould be most appropriate, a careful examination of the psychiatricprofile and the available resources is necessary. This is often not possiblewithin the environment of a first aid department, for logistic andoperational reasons. The outpatient clinic “Orientating Interviews”was set up in 1998 at the Psychiatric Clinic of Milan State Universityin order to bridge the gap. This is a service without any appointmentlist, where users have free access, thus permitting patients to be immediatelyaccepted for treatment. During the first visit the user’s reasonsfor requesting the service are explored, together with the expressedneeds. A diagnostic evaluation is made and indications for treatmentare provided, in accordance with the expressed needs and the psychopathologicalprofile. If a clinical condition which falls within thedefinition of psychiatric emergency is found, the user is referred to thepsychotherapy unit for specialized emergency interventions, whichmay take the form of crisis intervention (supportive psychotherapylasting for 8-12 sessions once a week), brief psychotherapy, a medium-termanalytically-oriented treatment (40-60 weekly sessions) orpsychiatric therapy (support sessions plus drug therapy) with periodiccheck-ups.Suicidal patients with borderline personality disorder have anincreased risk of completed suicide and poor treatment response.After recent research indicated that both antidepressant medicationand psychotherapy improve the outcome of borderline patients with101

SS52.3.EMERGENCY PSYCHIATRY AND THE REQUESTOF PSYCHIATRIC INTERVENTION BY GENERALPRACTITIONERSP.M. Furlan, R.L. Picci, S.VenturelloMental Health Department, San Luigi Gonzaga Hospital,University of Turin, ItalyThis research stems from the fact that in Italy the rationale of the psychiatricreform has been to involve most of the categories of healthprofessionals in psychiatric care rather than isolating it in a separatemental health setting. As a result, mental disorders are more likely tobe treated by non-psychiatric health professionals. Furthermore, theneed to reduce costs means that psychiatric specialists might not beinvolved at all or only involved in a later stage. These and other factorshave led us to concentrate our study on the role of general practitionersin psychiatric treatment and on the role of doctors workingin the emergency ward. We studied one sample for each of the above,consisting of 50 subjects. Our preliminary results show that the numberof requests for specialist psychiatric intervention by general practitionersdecreased by 50% if these doctors had attended an emergencymedicine training course. Furthermore, we evaluated whetheror not the request for specialist psychiatric consultation was appropriate.Here too, our findings are revealing a remarkable differencebetween general practitioners with specific training and those withoutit. We highlight some of the problematic issues raised by the studyand suggest some possible solutions.SS52.4.PSYCHIATRY AND EMERGENCY MEDICINE INMETROPOLITAN AREAS: BETWEEN SEPARATIONAND INTEGRATIONL. Ferrannini, P.F. Peloso, M. VaggiDepartment of Mental Health, Genoa, ItalyModern psychiatry has to provide an intervention in situations whichare different with respect to goals (from prevention to rehabilitation),settings (hospital, community, residential facilities, houses), timeframe (from emergency to lifetime treatments). Therefore, the linkbetween the hospital and the community, and between somatic medicineand psychiatry, becomes more and more important. The differencesin the needs of the population and in the commitments whichare required become even more complex in the urban areas, wherethe organization frames have to be specific and flexible at the sametime, finding a balance between an immediate taking care of patients,some of them with new pathologies, and their consent to the treatment.The experience of a community psychiatry program in Genoa ispresented.SS52.5.FAMILY INTERVENTIONS IN CHILDHOODPOST-TRAUMATIC STRESS DISORDERG. PierriDepartment of Neurological and Psychiatric Sciences,University of Bari, ItalyIn childhood, post-traumatic stress disorder (PTSD) may be the consequenceof sharing a sexual activity not suitable to the age, of beingthe victim of actual or threatened physical violence, or of having witnessedevents which can arouse strong emotional feelings. The manifestationsof the disorder in children may include impulsive or selfinjuriousacts, physical discomfort, feelings of despair or shame, isolationand refusal of contacts with the surrounding world. Therapeuticinterventions are different and of various theoretical derivation. Inour experience, what seems fundamental is the intervention on thefamily, implemented with various techniques, so that the therapeuticaction is naturally mediated by educational figures with whom thechild has a meaningful affective bond.SS53.COMMON MENTAL DISORDERS IN PRIVATEPRACTICE (Organized by the WPA Sectionon Private Practice)SS53.1.AFFECTIVE CONDITIONS IGNORED INACADEMIC PSYCHIATRYH.S. AkiskalUniversity of California at San Diego, CA, USAThe last decade has witnessed an increasing gulf between clinical psychiatryand academic psychiatry. The focus on research by academicfaculty who are increasingly divorced from patient care has led toconcepts and data whose pertinence to clinical practice is, accordingly,increasingly irrelevant. They tend to focus, for instance, on “pure”disorders: dementia, schizophrenia, mania, major depression, posttraumaticstress disorder, individual personality disorders, anorexianervosa, and addictive disorders. Clinicians treat highly comorbiddisorders involving various combinations of the above, in particularthose involving dysthymia, bipolar II disorder, bulimia, social phobia,panic disorder, and substance/alcohol use disorders. We submit thatresearch conducted by clinicians represents a “corrective” alternativeto academic research.SS53.2.BIPOLAR II DISORDER: NEW RESEARCH FINDINGSF. BenazziE. Hecker Outpatient Psychiatry Center, Ravenna, ItalyBipolar II disorder (BP-II), defined as a mood disorder with majordepressive episodes (MDE) and hypomanic episodes, is much morecommon than reported by DSM-IV (0.5%). Community prevalencewas found to be as high as 11%. Higher prevalence of BP-II is relatedto improved probing for past hypomania and to interviews done byclinicians. Probing for past hypomania was improved by focusingmore on overactivity (increased goal-directed activity) than moodchange. Overactivity is an observable behavior, easier to remember bypatients and family members/close friends than mood change. Recentstudies have shown that overactivity may have at least the same prioritylevel given by DSM-IV to mood change for the diagnosis of hypomania.DSM-IV requires an observable change in functioning duringhypomania, but does not state in the diagnostic criteria that functioningis often increased. Recent studies have shown that in hypomaniafunctioning may be more often increased or decreased according tothe non-tertiary-care versus tertiary-care setting (“sunny” and “dark”hypomania). It was shown that “dark” hypomania often had an underlyinghighly unstable temperament (cyclothymic temperament), whilethe “sunny” BP-II were more likely to be relatively stable between theepisodes. Duration of hypomania usually ranges from few days toweeks. A minimum duration of 2 days (versus DSM-IV 4 days) hasbeen validated. The cross-sectional picture of BP-II depression (MDE)was shown to be often an atypical depression (oversleeping, overeating),and also to have frequently concurrent hypomanic symptoms102 World Psychiatry 3:S1 - October 2004

(usually irritability, racing/crowded thoughts, psychomotor agitation,more talkativeness). Mixed depression (depressive mixed state) wasdefined as an MDE with 3 or more concurrent hypomanic symptoms.This definition was validated by its association with classic bipolar validatorssuch as young age at onset, many MDE recurrences, atypicaldepression, and bipolar family history. A dose-response relationshipwas found between number of intra-MDE hypomanic symptoms andbipolar family history loading in probands’ relatives. The distributionof intra-MDE hypomania symptoms was found to be near normal,supporting a dimensional definition of mixed depression. Worseningof mixed depression if treated only with antidepressants was alsoobserved, as well as the positive impact on mixed depression by treatingfirst the hypomanic symptoms by mood stabilising agents.SS53.3.LONG-TERM PHARMACOLOGICAL TREATMENTOF PANIC DISORDER IN CLINICAL PRACTICE:FOCUS ON RESISTANT FORMSC. ToniInstitute of Behavioral Science, Pisa/Carrara, ItalyData on pharmacological treatment of panic disorder (PD) derivedfrom controlled studies cannot be judged without the regular measurementsof outcomes in daily practice. In fact, patients enrolled incontrolled trials are usually young, physically healthy and suffer froman acute phase of their illness in the absence of severe comorbid conditions.“Atypical” forms of PD, in which symptom-limited attacks,unreality feelings and other psychosensorial features prevail, arealmost neglected. Moreover, drug treatment is typically episodic ordiscontinuous, occurring at random points, and does not capture thenaturalistic situation. Hence, the need to focus on sample characteristics,which distribute along a wide range of age, symptomatology,severity and comorbidity, as is the case in routine clinical practice. Ina sample of 326 PD patients treated with antidepressants in a settingof routine clinical practice and followed up for three years, weobserved a significant number of complete symptomatological remissions(nearly 95%), but in many cases our PD patients showed arelapsing course. The longest period of remission of PD was associatedwith low severity, medium-lasting course in patients with an onsetof the illness in young adulthood. A high percentage of patients whohad achieved symptom remission tended to drop out from furthertreatment; adherence to long-term treatment with antidepressantswas predicted by severe and long-lasting symptomatology. Furtherinformation is needed with regard to drug effectiveness and therapeuticmanagement in the long-term treatment of PD, especially focusingon “atypical” forms, bipolar II comorbidity and long-term use of benzodiazepinesas possible predictors of treatment failure.SS53.4.OBSESSIVE-COMPULSIVE DISORDER,DEPRESSION AND SOFT BIPOLARITY:A COMPLEX COMORBIDITYG. PerugiDepartment of Psychiatry, University of Pisa, ItalyOCD, which, nonetheless, pursued a more episodic course withgreater number of concurrent major depressive episodes. OCD bipolarshad a significantly higher rate of sexual and religious obsessionsand a significantly lower rate of checking rituals. They reported morefrequently panic disorder-agoraphobia and the abuse of different substances(alcohol, sedatives, psychostimulants and coffee). OCDprobands with non-bipolar major depressive co-morbidity (“unipolar”OCD) were older in age, had a more chronic course with morefrequent hospitalizations and suicide attempts and had greater comorbiditywith generalized anxiety disorder when compared with theremaining of OCD cases. Finally, they were more likely to haveaggressive obsessions and those with philosophical, superstitious andbizarre content. These data suggest that co-morbidity with bipolarand unipolar affective disorders has a differential impact on the clinicalcharacteristics, co-morbidity, and course of OCD. Selective serotoninreuptake inhibitors (SSRIs) represent the first choice treatmentfor comorbid OCD and major depression, which would suggest adiagnostic priority for OCD when concomitant with major depression.In bipolar-OCD patients, clomipramine and, to a lesser extent,SSRIs may worsen the course of bipolar disorder, especially if initiatedbefore treatment with a mood stabilizer. When antidepressants areused, SSRIs should be preferred and started after an adequate moodstabilization has been achieved.SS53.5.BIPOLAR DISORDER IN CHILDREN ANDADOLESCENTSG. Masi, M. Mucci, S. Millepiedi, N. BertiniScientific Institute of Child Neurology and Psychiatry “StellaMaris”, Calambrone, Pisa, ItalyIf adult-onset bipolar disorder (BD) is a well-established clinicalentity, only recently clinicians have begun to take this diagnosis seriouslyin childhood. A timely diagnosis of early-onset BD is crucial,as it can provide the best opportunity for possible prevention ofbehavioral disorders, failure at school and subsequent psychosocialimpairment, which is the major risk for the chronic forms of BD.This paper describes phenomenology, diagnosis, natural history andtreatment of BD in children and adolescents. Some possible precursorsare examined, such as temperamental dysregulation, majordepressive disorder and/or dysthymia, anxiety disorders and externalizingdisorders (attention-deficit/hyperactivity disorder and conductdisorder). Phenomenology of early-onset BD is describedaccording to two different definitions, the “narrow”, adult-type definition,and the “broad” definition, which considers the atypicality ofthe early-onset clinical picture (non-episodic course, prevalentlydysphoric mood, frequent mixed or rapid-cycling episodes). The naturalhistory is briefly described, considering the relapse rate as wellas the risk of suicide or dangerous behaviors and of superimposedsubstance abuse during adolescence. Finally, drug treatment strategiesare described, considering the first-choice drugs, the managementof treatment-resistant episodes, and the problem of duration ofpharmacological prophylaxis.Clinical and epidemiological studies on obsessive-compulsive disorder(OCD) have largely focused on co-morbidity with major depression.Less attention has been devoted to the co-morbidity betweenOCD and bipolar disorder. In the present paper we deal with a morecomplex pattern of co-morbidity involving bipolarity. As contrastedto non-bipolar OCD, these patients had a more gradual onset of their103

ZONAL SYMPOSIAZS1.INTERDISCIPLINARY APPROACHES TOTREATMENT OF MENTAL DISORDERS:THE EXPERIENCE OF EASTERN EUROPE(Organized by the WPA Eastern Europe Zone)ZS1.1.COMPREHENSIVE (PHARMACO- ANDPSYCHOSOCIAL) TREATMENT FORSCHIZOPHRENIC PATIENTSI.Y. Gurovich, A.B. Shmukler, Y.A. StorozhakovaMoscow Research Institute of Psychiatry, Moscow, RussiaWe evaluated the effectiveness of a comprehensive biopsychosocialtreatment for problematic schizophrenic populations emerging in anaturalistic setting: a) patients with frequent hospital admissions; b)patients with long-term hospital stay (hospital residents); c) patientswith early psychosis. All groups were assessed clinically and with theuse of the Positive and Negative Syndrome Scale (PANSS) and scalesevaluating family burden, social functioning and quality of life, socialnetworks, instrumental and emotional support. These indices wereassessed before and after the complex treatment program includingpsychopharmacotherapy and psychosocial interventions (psychoeducation,social skills training, neurocognitive training, ongoing psychosocialsupport). The program allowed to achieve significantdecrease of the number of hospital admissions and the duration ofhospital stay and to maintain a high level of social functioning andquality of life with less family burden and better social support network.Treatment of early psychoses was provided in an outpatient setting.ZS1.2.INTERDISCIPLINARY INTERACTION OFFAMILY MEDICINE, PSYCHIATRY, CARDIOLOGY:THE EXPERIENCE OF KYRGYZSTANV. Solozhenkin, T. Nelubova, X. SolozhenkinaKyrgyz-Slavonic University, Bishkek, Kyrgyz RepublicA system of interdisciplinary interaction was created, initiated by theKyrgyz Psychiatric Association. It included two stages. First stageincluded the analysis of possible areas of interdisciplinary interaction;the evaluation of the situation in the country; the statistical analysisof diagnostic, including laboratory and paraclinical, and therapeuticapproaches and the analysis of failures of educational programs forfamily doctors on the diagnostis of affective disorders in primary care.In the second stage, on the basis of the results of the analysis, wedefined the following disorders as the subjects of multidisciplinaryscientific and practical work: vegetative dystonia, neurocirculatoryasthenia, liquor (cerebrospinal fluid) hypertension, headaches. Wealso encouraged the update of old diagnostic categories, the use ofinformative, evidence based categories and the adoption of schemesof therapy in the frame of evidence based medicine. Old didactictechnologies were revised. We selected a model of multidisciplinaryteam as the most effective form of interdisciplinary interaction.ZS1.3.INSURANCE MEDICINE AND STATE PROGRAM OFPSYCHIATRIC CARE - EXPERIENCE OF GEORGIAG.B. NaneishviliM. Asatiani Research Institute of Psychiatry, Tbilisi, GeorgiaSince 1995 in Georgia there has been a gradual reform in the healthsystem. The introduction of free market principles of economic relationsand a large administrative, organizational and financial freedomof medical establishments has required new approaches to theorganization of psychiatric service. The difficult economic situationhas produced the necessity to define not only priority directions inthe medicine financed by the state and free of charge for the citizensof the country, but also to select diseases which are socially mostsignificant. The limitation of resources was reflected also in the stateprogram for psychiatric care, where the limited responsibilities ofthe state in providing care are precisely determined. One of the mostimportant and difficult problems is the coordination with the professionalactivities of specialists of other medical disciplines in thestate program for psychiatric care. Original solutions of these problemshave been found, within the framework of limited resourcesand of rigid medical standards.ZS1.4.TEAM WORK IN PROVISION OF AID FOR PEOPLEWITH STRESS-RELATED DISORDERSK. Idrisov, K. AkhmedovaMoscow Research Institute of Psychiatry, Moscow, RussiaWe describe the experience of team work in two Chechen campusesin Ingush Republic with a population above 20 thousand. Two centersof medical psychological help (MPHC) were opened, and in eachof them a team of specialists (a psychiatrist, psychologists, a generalphysician, nurses and hospital attendants) started to work. In the primarystage of post-traumatic stress disorder (PTSD), psychologistsfrom MPHC carried out debriefing sessions during regular campusrounds. Among 5134 participants in these sessions, 2354 (45.8%)referred to MPHC and got appropriate psychological and psychiatrichelp. 52.2% of them needed psychopharmacotherapy and were treatedby a psychiatrist. 29.3% consulted a psychologist and 18.4% wereincluded in closed psychotherapeutic groups. In the secondary stage,group therapy was carried out in 5 groups including 54 women andtwo groups including 40 men with PTSD and other stress-related disorders.An ethnocultural approach was used taking into accountnational and religious peculiarities of the groups’ participants.ZS1.5.THE DEVELOPMENT OF PSYCHOSOCIALTREATMENT METHODS IN UKRAINEV. ShumlyanskyRegional Psychiatric Hospital, Zhitomir, UkrainePsychiatric care in Ukraine has been in the past at a distance fromgeneral healthcare network and concentrated on the contingent ofpatients with psychotic disorders. The development of psychiatriccare in Ukraine has been directed towards the reconstruction of apsychiatric health protection system, to develop out-patient andhalf-stationary structures which would provide social support andrehabilitation to patients, to organize specialized departments andcenters, to develop psychosocial methods of therapy and psychologicalcounseling. Psychiatric services in the Zhitomir area of Ukraineare an example of such transformations. During the last 10 years the104 World Psychiatry 3:S1 - October 2004

number of in-patient beds was reduced by 50%. A sanatorium in thesuburbs was opened for rehabilitation of patients leaving hospitals.A counseling center was created where, along consultations, cognitivebehavioral therapy, art therapy, motion therapy and communicationaltraining are available. The cooperation with social organizationsof relatives and users and with social services has beenachieved. Patients’ self-support groups work effectively.ZS1.6.NEUROPSYCHOLOGY IN RUSSIAN PSYCHIATRYV. KrasnovMoscow Research Institute of Psychiatry, Moscow, RussiaNeuropsychology was developed in Russian psychiatry mainly followingthe studies of A.R. Luria. The works of Luria are well knownin other countries. His concept of neuropsychological syndromesbecame the foundation for applied methods widely used in psychiatry,in particular the set of tests called Luria-Nebraska. By this timewe can mention both similarities and differences in the application ofneuropsychological methods in Russia and in other countries. In Russia,as well as in the USA and Western Europe, neuropsychologicalmethods are used to diagnose dementia of Alzheimer type and multiinfarctnature, and for the study of neurocognitive deficits duringschizophrenia. At the same time, due to some historical conditions,several specific branches of neuropsychology have been formed inRussia. One of them is related to the development of neurorehabilitation.Luria’s particular interest in aphasia led to the development ofneuropsychological training methods for the recovery of speech andother higher psychic functions after strokes and cerebral injuries.Another trend is related to the study of mild, non-demented forms oforganic psychosyndrome and the study of therapeutic efficacy ofnootropic and neurometabolic agents and their influence on cognitivefunctions.ZS2.PARTNERSHIP IN MENTAL HEALTH CARE INAFRICA (Organized by the WPA Southern andEastern Africa Zone)ZS2.1.THE NEED FOR EVIDENCE-BASED RESEARCH INAFRICAN PSYCHIATRYR. EmsleyDepartment of Psychiatry, Cape Town, South AfricaThe introduction of new technologies and medications into clinicalpsychiatry has resulted in a widening of the gap in the standard ofcare between developed and developing countries. For example, theconsiderable advantages of the atypical antipsychotics are likely tomake a substantial difference to patients in terms of improved socialand vocational functioning and general quality of life. However, thegreater acquisition costs of these drugs put them beyond the reachof large sectors of the world’s population - their availability in Africais extremely limited. To make matters worse, in developing countriespolicy makers usually award low priority to the development ofservices for people with mental illness, other health issues beingperceived as more important. Research findings in the developedworld cannot be generalized to developing countries. Cost-effectivenessstudies in low-income countries need to be undertaken.Other more affordable treatments need to be researched. The considerableevidence for improved safety and efficacy of low-dosecompared to high-dose classical antipsychotics offers an alternativethat could be implemented immediately in low-income countries.ZS2.2.CONTRIBUTION OF TRADITIONAL HEALERS INMENTAL HEALTH CAREF. NjengaUpper Hill Medical Center, Nairobi, KenyaAfrica has a small and diminishing number of practicing mentalhealth workers. Most of sub-saharan Africa has less than one psychiatristper million population. Some African countries do not have asingle psychiatrist. The majority of people suffering from psychiatricdisorders are in the circumstances seen by traditional healers, whoare in most cases the first point of contact with patients. This paperdescribes a Kenyan project that examines the knowledge, attitude andpractices of traditional health workers in a rural setting. More than90% were male, with an average age of 55 years and a mean durationof practice of 22 years. 50% had primary education (7 years) while athird had no formal education. 70 percent had undergone apprenticeshipswith a father or grandfather with a mean duration of 17years. Prayers, herbs and the removal of spirits were the main methodsof treatment. Referral systems work in both directions, from thetraditional healers to the health centers and back, creating in theregion a harmonious working environment with mutual respect foreach other’s skills. This model holds much promise for the future ofmental health in Africa.ZS2.3.NON-GOVERNMENTAL ORGANIZATION (NGO)PARTNERSHIPS IN MENTAL HEALTH CARED. BasangwaButabika National Referral Mental Hospital, UgandaThe contribution of mental disorders to the global burden of diseaseis now known to be significant the world over. The situation is evenworse in the developing world, where both human and financialresources are grossly limited amidst the increasing burden of diseasecaused by the poverty, civil strife and HIV/AIDS. Mental illness isalso seen to increase with upcoming industrialization, urbanizationand the growing tensions of a rapidly changing society. Access tomental health care in many parts of Africa is quite limited and mainlyconcentrated in urban areas. In a bid to improving equity andaccess, it has been found necessary to bring on board other players toback up the traditionally known caregivers. Many countries nowhave polices to address a multidisciplinary approach to care incorporatingprivate and public sectors. The paper will discuss the variouscontributions of non-governmental organisations to mental healthcare delivery in Africa based on the Ugandan experience.ZS2.4.MULTIDISPLINARY APPROACH IN MENTAL HEALTHCARE - A MALAWI EXPERIENCEJ. TugumisirizeUniversity of Blantyre, MalawiMalawi, a nation with a population of 12 million, currently has no psychiatrists,social workers and psychologists in the government psychiatricservices. The backbone of the psychiatric health services are seniorenrolled psychiatric nurses who are helped by 4 psychiatric clinicalofficers, and 10 registered psychiatric nurses. One district, however,receives psychiatric services from a missionary order, The St. John of105

God, who provide an excellent needs based multidisciplinary mentalhealth care by a team of clinical officers, psychiatric nurses, counsellors,community health workers and rehabilitation assistants. It will beargued that this model should provide a framework to the governmentof Malawi for planning and provision of nationwide mental healthservices.ZS3.MENTAL HEALTH AND PSYCHIATRY IN LATINAMERICA (Organized by the WPA SouthernSouth America Zone)ZS3.1.MENTAL HEALTH AND PSYCHIATRY IN LATINAMERICA: MEXICO AND CENTRAL AMERICAPERSPECTIVESE. Camarena-RoblesWPA Zonal Representative, Zone 3The situation of mental health care and psychiatry in Mexico andCentral America is very peculiar. The population who lives in thisregion is close to 200 million people. In the last decade we have seenimportant advances in their health indicators: increase in lifeexpectancy, high coverage in vaccination, reduction and control ofmortality-morbidity by endemic causes. Health systems in thesecountries consist of three different sectors: private services, socialsecurity and public services for the non-insured population and thosewithout access to the private market. The amount of resources aimedto sanitary expenses as a percentage of the gross domestic product ismore than 5%, with more than half coming from public resources.The average amount of money expended for people’s health care is upto US$ 100 per capita. The available beds for psychiatric patients aremore than 1/10,000 people and in most countries the number of psychiatristsis more than 5/100,000 people. The countries have specificlegislations for the care for people with mental disorders and in someof them there are resources to give the necessary assistance in primarycare, with facilities guaranteeing treatment for poor people.ZS3.2.LATIN AMERICAN PSYCHIATRY: A PERSPECTIVEFROM NORTHERN SOUTH AMERICAE. BelfortWPA Zonal Representative, Zone 4The task to evaluate in subjective terms the present situation of mentalhealth and psychiatry in Latin America is an ambitious and complexone, especially when we know, from our experience, that mentalhealth policies in the region are not adequate to the culture and needsof the Latin America population. The increasing demands and thepresence of new nosological entities, not described yet in any diagnosticmanual require a different understanding and a betterapproach. On the other hand, the lack of prevention and promotionprograms of mental health, as well as the absence of health servicesfor extreme populations, are also important issues to be considered inthe evaluation. In this sense, as the WPA Zonal Representative forZone 4, which includes Bolivia, Colombia, Ecuador, Peru andVenezuela, I will describe some indicators and proposals in order tobetter address the reality and the needs of the Zone.ZS3.3.MERCOSUR REGION PERSPECTIVESM.R. JorgeWPA Zonal Representative, Zone 5The Mercosur is a region in South America officially composed byArgentina, Brazil, Paraguay and Uruguay, but which also includesChile. Brazil is a Portuguese speaking country and all others areSpanish speaking countries, but they all share a common heritage andculture from the Iberic peninsula. There are some differences in theway health services and policies were and are organized in thesecountries but they have shared - and continue to do so - some commonexperiences in the mental health area. Up to recent times, mentalhealth care was provided by governments mostly in large psychiatrichospitals but, after the Caracas Declaration in 1990, a change inthis scenario is occurring. Legislation on mental health in some countrieshas changed since then, with a shift from an emphasis on hospitalcare to community care and also on protecting the rights of psychiatricpatients. As a consequence, a number of large hospitals havebeen closed and others reduced their number of beds. General hospitalunits for psychiatric patients are growing in number as well as outpatientservices. A considerable number of Universities have trainingprograms in psychiatry and research has increased in the last fewyears. Advocacy movements are also growing in the region and someusers and family associations have been created in large and mediumsized cities. But social and economical problems experienced by allcountries in the region are still shaping mental health and access tocare in those countries. Poverty, violence, substance abuse, stigmaand discrimination against mental illness, among other factors, arealways present in the daily life of ill or not ill people. Some numberswhich illustrate this situation will be provided and some proposalsdiscussed as a way to improve mental health in Latin America.ZS4.DEVELOPING THE IDENTITY OF THECONTEMPORARY EUROPEAN PSYCHIATRIST(Organized by the WPA Western Europe Zoneand the WPA Northern Europe Zone)ZS4.1.THE IDENTITY OF PSYCHIATRY AS A PROFESSIONAND TRAINING AS A TOOLA. LindhardtPsychiatric Clinic, University Hospital of Copenhagen, DenmarkAmongst the medical specialities psychiatry is probably the disciplinemost challenged by stigmatisation. This comes as well from the insideas from the outside of the medical disciplines. Psychiatry is based onnatural science as well as other scientific disciplines. This is a fascinationand a challenge for the professionals in the field. In a numberof European countries recruitment and retention creates problems.Thus, to improve the image of psychiatry, a proper introduction to thebroadness of the speciality must take place already at a pregraduatelevel, emphasising the great scientific advancements seen in therecent years integrated with social and psychological aspects. Trainingin a broader sense will here be another important tool. The paperwill present some work carried out by the Section of Psychiatry of theEuropean Union of Medical Specialists (UEMS) on retention andrecruitment and on stigmatisation within the medical disciplines.Also, some results from a survey on psychotherapy training as part oftraining in psychiatry in Europe will be presented. In most European106 World Psychiatry 3:S1 - October 2004

countries psychotherapy is seen as a very important psychiatric treatmentmodality which needs proper assessment of psychopathology. Aqualified psychiatrist should always be responsible for an assessmentprior to any psychotherapeutic intervention carried out inside thefield of mental health services.ZS4.2.PROMOTING THE IDENTITY OF THECONTEMPORARY EUROPEAN PSYCHIATRISTW.W. FleischhackerDepartment of Biological Psychiatry, Medical University ofInnsbruck, AustriaThe stigma attached to patients suffering from psychiatric disordershas generalized to the whole field of psychiatry. This includes peopleworking in the mental health professions, in particular psychiatrists.The main reasons for this stigma are found in fear (both rational andirrational) and ignorance. As other professions (psychologists, psychotherapists,etc.) are increasingly assuming responsibilities in mentalhealth care, the role of the psychiatrist has become diffuse, both inthe perception of health professionals and the lay population. Clarificationsas well as corrections of false beliefs must be sought on all levels.Ideally, this will be done in parallel efforts, targeting medical students,residents of all fields of medicine and the general public. Twokey messages will support this: firstly, a clear and concise definition ofthe role of the contemporary psychiatrist (in contrast to the morerestricted expertise of psychotherapists and psychologists) and secondlythe provision of information with regard to recent achievementsin the field (also in quantitative and qualitative comparison toother fields of medicine). As psychiatrists are generally not experts inpublic relations, professional help from this end must aid this process.In summary, the field needs to proactively deliver clear and positivemessages.ZS5.ADMINISTRATION OF HEALTH SERVICES ANDEDUCATIONAL PROGRAMS IN LATIN AMERICA(Organized by the WPA Northern South AmericaZone and the WPA Mexico, Central America andthe Caribbean Zone)ZS5.1.HUMAN DEVELOPMENT, POVERTY AND MENTALHEALTH IN CENTRAL AMERICAL. Alemán NeyraNicaraguan Association of PsychiatryThe region of Central America has experienced in the last 25 yearsserious armed conflicts, natural disasters and structural adjustmentsthat have sank this region into poverty, according to the UnitedNations Development Program (UNDP) Human Development Index,with the exception of the Republic of Costa Rica. This serious economiccrisis has been the decisive factor leading to health deteriorationof the population and consequently of its mental health component.The main indicators of human development of the region arepresented, as well as the investment of the governments in the healtharea, the mental health programs which have been developed, thetraining and distribution of specialized human resources dealing withmental health problems, and their relationship to the health profilesof Central American populations. Psychosocial problems related tomigration, displacement, violence, alcoholism, drug abuse, accidentsand suicidality, among others, contribute to shape the current profileof mental health problems, and they represent a challenge for psychiatristsand other specialists to adopt new modalities of service organization,intersector work, networks and community programs, in thelight of the integral concept of health. A further element of this situationis the move of several mental health professionals and specialistsfrom the state institutions to the private sector. The Associations,Societies and Unions have an important role to play in the integrationof actions in favor of public policies and programs which may benefitthe population.ZS5.2.MENTAL HEALTH SERVICES ADMINISTRATIONIN MEXICOE. NúñezMexican Health Ministry, Mexico City, MexicoThe mental health services administration in Mexico was born in theyear 1943, with the establishment of the Health and Assistance Secretariatand the Mexican Institute of Social Security. These institutionscomplement each other in dealing with the health services forthe national population. Public politics for health services and in particularmental health services were for four decades based on a centralizedmodel, which limited the organization of services for bothcare and education in most of the national territory. In 1983, a newhealth legislation was established, which promoted a decentralizationof the public health services. This policy produced initially not homogeneousresults. Thus, the process was strengthened fifteen years afterits initial formulation. During the evolution and trajectory of thisprocess, the organization of the mental health services has beendirectly influenced. There have been both some advances and somedelays. Therefore, it was proposed to separate these services from thegeneral decentralized model.ZS5.3.CHILD TRAINING PROGRAMS IN MEXICOE. Camarena-RoblesWPA Zonal Representative, Zone 3It is very important to emphasize that Mexico is a heterogeneouscountry, where the level of socio-economic development varies verymuch from one region to another. There are some highly developedstates as for their infrastructure and level of education, and there aresome others that are underdeveloped. This has favored a big concentrationof resources in large cities and an abandonment in rural areas.This is the reason why the Federal Government Program of MentalHealth has been created. Mexico’s Child Mental Health Programremains integrated in this latter program, that establishes strategiclines and objectives including the child and adolescent populationwith mental disorders. The main objectives include the extension ofthe ambulatory and hospitalization net services for the children withmental health problems. Some more actions derive from these objectives.Among these is the opening of mental health services in highlyspecialized hospitals, i.e. the regional ones, with a homogeneous geographicdistribution due to the complexity of the Mexican territory. Wehave started training for all primary care physicians in the detection ofthe main children’s mental disorders that should be diagnosed in primarycare. Also, an educational plan has been developed for teachers.This will be a long-term project, because there are more than 170,000teachers in our country. This general program has been complementedwith a specific program for fighting attention-deficit/hyperactivity disorder(ADHD). Other activities are those related to the collaboration107

with the Public Education Secretariat, aiming to modify the curriculafor the education of the teachers, so that they acquire a better knowledgein the area of child psychopathology.ZS5.4.CHILDHOOD TRAINING PROGRAMS IN VENEZUELAE. BelfortWPA Zonal Representative, Zone 4The mental health policy in the Latin American region has not beenable up to now to keep abreast with recent developments in theregion. The ethnic diversity of the population, as well as the social,economic, political, and legal structural difficulties are among theobstacles to the advance of health policies. Mental and behaviouralproblems related to these difficulties, including domestic violence,anxiety and mood disorders, drugs and alcohol abuse, symptomsassociated to nutritional problems, contamination of water and air,etc, are having an increasing impact on the cognitive and emotionaldevelopment of the child and adolescent population. The analysis ofthese aspects is of great importance for the development of trainingprograms in childhood psychiatry, and certainly, for the developmentof a quality of life more adequate to human dignity. A succinct revisionof these vicissitudes problems and of their implications for theimplementation of childhood training programs in Venezuela will beprovided.ZS5.5.THE PROFILE OF THE PSYCHIATRIST IN LATINAMERICA: A SURVEYR.N. CordobaColombian Psychiatric AssociationWe performed a randomized survey using e-mail addresses provided bynational psychiatric societies, in order to build up a profile of the psychiatristin Latin America. The survey covered the following countries:Argentina, Brazil, Colombia, Costa Rica, Cuba, Dominicana, Ecuador,Chile, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Peru,Panama, Paraguay, Uruguay, Venezuela and Bolivia. The sampleincluded 4600 psychiatrists. The questions were 36, and dealt withissues such as education, professional and financial status, level of satisfactionwith the specialization and quality of life. The ultimate aimwas to explore the worries and wishes of Latin American psychiatrists.ZS6.PERSPECTIVES ON PSYCHOTHERAPY FROMTHE US (Organized by the WPA United States ofAmerica Zone)ZS6.1.SOME NEUROBIOLOGICAL ASPECTSOF PSYCHOTHERAPYJ. KayDepartment of Psychiatry, Wright State University School ofMedicine, Dayton, OH, USALearning and memory are associated with alterations in synapticstrength. This presentation explores the process of memory consolidationleading to persistent modifications in synaptic plasticity as amechanism by which psychotherapy facilitates changes in the permanentstorage of information acquired throughout the individual’s life.The psychobiological inter-relationships of affect, attachment, andmemory offer a perspective regarding the treatment of clinical disturbancesof affect as well as delineating basic therapeutic concepts suchas transference and working through. Imaging studies will bereviewed that demonstrate that psychotherapy changes both brainfunction and structure.ZS6.2.COMPUTER-ASSISTED PSYCHOTHERAPY:ADVANCES AND OPPORTUNITIESJ.H. WrightDepartment of Psychiatry and Behavioral Sciences,University of Louisville, KY, USARecently developed computer programs for psychotherapy have beenwell received by patients and have been shown to be efficacious inclinical applications. Newer programs use multimedia, virtual reality,and hand-held computers to provide engaging and stimulating learningexperiences. Typically, computer-assisted therapy is based onempirically supported interventions such as cognitive-behavior therapy(CBT) or behavior therapy in which learning is considered to be akey component of the treatment process. Some of the advantages ofcomputer-assisted psychotherapy include improved efficiency oftreatment, decreased cost, effective delivery of psychoeducation,reduced burden on the clinician to perform repetitive therapy tasks,vivid illustrations of therapy methods, and rehearsal of coping skills.Advances in the development of computer-assisted therapy aredetailed. These include virtual reality interventions for the treatmentof anxiety disorders, hand-held computer adjuncts, and multimediaprograms for depression. Research with a DVD-ROM program forcognitive-behavior therapy has shown that efficacy of CBT fordepression can be maintained while substantially reducing theamount of therapist time. In a randomized, controlled trial, computer-assistedtreatment with this program was superior to standard CBTin teaching therapy skills and reducing maladaptive cognitions. Thereare many opportunities for using computer-assisted psychotherapy toaid clinicians in their work with patients, improve access to treatment,and enhance learning.ZS6.3.TRAINING REQUIREMENTS IN PSYCHOTHERAPYFOR US PROGRAMSD. WinsteadDepartment of Psychiatry and Neurology, Tulane UniversityHealth Sciences Center, New Orleans, LA, USAThe Accreditation Council for Graduate Medical Education(ACGME) sets educational requirements for all residency programsin the United States. In order for a program to be accredited, theymust submit comprehensive program information and then opentheir program for a site visit by a representative from ACGME. Inrecent years the ACGME has shifted the focus of training requirementsby adding core competencies for each specialty. In psychiatrythis has included five psychotherapy competencies: brief psychotherapy,cognitive-behavioral therapy, combined psychotherapy andpharmacotherapy, psychodynamic psychotherapy, and supportivepsychotherapy. Programs have struggled with how best to teach thesetherapies and how to measure competence. Most programs continueto use patient logs, audiotape and/or videotape recordings and directobservation as part of the supervisory and assessment process. Asbest practices evolve, consensus will compel programs to adopt thesenew training and evaluation measures. While these new competencyrequirements have been criticized for a variety of reasons, there has,108 World Psychiatry 3:S1 - October 2004

nevertheless, been a good faith effort by most programs to complywith these new requirements.ZS6.4.USING PSYCHOTHERAPEUTIC TECHNIQUES TOIMPROVE PHARMACOTHERAPY OUTCOMESA. TasmanDepartment of Psychiatry and Behavioral Sciences, University ofLouisville, KY, USAIt is well known that adherence to recommended medical treatmentis improved in the context of an ongoing and trusting doctor-patientrelationship. Unfortunately, the clinical approaches advocated withinmanaged care programs, as well as other forces, have led to decreasedattention to this important aspect of our clinical encounters. Thispresentation will review a variety of aspects of the doctor-patient relationshipfrom the perspective of both the patient and the physician.Issues discussed will focus on improvement of compliance with medicationtreatment. Topics will include the “illness belief system”, symbolicmeaning of medications, and transference/countertransferenceissues. Increased attention to these aspects of patient care in bothoffice and hospital setting improves patient adherence with recommendedtreatment, thus providing higher quality care and greaterpatient satisfaction.ZS7.MENTAL HEALTH SERVICES IN NORTH AFRICA(Organized by the WPA Northern Africa Zone)ZS7.1.MENTAL HEALTH SERVICES IN EGYPTT.A. OkashaInstitute of Psychiatry, Ain Shams University, Cairo, EgyptSix hundred years ago, before Europe had mental health services ingeneral hospitals, Egypt had such a service in Kalawoon hospital inCairo. In fact, in that hospital there were four wards: surgery, medicine,ophthalmology and psychiatry. In 1942 Egypt started to implementthe concept of psychiatric services in general hospitals. Egyptlies on the Mediterranean Sea; part of it lies in Africa and part of it(Sinai) lies in Asia. Egypt is considered African, Mediterranean, Araband a Middle Eastern country at the same time. Egypt is one millionsquare kilometers, with a population of 70 million. 97% of Egyptianslive on 4% of the land, mainly in the Delta region and the Nile valley.The population density in Egypt is 59/sqKm, while the population inCairo is about 15-16 million in the daytime, and approximately 12million during the night. The population density in Cairo is31,697/sqKm. Cairo is considered one of the most crowded cities inthe world. Egypt is divided into 24 governorates and has around130,000 doctors, 1000 psychiatrists, 250 clinical psychologists and1355 psychiatric nurses. Psychiatric services are provided throughgeneral hospitals, state hospitals, university hospitals and private hospitals,amounting to about 9000 beds. Egypt is moving towards primarycare in psychiatry through general practitioners and this hasbeen incorporated into the National Mental Health Program for thepast 12 years, rather than community care, which is not feasiblebecause of financial, cultural and religious beliefs. This presentationwill review the mental health services in Egypt at the moment togetherwith future plans.ZS7.2.MENTAL HEALTH SERVICES IN MOROCCOD. MoussaouiIbn Rushd University Psychiatric Center, Casablanca, MoroccoThere are about 300 psychiatrists in Morocco, 620 psychiatric nurses,75 clinical psychologists. There are very few social workers and nooccupational therapist. The three academic departments in Casablanca,Rabat, and Marrakech are in charge of training psychiatrists andpsychiatric nurses, as well as undergraduates. Concerning psychiatricinstitutions, there are 1,900 psychiatric beds in the entire country (30million inhabitants) divided between psychiatric hospitals and psychiatricwards integrated into general hospitals. This low figure ofpsychiatric beds is even worse when one considers that there is nopsychiatric institution for children and adolescents, and no privateclinic in psychiatry. Most of the activities of mental health is done inthe outpatient sector. For example, more than 60,000 patients areseen in the ambulatory mental health units of Casablanca every year.A national epidemiological survey will be finalized in the comingmonths and its results will allow planning for better mental healthservices.ZS7.3.MENTAL HEALTH SERVICES IN SUDANA. AbdelrahmanUniversity of Khartoum, SudanSudan is the largest country in Africa, with a million square miles, 33million people and nine neighboring countries. As many countries inAfrica, Sudan suffered much from poverty, illiteracy, drought and civilwar. The effects of these problems on the mental health of people areconsiderable. The objectives of this presentation are to highlight thesituation of mental health services in Sudan and share ideas with colleaguesfrom other African countries in the region. Currently there isa great shortage of services, with one psychiatrist for a million population.The majority of facilities are urban based, with over 70% in thecapital city Khartoum. Psychologists and psychiatric social workersare very few. Psychiatric medical assistants act as psychiatrists inmany regions. A national mental health program has been establishedrecently, with a recognizable effort to improve the situation. Majorareas of interest in the program include training of general practitioners,paramedical staff and teachers. Training manuals and other materialsare in preparation. Despite many endeavors, the mental healthact has not been endorsed yet. There are many constrains and healthplanners still need to be convinced and encouraged to put moreemphasis on this issue. Mental health services at the primary healthcare level are an important priority. Training is crucial. With expectationof peace in the country soon, the future looks better. Mentalhealth is expected to improve.ZS7.4.MENTAL HEALTH SERVICES IN ETHIOPIAM. ArayaDepartment of Psychiatry, University of Addis Ababa, EthiopiaEthiopia is a country located in the Horn of Africa with a populationof about seventy million. It is a federal government consisting of ninestates representing over eighty nations and nationalities. The establishmentof modern mental health services in Ethiopia dates back tothe time of the departure of Italian occupants in 1939 where the generalhospital they used for the indigenous people was later turned intoa mental asylum. For almost half a century, the psychiatric hospital109

emained a place of confinement for the mentally ill and persons withbehavior incompatible to the societal as well as political norms of thecountry. The department of psychiatry was established in 1966 as aunit in the department of medicine by a Dutch psychiatrist, R. Giel,from the University of Groningen. Both the psychiatric hospital with360 beds and the outpatient department in a general hospital in AddisAbaba, the capital of Ethiopia, serve as treatment, training andresearch centers for the whole country. The department is run bythree full time psychiatrists, while five psychiatrists work in the psychiatrichospital. All the psychiatrists are stationed in Addis Ababa;therefore, most of the psychiatric service throughout the country isgiven by psychiatric nurses. Besides treatment service, the main activitiesinclude teaching clinical psychiatry to medical students, psychiatricnurses and residents in psychiatry. Continuing medical educationto general medical practitioners and other specialists is alsogiven on a regular basis. Community oriented mental health researchis also an integral part of the general mental health service in thecountry. Since 1966, over fifty papers were published in reputablejournals and several epidemiological surveys and clinical trials areongoing.ZS7.5.MENTAL HEALTH SERVICES IN TUNISIAS. Douki, F. Nacef, S. Ben ZinebHospital Razi, Tunis, TunisiaUntil recently, mental health was given low priority in Tunisia, as inother developing countries faced with major health concerns such asepidemic diseases or infant mortality. Thus, while remarkable progresseswere achieved in the field of physical health, psychiatryremained the “Cinderella” of medicine. Nowadays, only 150 psychiatrists(representing 4% of the total specialists) and 800 beds (representing5% of the total hospital capacity) are available to a populationof 10 millions. Consequently, a significant proportion of the populationdoes not have access to mental health facilities, while epidemiologicaldata and many indicators have been highlighting, foryears, a huge growth in mental health care needs. The result is a practiceof “psychiatry in emergency”, providing an immediate solution tosevere psychiatric breakdowns but failing to provide sustained care orto deal with the many mental health problems challenging today oursocieties. But, this shortage gives us the great opportunity to build upa mental health care system more complying with the current knowledgeand with our specific context. We have thus the unique chanceto skip the deinstitutionalization stage with its significant casualtiesand to move directly to community care where a strong family supportand a dense primary care network are major resources to rely on.This is the aim of the national mental health program adopted in1992. It appears paradoxical that a lack of traditional services is probablythe source of more opportunities than constraints in our countries,providing the possibility to implement the most cost-effectivestrategy to cope with the modern needs in matters of care.ZS8.PSYCHIATRY IN CENTRAL EUROPEAN COUNTRIESWITHIN THE PROCESS OF AFFILIATION TO THEEUROPEAN UNION (Organized by the WPA CentralEurope Zone)ZS8.1.PSYCHIATRY AND MENTAL HEALTH CARE INPOLANDJ. BombaChair of Psychiatry, Jagiellonian University Collegium Medicum,Kraków, PolandPsychiatry has been developing in Poland into an independentmedical specialty and scientific discipline in a specific context,which resulted in changing connections with German, French andrecently English language medicine. The process of deinstitutionalisationstarted since the 1970s. The mental health care system is basedon multiprofessional teamwork. The best developed network of facilitiesis within the bigger urban centers. Treatment is paid by healthinsurance, but patients pay themselves (more than 50%) for new psychotropiccompounds in outpatient care. The mental health act guaranteesfree choice of service, treatment in the least oppressive conditionsand patient consent. As financing of health care is insufficient,one should expect a movement of young specialists to countries ofhigher standards. Undergraduate training of physicians includes psychology(behavioral sciences) and psychiatry. A national curriculumadapted to European standards is obligatory for medical schools.Postgraduate training of psychiatrists has been changed in the 1990sinto a 5-year residency system. Child and adolescent psychiatryrequires additional 2 years of residency training. A national boardexamination is the final stage of training. A continuous educationprogram is now being organized. Nevertheless, the Polish PsychiatricAssociation has its own system of credits and sponsors additionaltraining in psychotherapy, forensic psychiatry, and gerontopsychiatry.The main areas of research in psychiatry are neurobiology of cognition,molecular genetics, psychotherapy, family therapy, communitypsychiatry, epidemiology and psychopharmacology.ZS8.2.PSYCHIATRY OF THE 20TH AND 21ST CENTURY INHUNGARY: A SHORT HISTORICAL OVERVIEWF. TúryInstitute of Behavioural Sciences, Semmelweis University,Budapest, HungaryDuring the first half of the 20th century, Hungarian psychiatry wasintensively influenced by German and French literature. A wellknownpsychoanalytic school, the so-called Budapest School, wasestablished, its main figure being Sándor Ferenczi, one of SigmundFreud’s best pupils. Sándor Radó, Géza Róheim and Mihály Bálintwere also excellent analysts. In this period a high-level neuropathological/biologicalresearch can also be mentioned, e.g. the work ofLászló Meduna and his cardiazol shock treatment based on neuropathologicalobservations. After the Second World War, psychologicalsciences were suppressed for several decades. An intensive interestin psychotherapies started in the 1970s, and the most importantpsychotherapeutic methods became known: behavioural therapy,family therapy, hypnotherapy. From the 1980s an intensive and highlevelbiological trend appeared in research, with several internationalcollaborations. After the political change at the beginning of the1990s, the major psychotherapeutic methods became widespread,110 World Psychiatry 3:S1 - October 2004

with vigorous educational activities. At the same time, pharmacotherapyreached a high level, with the availability of the newest psychotropics.In the last decade an integration of biological and socialpsychiatry can be observed in Hungary. This can be found also in theeducation of the residents in a four-year system. In everyday practice,the influence of outpatient care has become strong, and the totalnumber of hospital beds has decreased gradually. Nowadays the mainproblems may arise from the decreasing prestige of the medical profession,resulting in the emigration of good psychiatrists to West-European countries. The presentation will also address the newestprevention programs in mental health care.ZS8.3.BULGARIAN PSYCHIATRY TODAYL. JivkovMunicipal Psychiatric Dispensary, Sofia, BulgariaWe present the current state of psychiatry in Bulgaria after thechanges which came into effect in 1990, perceived within the economicand social context of the country. We try to show the relationshipbetween psychiatric tradition and the strategy for changes in psychiatriccare, as well as the different points of view for the developmentof both biological and psychosocial therapeutic approaches.The National Program for Mental Health and the forthcomingchanges in the legislation concerning mental health are presented. Wealso present the current state of the educational system and trainingprocess of professionals in psychiatry (psychiatrists and psychiatricnurses), having in mind that the education of nurses has just beenevolving. The role of non-governmental organizations like the BulgarianPsychiatric Association, the Association for Private PsychiatricPractice, the organizations of users of psychiatric care, etc. is discussed.The presentation reviews the existing international relations,including those with the Balkan countries and the conditions fortheir development.ZS8.4.MENTAL HEALTH REFORMS IN MACEDONIAA. NovotniUniversity Clinic of Psychiatry, Medical Faculty, Skopje, Republicof MacedoniaThe current situation of the Macedonian society is marked by a longtermeconomical, political and social crisis, unemployment andpoverty. The Macedonian family itself is passing through a transitionalperiod: the traditional (multigenerational) family is being disintegrated,but the modern (nuclear) family is still not socially stable. Allthese factors indicate the increase of the scope and intensity of psychosocialproblems and indirectly mental health issues in our country.Evidence-based data and an organized approach concerning variousmental health problems are still missing in Macedonia. The mentalhealth reforms are in the initial phase, trying to implement thetransition from the “old” system of working within big psychiatrichospitals to community based mental health services. We will reportthe initial success in establishing a community based mental healthcentre in Macedonia.ZS8.5.CURRENT TRENDS IN CZECH PSYCHIATRYJ. RabochDepartment of Psychiatry, Charles University, Prague, CzechRepublicCzech Republic had in the year 2002 10,230,060 inhabitants. Thehealth care budget was 7.4% of the gross domestic product. We estimatethat less than 3.9% of the health care budget went into mentalhealth care. 52.2% of this amount went to mental hospitals, 22% wasspent for drugs, 15.6% went to out-patient clinics, 9.6% to psychiatricdepartments of general hospitals. Community care is substantiallyunderfunded. We have 1,154 physicians working in psychiatry(11.5/10,000). Most of them (52.2%) work in out-patients clinics. Inthe last decade, every year, 50-70 young doctors passed the psychiatricboard examination. The system of postgraduate training has recentlysubstantially changed. We have separate training programs for adultpsychiatry, child psychiatry, old age psychiatry, drug addiction andsexology. We have 30 psychiatric hospitals with 9,616 beds and 33 psychiatricunits in general hospitals with 1,546 beds. The overall numberof beds decreased from 14/100,000 in 1990 to 11.1/100,000 in 2002.However, in recent years this trend has stopped. The average length ofhospitalisation, despite its decline in the last decade, remains high: 73days in psychiatric hospitals and 23 days in general hospitals. Thereare no official statistics regarding community psychiatry. Thanks to theEuropean research project EDEN, we know more about the functioningof the 35 day care centres in our country, which are located mainlyin bigger towns and mostly provide psychotherapeutic and rehabilitationactivities. Protection of the human rights and dignity of peoplesuffering from mental disorder is a hot topic in our country. The detentionprocess is controlled according to our law by independent courts.Two Prague psychiatric facilities are participating in the Europeanproject EUNOMIA, which is mapping coercive treatment measures inpsychiatry and is trying to find the best way in clinical practice for thisvery sensitive part of mental health care.ZS8.6.ROMANIAN PSYCHIATRY: THE CHALLENGES OFPRESENT AND FUTURET. UdristoiuUniversity of Medicine and Pharmacy, Craiova, RomaniaWith an area of 237,500 SqKm and a population of 21.7 million people,Romania is geographically the second biggest country in CentralEurope. In 1974 and 1980, two important epidemiological studieshave been conducted focusing on psychiatric disorders. These studieshave shown a general prevalence of 18.34% and 16.33%, respectively.Several but still rather small scale studies have revealed an almostconstant increase of the suicide rate, starting in the early 1980s, butwithout an accurate evidence concerning the real proportion of thisphenomenon at the national level. The offer of psychiatric services –inpatient, day-care and outpatient ones – was and still is modest:about 4 psychiatrists/100,000 people and 0.7 beds/1,000 patients,with very limited possibilities for supporting and supervising the outpatients.The access of people is further reduced by the concentrationof this offer in the capital and the major cities. The main problems ofthe present are the legacy of the communist period, that has pushedpsychiatry aside, the economical situation and the mentality of thepeople, the medical community and the authorities. Somatic medicinestill dominates to the prejudice of our specialty. In 2000, psychiatriccare consumed only 3% of the health care expenses. The hegemonyof somatic medicine is reflected also in undergraduate and111

postgraduate psychiatric training. Currently, postgraduate trainingconsists of 28 months of training in psychiatry and 32 months inother specialties. Psychiatric care is currently limited to secondaryprevention, which is almost fully based on biological therapy. There isa national rehabilitation program, but it is underfunded, small scaleand with almost null results. Also, “by tradition”, the quality of thepatients’ life is practically not taken into consideration. Scientificresearch is addressed mainly to the clinical and therapeutic level andscarcely to the epidemiological level. After 1990, some progress hasbeen made: the informational opportunities, the establishment ofassociations and publications, the appearence of second generationantipsychotics and antidepressants, the law for mental health and forthe protection of the persons with psychiatric disorders, the participationin international multicenter trials. The most important prioritiesare primary prevention and rehabilitation, the life standards inthe psychiatric facilities, the care of chronic and forensic patients, suicideprevention and the institutional management. In order to reachthe psychiatric standards of the countries in the European Community,we need a clear policy, based on a realistic strategy of implementingthe experience of the developed countries and adapting it to ourculture with decent financial means.ZS8.7.THE NATIONAL MENTAL HEALTH PROGRAMME INSLOVAKIAL. Vavrusova, A. Mayer, P. Breier, P. Nawka, J. VranovaDepartment of Psychiatry, University Hospital Ruzinov,Bratislava, Slovak RepublicThe National Mental Health Programme, a complex and multisegmentprogramme, has been developed according to the recognition ofthe situation of mental health care in Slovakia and with the help ofthe Report of Assessment mission of the World Health Organization(WHO). The WHO performed an audit in Slovakia in June 2003 andpointed out some most important topics. Expenditures on mentalhealth are at present only 2% of health budget, a large proportion ofthe funding goes into psychotropic drug prescription; there is a lackof substantial communication, cooperation and cofunding fromhealth and social services at ministerial, regional and local levels;there is an absence of community-based mental health care; mentalhealth care delivery is heavily influenced by health insurance companiesand this imposes limitations on multi-disciplinary cooperation;there is no adequate implementation of the biopsychosocial approachin medical training programmes; there is no credible professional psychiatricnurse training; there is a severe lack of nursing staff in inpatientmental health care; day hospital functioning is limited by systemrestrains and shortage of funding. In the National Mental Health Programmedetailed plans with time span are proposed. This includesplanning of mental health delivery, promotion and prevention strategies.This programme was formulated in collaboration with representativesof mental health professionals, user and family representativesand other relevant non-governmental organizations. The NationalMental Health Programme includes national-regional-local participation.It includes a clear description of tasks to be taken by involvedministries and local governments. It includes a timetable of actionsfor implementation and a statement on resources required for programmeimplementation. Special attention is given to needs of childrenand adolescents and of the elderly with mental disorders. Acommunity psychiatry based approach will be developed. TheNational Mental Health Programme raises awareness, strengths tolerance,pluralism and equity for people with mental disorders.ZS8.8.MENTAL HEALTH CARE IN SERBIA ANDMONTENEGRO: THE PROBLEM OF REFUGEESO. Zikic 1 , G. Grbesa 1,2 , D. Lecic-Tosevski 2,31 School of Medicine, University of Nis; 2 National Committee forMental Health; 3 School of Medicine, University of Belgrade,Serbia and MontenegroWar in the region of ex-Yugoslavia has caused the forced migration ofa huge number of people. At present, there are 702,000 refugees livingin Serbia and Montenegro. Most of them have experienced multipletraumas, which caused significant distress. According to our studies29.2% of refugees manifest chronic post-traumatic stress disorder,while 40% of them have an adjustment disorder. 1.300 refugee familiesdo not know the destiny of their members. This severe trauma preventsthem from completing the process of mourning. In addition topost-traumatic stress disorder, refugees suffer from other mental andsomatic disorders, which represent a huge burden for health servicesof the country. The organization of mental health care has to adjust tospecific needs of the refugee population. In a first stage, programs ofpsychosocial assistance were undertaken by many governmental andnon-governmental organizations. Future programs of mental healthcare for refugees should take care of demographic and cultural specificitiesof this population, originating from various regions of ex-Yugoslavia. The National Committee for Mental Health has identifiedthe mental health care of refugees in the community as one of the targets,with their social integration as one of the objectives.ZS9.MENTAL HEALTH AND PRIMARY CARESERVICES WORKING TOGETHER: THE CANADIANEXPERIENCE (Organized by the WPA Canada Zone)ZS9.1.COLLABORATION BETWEEN FAMILYMEDICINE AND MENTAL HEALTH SERVICES:PROBLEMS AND SOLUTIONSN. Kates, M. CravenHamilton HSO Mental Health and Nutrition Program andMcMaster University Department of Psychiatry and BehaviouralNeurosciences, Hamilton, Ontario, CanadaWe discuss the challenges Canada faces in the delivery of mentalhealth services to diverse and often isolated communities and the keyrole family physicians play in managing mental health problems inalmost every Canadian community. Moreover, we review problemsthat can arise in the relationship between mental health and primarycare services. We examine the consequences of these problems andthe significant changes that have taken place over the last seven yearsto strengthen the working relationship between the two areas. Thepresentation discusses the Canadian concept of shared mental healthcare and provides examples of innovative projects that have implementedthese principles and addressed significant problems facingthe Canadian Health Care system.112 World Psychiatry 3:S1 - October 2004

ZS9.2.SHARED MENTAL HEALTH CARE:THE CANADIAN PSYCHIATRIC ASSOCIATIONAND COLLEGE OF FAMILY PHYSICIANS OFCANADA COLLABORATIVE PROJECTM. Craven, N. KatesHamilton HSO Mental Health and Nutrition Program andMcMaster University Department of Psychiatry and BehaviouralNeurosciences, Hamilton, Ontario, CanadaWe describe a major initiative of the Canadian Psychiatric Associationand the College of Family Physicians of Canada to improve collaborationbetween the two specialties. In 1997 the two organisationsproduced a joint position paper on shared mental health care andthen set up a working group to implement its recommendations. Thispresentation summarises the recommendations of the position paperand the major activities and impact of the collaborative workinggroup on clinicians, health planners and funders. It highlights theimportance of the strong support both sponsoring bodies have provided.ZS9.3.THE COLLABORATIVE MENTAL HEALTH CAREPROJECT: DEVELOPING A NATIONAL STRATEGYN. Kates, M. CravenHamilton HSO Mental Health and Nutrition Program andMcMaster University Department of Psychiatry and BehaviouralNeurosciences, Hamilton, Ontario, CanadaWe describe a two year project, recently funded by the Canadian FederalMinistry of Health as part of the renewal of primary health carein Canada, to develop a national strategy for collaborative mentalhealth care. The project is sponsored by twelve national organizationsrepresenting psychiatrists, family physicians, nurses, socialworkers, occupational therapists, psychologists, pharmacists, dietitians,psychiatric nurses, consumers, family members and communityadvocacy groups. Its goals are to identify and analyze the current stateof collaborative care in Canada; to develop a joint declaration committingpartner organizations and their members to working together;to develop and disseminate strategies for implementing shared careand adapting it to the needs of particular communities or populations.The activities and expected outcomes of the project will bedescribed.ZS10.MODERN AND TRADITIONAL TREATMENTSIN THE CONTEXT OF A DEVELOPING COUNTRY(Organized by the WPA Western and CentralAfrica Zone)ZS10.1MODERN AND TRADITIONAL TREATMENT INTHE CONTEXT OF A DEVELOPING COUNTRYM. OlatawuraDepartment of Psychiatry, University College Hospital, Ibadan,NigeriaThe African, and unsophisticated people of all races, believe insupernatural phenomena. Saint Paul, writing to the Ephesians, stated:“For we are not fighting against people made of flesh and blood,but against persons without bodies - the evil rulers of the unseenworld, those mighty Satanic beings and great princes of darkness whorule this world, and against huge numbers of wicked spirits in thespirit world”. Issues raised above explain the prominence accorded toalternative remedies like roots, herbs, incantations and faith-healing.Faith-healing impact of the Born-Again Crusade is spreading likeprairie fire all over the world, the Western World inclusive. Aloe Veratea, Mistletoe (Viscum album) tea, etc, are now packaged like Liptontea to treat human maladies like arthritis, diabetes, hypertension, etc.ZS10.2.BARRIERS TO TREATMENT IN A DEVELOPINGCOUNTRYO. GurejeDepartment of Psychiatry, University of Ibadan, NigeriaThe treatments of psychotic and affective disorders have undergonemajor developments in the past two or three decades. Newer medicationshave become available and treatment guidelines have been suggested.However, for patients living in many developing countries,significant barriers remain in the receipt of adequate treatment. Manystill do not believe that orthodox medical care offers a credible sourceof relief for mental health problems. Stigmatization of mental disordersis rife and presents an impediment to the receipt of care. Newermedications are expensive and unaffordable to most as payment formental health service is often out-of-pocket, thus imposing a significantfinancial burden on patients and their relatives. Also, large sectionsof the community do not have access to mental health serviceand the filters for mental health problems at the various nodes of thehealth service may be almost impermeable. In this presentation, datawill be reviewed that highlight the barriers to treatment for patientswith mental disorders in Nigeria, a resource-rich but economicallypoor country.ZS11.COMMUNITY PSYCHIATRY IN THEMEDITERRANEAN REGION AND THE ROLEOF PSYCHIATRIC ASSOCIATIONS(Organized by the WPA Southern Europe Zone)ZS11.1.INTRODUCTION TO PSYCHIATRY AND COMMUNITYPSYCHIATRY IN THE MEDITERRANEAN REGIONL. KüeyWPA Zonal Representative, Zone 8This presentation aims to outline the main issues to be discussed bythe representatives of some of the member societies of the WPASouthern European Zone in this symposium. To provide a contextualframework, the socio-cultural characteristics of the region and the situationof psychiatry in these countries will be reviewed. Practice ofpsychiatry, especially community psychiatry, has been passingthrough serious changes in the Mediterranean countries. These countriesin transition had witnessed many psychiatric reformist movementsin the last couple decades, and the psychiatric associations aretrying to develop new policies to promote community mental healthin the region; so, the role of the psychiatric societies will also beanother issue of concern.113

ZS11.2.WHO ARE THE PATIENTS IN RESIDENTIALFACILITIES? A NATIONAL SURVEY IN ITALYG. de Girolamo 1 , A. Picardi 2 , G. Santone 3 , R. Micciolo 4 ,A. Fioritti 5 , I. Falloon 6 for the PROGRES group1 Department of Mental Health, Health Unit of Bologna, Italy;2 National Institute of Health, Rome, Italy; 3 Psychiatric Clinic,United Ancona Hospitals and Marche University, Ancona, Italy;4 Chair of Statistics, University of Trento, Italy; 5 Programme onMental Health and Substance Abuse, Health Unit of Rimini,Italy; 6 Department of Psychiatry, University of Auckland, NewZealandIn Italy, residential facilities (RFs) have completely replaced mentalhospitals for the residential care of mentally ill patients. We studiedall patients resident in 265 randomly sampled Italian RFs (20% ofthe total). Structured interviews focusing on each patient were conductedwith the manager of each RF and with staff; patients wererated with the Health of the Nations Outcome Scales (HoNOS) andGlobal Assessment of Functioning (GAF), and their physical disabilitieswere evaluated. Of the 2,962 patients living in the sampled facilities,most were males (63.2%) who had never been married, morethan 70% over 40 years of age; 85% had a pension, most commonlybecause of a psychiatric disability. A substantial proportion (39.8%)had never worked and very few were currently employed (2.5%);45% of the sample was totally inactive, and was not involved indomestic activities in the facility. Two-thirds had a diagnosis of schizophrenia;dual diagnoses and primary substance abuse were uncommon.Twenty-one percent had a history of severe interpersonal violence,but episodes of violent behaviours in the RFs were infrequent.The managers judged almost three-quarters appropriately placed inthe facilities and considered that only few had prospects of discharge.In conclusion, Italian RFs provide care to a large patientpopulation of severely mentally ill requiring residential care. Dischargeto independent accommodation is uncommon. Future studiesshould try to identify the best match between RF programs andpatients’ disabilities.ZS11.3.TOWARDS COMMUNITY PSYCHIATRY IN ISRAEL:DIRECTIONS, HOPES AND OBSTACLESZ. ZemishlanyIsraeli Psychiatric AssociationWe are living in an era of rapid changes, which do not spare thehealth care system, including mental health. The world has becomemuch more interconnected, leading to developments which frequentlyare global in nature. Therefore, when considering directions formental health care in the Mediterranean Region and Israel, we shouldbe aware of processes worldwide. The yearly World Health Organization(WHO) report released in 2001 contains, for the first time, anextensive section devoted to mental health. The report’s consensuswas that there is no health without mental health. It is recommendedthat mental health services should be based on community care closeto home, including admission to general hospitals. In the Israeli mentalhealth system of 2004, the WHO recommendations are far frombeing implemented. Body and mind are still separated as the nationalinsurance act does not include mental health yet. Mental health careis under the responsibility of the government (Ministry of Health).The mental health system is not integrated in the primary care systemand the proportion of psychiatric beds located in general hospitals isonly 4.8%. The rest are located in psychiatric hospitals. This discriminationbetween the general health system and the mental health systemcontributes to the stigmatization of mental patients. The IsraeliPsychiatric Association (IPA) is committed to promote psychiatriccare in line with the global changes and directions. The IPA is currentlyhighly involved in two reforms in order to promote communitypsychiatry. The first is the health insurance reform: mental healthshould be included in the National Health Insurance Law and theHealth Funds should take responsibility for mental health as in othermedical fields. This may enable the psychiatric patients to be underthe care of the general practitioner in continuity with the psychiatrichospital. The obstacles for the initiation of this reform are budgetissues and disagreements between the Ministry of Health and theHealth Funds. The second reform is the “structural” one: resourcesshould be transferred from the psychiatric hospitals to the community.This includes a 50% reduction of psychiatric beds (to 0.45 beds per1000), shortening of hospitalization days to 33 days in average anddeveloping a network of hostels, rehabilitation centers and outpatientclinics in the community. This reform is on its way. We believe thatthese two reforms are linked and should be performed in parallel. Theavailability of the psychiatric community services and their links tothe general health care system would increase compliance and reducerecurrence, readmissions and the stigma of patients suffering frompsychiatric disorders.ZS11.4.PSYCHIATRY IN GREECE: ADVANCES,PROBLEMS AND PERSPECTIVESG.N. Christodoulou, V. Alevizos, D. Anagnostopoulos,V. KontaxakisHellenic Psychiatric AssociationPublic psychiatry in Greece is currently in a transitional period fromthe traditional inpatient management to community psychiatry.Attempts aiming at this transformation have occurred in the 1950swith, for instance, the establishment of the mental health center(which later has developed into the most extensive service facility foroutpatients in Greece), but the most systematic interventions havebeen carried out since the 1980s, with an extensive reform implementedwith local and European Union funding. As a result of theseinterventions, the total number of inpatients in Greek public mentalhospitals from 1984 to 2004 has decreased and this has been associatedwith increase in extramural facilities. Much remains to be donewith respect to primary care, creation of alliances in the community,mental health promotion and qualitative improvement of extramuralservices.ZS11.5.PSYCHIATRY, COMMUNITY PSYCHIATRY AND THEROLE OF PSYCHIATRIC ASSOCIATIONS IN TURKEYP. Gökalp 1 , B. Ulug 2 , L. Küey 31 Turkish Neuropsychiatric Society; 2 Psychiatric Association ofTurkey; 3 WPA Zonal Representative, Zone 8In this presentation, the mental health profile of Turkey, a countrywhich is not only a geographical bridge between Asia and Europe, butalso faces the challenge of belonging to east and west at the sametime, will be reviewed. After outlining the socio-demographic, socioeconomic,and cultural characteristics of the society, basic datareflecting the general health status of the population will be provided.The epidemiology of psychiatric disorders, and the financial, institutionaland human resources in the mental health field, along with therelevant policies, research and training activities, will be discussed.114 World Psychiatry 3:S1 - October 2004

The negative effects of the lack of a national mental health program,particularly on the issues of community psychiatry, will be underlined.As a conclusion, the psychiatric associations, in respect to theirroles in the development of mental health policy and programs, theimprovement of professional collaboration, and the promotion ofmental health, will be discussed.ZS11.6.PSYCHIATRY IN SPAIN: THE REAL MANAGEMENTOF THE CHRONIC DISORDERSM. Roca 1 , L. Caballero 21 Hospital Juan March, University of Balearic Islands, Palmade Mallorca; 2 Hospital Puerta de Hierro, Madrid, SpainIs there any evidence of a new approach in the Mediterranean psychiatryafter the implementation of community psychiatry? To discussthis question we studied the clinical management of chronicmental disorders in Spain, a Mediterranean country with a publichealth system that covers 98% of the population. We conducted adescriptive, cross-sectional, multi-centered study in outpatient mentalhealth centers and private offices. A total of 500 psychiatristsrecruited 1969 patients with a primary diagnosis of schizophrenia.Our objective was to find the real provided care of a large populationsample of schizophrenic patients in order to identify actual needs andfuture directions to provide an adequate health care.ZS11.7.COMMUNITY PSYCHIATRY IN CYPRUSY. KalakoutasPsychiatric Association of CyprusIn Cyprus, psychiatric reform was introduced in an organised form in1996. The objective was to move from the medical asylum model oftherapy to the biopsychosocial one and the provision of services fromthe mental hospital to the community. During these years the numberof inpatients has decreased from 436 in 1992 to 130 in 2003. A networkof community mental health services has been developed allover the island for the management and follow-up of patients in thecommunity securing the continuity of management. Day centres havebeen established and multidisciplinary teams are actively involvedboth in the management of cases and in the introduction of mentalhealth promoting programs.WORKSHOPSWO1.DISASTERS, TERRORISM AND TRAUMAWO1.1.PREPARATION FOR PSYCHIATRIC TREATMENTIN DISASTERS AND TERRORISMF.J. StoddardHarvard Medical School, Boston, MA, USATreatments in disaster psychiatry have grown initially to respond tonatural disasters and airplane crashes. Since worldwide terroristattacks, the Oklahoma City bombing, and September 11, 2001, thefield has applied lessons learned to plan interventions. Both thecourse of symptoms and preparations for prevention and optimaltreatment in adult and child mental health and rescue teams involvedin disaster response will be described.WO1.2.TERRORISM AND PUBLIC HEALTHR. Ursano, C.S. Fullerton, N. Vineburgh, M. HallUniformed Services Medical School, Bethesda, MD, USAMental health is the target of terrorist events. Because the psychologicalimpact of terrorism is so pervasive, large populations are affectedby distress, psychiatric disease, and behavioral responses that may beadaptive or maladaptive. The Institute of Medicine endorses a publichealth approach to managing the impact of terrorism that includesprevention, health promotion and treatment. Interventions integratingmental health and public health are needed pre-event, during theevent and post-event that address the agent, the vector, and populationsat risk. Disaster behavior is an important new concept to informinterventions, and includes evacuation, shelter-in-place, and quarantine.For biological terrorist agents the only countermeasures early inan outbreak, and for an extended time for a new disease agent, arebehavioral interventions. The behavioral issues of compliance andadherence are critical factors in protecting public health. Preventionand treatment of mental disorders are also critical. While the majoritywill experience only transitory distress, many individuals increaseuse of alcohol, tobacco, and other drugs, especially those with preexistingdisorders. People exposed to terrorism are at increased riskfor depression, generalized anxiety disorder and panic disorder. Planningfor the psychological responses to terrorism requires an integratedresponse across medical, emergency and public health authorities.WO1.3.TREATMENT OF THE CONSEQUENCES OFTRAUMA, DISASTER AND TERRORISMR.J. Ursano 1 , F. Stoddard 2 , R. Daniore-Quierci 1 , M. Hall 11 Uniformed Services Medical School, Bethesda, MD;2 Harvard Medical School, Boston, MA, USATrauma, disaster and terrorism share many aspects of possible psychiatricconsequences. The evaluation and treatment of distress as well aspsychiatric illness are important parts of intervention. A recent consensusconference of National Institutes of Mental Health, Departmentof Defense, Veterans Administration and the Red Cross has outlinedearly intervention – psychological first aid – for most exposed tomass casualty events. The American Psychiatric Association is finalizingtreatment guidelines for acute stress disorder (ASD), post-traumat-115

ic stress disorder (PTSD), and other disaster-related mental disorders.Both of these sets of recommendations will be reviewed to present upto date information on early treatment, the status of debriefing as atreatment and evidence based psychological and psychopharmacologicaltreatments of ASD, PTSD and other disorders.WO1.4.WORKPLACE INTERVENTIONS TO MANAGEAND PREPARE FOR THE CONSEQUENCES OFTERRORISMN. Vineburgh, R. Ursano, C.S. FullertonUniformed Services Medical School, Bethesda, MD, USAThe Institute of Medicine identifies the workplace as an importantenvironment for addressing the psychological impact of terrorism.Worksite health promotion can play a critical role in offering publichealth interventions for the pre-event, event and post-event phases.Terrorism may have the highest rates of psychiatric disorders andbroadest distress responses. Disaster and terrorism can increase distress,lead to altered health and risk behaviors, and increase socialdisruption and psychiatric illness in exposed populations. Pre-eventinterventions can educate employees about evacuation and shelterin-place,life-saving disaster behaviors, and raise awareness of maladaptivebehaviors such as increased substance abuse and domesticviolence. During an event, risk communication is essential to managehigh stress. Post-event programs can foster information and helpseeking,leading to early identification and triage of psychological disordersthat can impair health and productivity. Reluctant employersfearful of raising undue anxiety pose a challenge to workplace preparedness.Resiliency, the expected outcome of terrorism, is a currentand relevant topic of interest in worksite health promotion. We willdescribe key public health interventions for workplace disasterresponse and how a resiliency model can engage employer andemployee interest to help prevent, mitigate and foster recovery fromterrorism.WO2.TRAINING IN PSYCHIATRIC TREATMENTIN DIFFERENT EUROPEAN COUNTRIES(Special Workshop organized by the EuropeanFederation of Psychiatric Trainees)WO2.1.TRAINING IN PSYCHIATRIC TREATMENT INEUROPE: THE VIEW FROM THE EUROPEANFEDERATION OF PSYCHIATRIC TRAINEESJ. BeezholdEuropean Federation of Psychiatric Trainees; Norfolk MentalHealth Care NHS Trust, UKThe European Federation of Psychiatric Trainees (EFPT) is an independentfederation of national psychiatric trainee organizations fromacross Europe. It was founded by trainees in 1993, at which time onlyfour countries had national trainee organizations. Today it has 16member countries, all of which have national trainee organizations,and represents over 12000 psychiatric trainees. The EFPT holds anannual Forum in the host country of the current President, at which alltrainees are welcome. This presentation examines the role that theEFPT plays in promoting high quality postgraduate training in psychiatrythroughout Europe. A brief overview of the origin and history ofthe EFPT will be given. The structure, function and achievements ofthe EFPT will be reviewed. The way in which the EFPT relates to otherorganizations will be described. Particular emphasis will be placed onthe views of the EFPT regarding different aspects of psychiatric training.The way in which the EFPT has developed and promoted theseviews will be explored. Some of the difficulties, problems and solutionsto working across various national and international boundarieswill be discussed.WO2.2.MODERN AND CLASSICAL STRATEGIESCONVERGE: TREATMENT ISSUES IN TURKISHPSYCHIATRIC TRAININGD. EraslanEuropean Federation of Psychiatric Trainees; Department ofPsychiatry, Ege University Medical School, Izmir, TurkeyIn developing countries, such as Turkey, psychiatry is a growing disciplineand is gaining more and more attention. Psychiatry training isbecoming very popular among young doctors, especially with thegrowing awareness of the general public that psychiatric disorderscan be successfully treated. Anyway, the number of psychiatrists isstill not sufficient for the population, so there is still need for youngpsychiatrists, trained in newer treatment techniques. Psychiatrictraining takes place in vary different settings, including universityhospitals, where more time and investigation can be devoted topatients, state hospitals and long-stay hospitals. When traineesbecome specialists, they need to know both the modern psychopharmacologyand psychotherapy methods, and the old techniques likeelectroconvulsive therapy to handle all the problems they face. However,the different characteristics of the patients admitted to the differenteducational settings may cause several problems to trainees inlearning methods that are uncommon in one’s workplace. Theseproblems may be overcome by organizing common educational programs,eventually in cooperation with national and/or internationalassociations, spending part of the training in rotations in the differenthospitals, and improving contacts among national institutions andorganizations. With such a training organization, after having completedtheir training the new residents should be able to make a synthesisbetween the therapeutic techniques of the old neuropsychiatristsand the new treatment strategies, which, hopefully, will result ina successful generation of new psychiatrists.WO2.3.AN OVERVIEW OF PSYCHIATRIC TRAININGIN ROMANIA AND EASTERN EUROPEA. MihaiUniversity of Medicine and Pharmacy, Tg. Mures, RomaniaTraining in psychiatry and research work changed a lot in Romaniaafter 1989. Post-graduate education in psychiatry is organized atnational level in five university centres. Now training in psychiatrylasts 5 years, the log/book is similar to other European countries,training in psychotherapy is highly recommended, and basic knowledgeof psychotherapy is included in our training. Training in psychiatrictreatment is all the time updated and the Romanian Associationof Psychiatrists has elaborated guidelines for treatment of affectivedisorders and schizophrenia. Post-training education and continuingmedical education, which have been recently developed in Romania,include several courses about different themes in psychiatry and inpsychotherapy, both for specialists and general practitioners. Moreover,books, translations, internet access, participation to internationalmeetings have all contributed to develop scientific and116 World Psychiatry 3:S1 - October 2004

esearch work. Under these circumstances, a special training foryoung psychiatrists has been organized in Romania in the last years.Young psychiatrists are now involved in international networks ofdifferent kinds of psychiatric research. In this presentation, I willunderline the similarities and differences between psychiatric trainingin Romania and other Eastern European countries.WO2.4.TRAINING IN PSYCHIATRIC TREATMENTS:CURRENT PERSPECTIVES AND SPECIFICITIESIN FRANCEC. Hanon 1 , D. Mathis 21 Association pour la Formation Française et Européenne enPsychiatrie; Erasme Hospital, Paris, France; 2 EuropeanFederation of Psychiatric Trainees; Paul Guiraud Hospital, Paris,FranceTraining in psychiatric treatments in France is an important issue ata time of serious decreasing in the number of trainees. This year, areform of training schemes is in discussion, and in the next monthscurrent organisation of training may change. Currently, traininglasts 4 years and its global framework is nationally defined. Eachregion of France has however its specificities and theoretical referencesthat offer an important diversity. Community psychiatry has along history in France and represents the basis of the psychiatrichealthcare system. Community departments are often non-universitary,but nonetheless they are considered as training centres. Fulltraining in psychotherapy is not compulsory, and most universitiesdo not provide it. Therefore, private psychotherapic institutes havea particular role in training, especially those with a psychodynamicorientation. Since 1998, trainees in psychiatry are organised in anational association, the Association pour la Formation Françaiseet Européenne en Psychiatrie (AFFEP), and are getting more andmore involved in training issues. The most important aim of thisassociation is to improve the quality of initial training by providinginformation to trainees and participating in the evaluation of themedical practical and theoretical training. In this contribution, wewill describe the current training scheme and we will discuss theproject of the French reform.WO2.5.LEARNING HOW TO TREAT PSYCHIATRICPATIENTS: PSYCHIATRIC TRAINING IN ITALYU. Volpe, A. FiorilloDepartment of Psychiatry, University of Naples SUN,Naples, ItalyIn Italy, the training in psychiatry lasts 4 years. During this period,trainees have to acquire evidence-based notions and practical skills inthe three main areas of psychiatric treatment: psychopharmacology,psychosocial interventions and psychotherapies. The learning processof how to treat patients is accomplished by an integration of theoreticalknowledge and practical activities within several areas such as biologicalpsychiatry and neuropsychopharmacology, psychopathologyand psychiatric methodology, clinical psychiatry, psychotherapy, andsocial psychiatry. At the end of every year, residents have to demonstratethe acquisition of such skills. At the end of the training, they getthe diploma of specialist in psychiatry and psychotherapy by discussinga thesis on clinical or research work. In this presentation, wewill describe the structure and scope of both medical and psychiatrictraining in Italy, and we will review the current needs of Italian psychiatrictrainees. Specific issues concerning psychotherapeutic, pharmacologicaland community mental health training, as well as practicalitiesabout how supervision is provided to Italian psychiatrictrainees, are more broadly discussed, also in reference to other Europeanmodels of psychiatric training. Finally, we will present new proposalsand recent activities in the field of psychiatric training in Italy.WO3.DIAGNOSIS AND TREATMENT OF CATATONIAWO3.1.RELEVANCE OF THE CATATONIC SYNDROMETO THE MIXED MANIC EPISODES. Krüger 1 , P. Bräunig 21 Department of Psychiatry, University of Dresden;2 Klinik für Psychiatrie, Verhaltensmedizin und Psychosomatikam Klinikum Chemnitz, Dresden, GermanyCatatonic symptoms have been associated with mixed mania in theolder psychiatric literature; however, to date no systematic studieshave been performed to assess their frequency in these patients. Thispresentation will focus on a study performed to assess the frequencyand clinical relevance of the catatonic syndrome in mixed mania.Ninety-nine patients with bipolar disorder manic or mixed episodewere assessed for the presence of catatonia using the Bräunig CatatoniaRating Scale (BCRS). Severity of mixed symptoms and associatedcomorbidity were also systematically assessed. Thirty-nine patientsfulfilled criteria for mixed mania, of whom 24 were catatonic. Amongthe patients with pure mania, only 3 were catatonic. Eighteen catatonicpatients with mixed mania required admission to the acute careunit (ACU) because of the severity of the acute episode. Treatmentsbetween the two groups differed significantly in that catatonicpatients required higher dosages of benzodiazepines and atypicalantipsychotics. These data suggest that catatonia is frequent in maniaand linked to the mixed episode. Catatonia in mixed mania is likely tobe found among the severely ill group of patients with mixed mania,who require emergency treatment. The likelihood of overlookingcatatonia in less severely ill patients with mixed mania is low and itdoes not need to be routinely assessed in a general ward. Catatonicmixed mania requires adjustment of treatment strategies in order notto worsen the catatonic syndrome.WO3.2.MALIGNANT CATATONIAS.C. Mann, S.N. CaroffDepartment of Psychiatry, University of Pennsylvania School ofMedicine and Department of Veterans Affairs Medical Center,Philadelphia, PA, USAMalignant catatonia (MC) is a life-threatening neuropsychiatric disordercharacterized by hyperthermia, catatonic stupor or excitement,altered consciousness and autonomic dysfunction. Prior to the introductionof modern psychopharmacologic agents, MC was widely recognizedas a possible complication of acute psychotic illness. Althoughthe incidence of MC may now have declined, it remains the subject offrequent case reports. Based on a comprehensive review of the literature,we propose that MC continues to occur and represents a syndromerather than a specific disease. While most often an outgrowth ofthe major psychoses, MC may also develop in association with diverseneurologic and medical conditions. From this perspective, neurolepticmalignant syndrome (NMS), a potentially fatal complication ofantipsychotic drug treatment, may be viewed as a drug-induced form of117

MC. Our review also supports a conceptualization of catatonia as acontinuum, with milder forms at one end (simple catatonia) and moresevere forms involving hyperthermia (MC) at the other end. In addition,findings from our review suggest that simple catatonia, MC andNMS share a common pathophysiology involving reduced dopaminergicneurotransmission within the basal ganglia-thalamocortical circuits.Electroconvulsive therapy is an effective and practical treatmentfor MC resulting from psychiatric and neuromedical conditions,including NMS. Antipsychotic drugs should be withheld wheneverMC is suspected.WO3.3.CATATONIC SCHIZOPHRENIA REVISITED.DEMOGRAPHIC AND CLINICAL CORRELATESG.S. Ungvari 1 , S.K. Leung 2 , F.S. Ng 2 , H.K. Cheung 2 , T. Leung 11 Department of Psychiatry, Chinese University of Hong Kong;2 Castle Peak Hospital, Hong KongThis study aimed to determine the frequency of catatonic syndrome inchronic schizophrenia and its association with socio-demographicand clinical variables. Cross-sectional assessment of 225 randomlyselected patients (age 42±7 yrs; length of illness 20.4±7.5 yrs) withDSM-IV schizophrenia was conducted using standard rating instrumentsfor catatonia, extrapyramidal symptoms (EPS) and psychotic,depressive and obsessive-compulsive symptoms. Using a narrow definitionof catatonia (the presence of 4 or more signs/symptoms withat least one having a score of 2 or above on the Bush-Francis CatatoniaRating Scale, BFCRS), 72 subjects (32%) met criteria for the catatoniagroup (number of catatonic signs 5.9±2.0; BFCRS sum score8.7±3.4). Mannerisms, grimacing, stereotypes, posturing and mutismwere the most frequent symptoms both in the catatonic group and thewhole sample. Catatonic subjects had significantly earlier age ofonset, more negative symptoms, and were more likely to receive benzodiazepinesthan their non-catatonic counterparts. The severity ofcatatonia was predicted only by earlier age of onset and more negativesymptoms. This study confirms that, if methodically assessed,catatonic signs and symptoms are prevalent in patients with chronicschizophrenia. Catatonia could be differentiated from EPS. Catatonicfeatures indicate a generally poor prognosis in the chronic phase ofschizophrenia.HIV infection. The paper will include information on how to successfullywork with cognitively impaired populations with minorcognitive-motor disorder, HIV associated dementia, and mood disorders.WO4.2.THE MULTIPLY DIAGNOSED HIV PATIENT:SEVERE MENTAL ILLNESS, SUBSTANCE USE,AND HIVF. CournosColumbia University, New York, NY, USAThe need for multiple diagnoses is becoming increasingly common asHIV-infected patients live longer because of antiretroviral treatments. Anumber of surveys of persons with HIV infection have shown an elevatedpremorbid rate of psychiatric disorders when compared to ratesin the general population. Psychiatric treatment of patients living withHIV infection should include active monitoring of substance abuse,since it is often associated with risk behaviors that can lead to furthertransmission of HIV and treatment nonadherence. This paper will offerguidelines for the differential diagnosis of the HIV-infected patient,more specifically the patient diagnosed with a severe mental illness, aswell as offer treatment strategies for the multiply diagnosed patient.WO4.3.INCORPORATING PRIMARY AND SECONDARYPREVENTION STRATEGIES INTO PSYCHIATRICPRACTICEM. WainbergColumbia University, New York, NY, USAAs psychiatrists continue to work more with patients infected withand affected by HIV/AIDS, it will become increasingly more necessaryto introduce primary and secondary prevention strategies in psychiatricpractice. This paper will relay proven and practical methodsof primary prevention. Successful intervention strategies at the secondaryprevention level will also be addressed. The methods introducedtransfer across cultures and are effective tools for working witha diverse patient population, including those individuals with multiplediagnoses.WO4.HIV/AIDS AND PSYCHIATRIC DISORDERSWO4.1.DIFFERENTIAL DIAGNOSIS AND COMMONPSYCHIATRIC DISORDERS IN HIV POSITIVEPATIENTSF. FernandezUniversity of South Florida, Miami, FL, USAIt is vital for clinicians to successfully evaluate cognitive, affective,and behavioral dysfunction in HIV-infected patients. Diagnosingcognitive impairment is increasingly complex. Studies indicate thatneurological illnesses are the initial manifestation of AIDS in 7% to20% of patients. Furthermore, frequency of neuropsychiatric complicationsincreases over the course of the illness. HIV infection ofthe central nervous system can lead to a range of neurological andneuropsychiatric symptoms, including but not limited to minor cognitive-motordisorder. We will discuss useful, practical skills andtools for effectively assessing cognitive impairment associated withWO5.METHODOLOGICAL CHALLENGES INNON-INDUSTRY-SPONSORED MULTICENTERCLINICAL TRIALSWO5.1.RECRUITMENT PROBLEMS INNON-INDUSTRY SPONSORED CLINICAL TRIALSJ. Peuskens, M. De HertUniversity Centre St. Jozef, Katholieke Universiteit, Leuven,BelgiumIn the last 10 to 15 years, an increasing number of new antipsychoticdrugs have been developed and have become available for the treatmentof psychotic disorders. However, the methodology and theresults of industry-initiated and sponsored randomised clinical trials(RCT), as well as their relevance for every day clinical practice, arebeing questioned. Industry-initiated and sponsored trials frequentlyfocus on the efficacy and safety of new drugs and are performed inselected, narrowly defined patient groups and under controlled con-118 World Psychiatry 3:S1 - October 2004

ditions, thus offering only partial information on the effectiveness ofa drug in real life clinical practice. Non-industry sponsored clinicaltrials (NISCT) try to reproduce results of RCT in larger or more “natural”patient populations or to address specific, clinically relevantquestions using a controlled and less controlled, more exploratory oreven open study design. Although NISCT have to respond to thesame methodological requirements as industry sponsored trials, theywill be confronted with difficulties, often due to limited funding. Themore personal interest and engagement of the investigator may raisespecific problems. As NISCT are often performed later in the “life” ofa drug, these trials can build on previously obtained information,which may facilitate the definition of inclusion and exclusion criteria,the prediction of effects and power analysis. Also, a more “naturalistic”design may appeal more to investigators and patients, simplifyingrecruitment. However, problems arise if larger patient groups areincluded and (consequently) different centres are participating, andinterventions to reduce heterogeneity and to secure correct and timelypatient enrolment are needed. Investigator-initiated trials maydemand for control of non-interactional effects and for interactional(specifically expectancy) effects.WO5.2.THE EUROPEAN FIRST EPISODE SCHIZOPHRENIATRIAL (EUFEST)W.W. Fleischhacker for the EUFEST Study GroupDepartment of Biological Psychiatry, Medical Universityof Innsbruck, AustriaSecond-generation antipsychotics have been shown to be at least aseffective as the earlier antipsychotics in treating schizophrenia andpreventing recurrence of psychosis. Clinical trials have also persistentlyshown a lower incidence of extrapyramidal side effects (EPS) withthe newer agents. However, most of the studies comparing the secondgenerationwith the older antipsychotics have been conducted in moreor less chronic patients with schizophrenia. Another problem is evenmore pervasive: studies examining drug effects are usually conductedin highly selected samples, for instance excluding patients with concomitantdrug abuse or aggressive or suicidal patients. Thus, the generalizabilityof the studies assessing the efficacy of the newer antipsychoticsis limited at best. Indeed, it has been argued that the EPSadvantages of the new antipsychotics would fail to materialize whencompared with lower doses of traditional antipsychotics. This issue,however, has not been tested in first-episode schizophrenia patients.The European First Episode Schizophrenia Trial (EUFEST) is set up toprovide an answer to these problems: the study compares the one yearoutcomes of an unselected group of first episode patients after treatmentwith various second-generation antipsychotic medications(amisulpride, quetiapine, olanzapine and ziprasidone) to that of a lowdose of haloperidol, as measured by duration of retention to allocatedtreatment in 500 patients. This is an open clinical trial with randomtreatment allocation. The study is currently running in 13 Europeancountries involving 32 sites.WO5.3.CHALLENGES FOR THE EUROPEAN FIRSTEPISODE SCHIZOPHRENIA TRIAL (EUFEST)H. Boter 1 , R. Kahn 1 , W.W. Fleischhacker 21 Division of Neuroscience, University Medical Center, Utrecht,the Netherlands; 2 Department of Biological Psychiatry, MedicalUniversity of Innsbruck, AustriaMost studies comparing second-generation antipsychotics with classicalneuroleptics have been conducted in patients with chronicschizophrenia or used high doses of classical antipsychotics. Therefore,the European First Episode Schizophrenia Trial (EUFEST) wasdeveloped to assess the effectiveness of low doses of haloperidol andregular doses of amisulpride, olanzapine, quetiapine, and ziprasidonein first-episode patients. This investigator-driven - instead of industrysponsored- clinical trial in 16 European countries has its own challenges.For example, in industry-sponsored trials the pharmaceuticalindustry will often co-ordinate the trial and arrange permission fromthe local and national ethics committees to start the study, organizethe translation of forms, distribute investigator manuals and otherequipment, etc. In contrast, participants in this investigator-drivenstudy have to perform these mostly time-consuming tasks themselves.Another problem is that legislation differs between countries. A fewcountries require that the randomized drugs are still recognizable asstudy drugs even though they are registered. Sometimes it is alsoobligatory that the insurance company - that covers for potentialharm caused by the study protocol - has a local office. Furthermore,in most countries one or more of the study drugs are still not registered,which prohibits randomization of these drugs. Finally, in somecountries health insurance companies do not reimburse the costs ofall the study drugs. We conclude that we are doing this study together:all participating investigators need to put a lot of effort in EUFESTto make it a successful trial.WO5.4.CURRENT STATUS AND CONTROVERSIESIN ANTIPSYCHOTIC DRUG EFFECTIVENESS:UPDATE FROM THE CATIE STUDYJ. LiebermanUniversity of North Carolina, Chapel Hill, NC, USAThe Clinical Antipsychotic Trials of Intervention Effectiveness(CATIE) project is a National Institute of Mental Health-sponsoredresearch project to evaluate the clinical effectiveness of atypicalantipsychotics in the treatment of schizophrenia and Alzheimer's disease.Although they were first developed for schizophrenia, antipsychoticdrugs are now broadly used for other disorders, includingbehavioral signs and symptoms associated with Alzheimer's disease.Despite their widespread use in these conditions, the overall effectivenessand safety of these drugs remain unclear. In recent years clinicalpsychopharmacology research has been dominated by the pharmaceuticalindustry. While industry-sponsored research is critical to newproduct development, its emphasis is on meeting regulatory and marketingrequirements rather than the effectiveness of the drugs at thegeneral population level. As a result, industry-sponsored research doesnot address broad public health needs or the needs of individual practitionersseeking to make good clinical decisions for individualpatients. The CATIE trials are examples of practical clinical trials -they are meant to produce results that are generalizable to typicaltreatment settings and to generate information that is useful to clinicaland policy decision-makers. The trials have been underway since 2001and will be complete by the end of 2004. Information on the safety and119

effectiveness of the drugs that has become available since the trailsbegan has only increased the importance of the two CATIE trials.WO6.DIAGNOSING AND TREATING SOCIAL PHOBIAWO6.1.SOCIAL PHOBIA: DIAGNOSTIC CONSIDERATIONSP. RuizDepartment of Psychiatry and Behavioral Sciences,University of Texas Medical School at Houston, TX, USASocial phobia is one of the most frequently observed types of anxietydisorders. In the United States, approximately 5.3 million people sufferfrom social phobia in a given year. In general, women suffer morethan men do from social phobia, at an approximate rate of 2 to 1.However, men tend to seek help for social phobia more frequentlythan women. Social phobia tends to develop during childhood orearly adolescence; rarely does it develop after age 25. With respect tofunctional risk factors, persons suffering from social phobia are lesslikely to marry, they suffer from a marked increase of academic andoccupational problems, and they have an increased incidence of substanceuse problems. Additionally, there is a clear comorbidity riskbetween social phobia and depressive disorders, as well as anincreased incidence of suicide among persons suffering from this disorder.Within this context, it is also important to discuss the uniqueand specific clinical cues that could help psychiatrists and primarycare practitioners to differentiate social phobia from other types ofanxiety disorders. Additionally, specific attention needs to be given torelevant comorbidity factors such as substance-related disorders,alcohol use disorders and panic disorder.WO6.2.PSYCHOPHARMACOLOGICAL TREATMENTOF SOCIAL PHOBIAJ. RabochFirst Medical School, Charles University, Prague, Czech RepublicSocial phobia has received much attention and priority in recentyears in the field of psychiatry. In many ways, this focus is the resultof the current treatment techniques that have proven to be helpful inthe management of this psychiatric condition. In particular, antidepressantmedications. This has brought light and hope for those whosuffer from this type of disorder. In the past benzodiazepines were theonly psychopharmacological option to treat this disorder. As expected,fear and resistance were always present when using benzodiazepinesin the management of this psychiatric illness as a result ofthe possibility of patients’ developing addiction to these psychopharmacologicagents. Nowadays, this situation has changed a great deal.In this presentation, focus and attention will be given to the mostappropriate approaches in the psychopharmacological treatment ofsocial phobia, with emphasis on the use of selective serotonin reuptakeinhibitors (SSRIs).WO6.3.PSYCHOTHERAPY IN SOCIAL PHOBIAM.I. López-IborDepartment of Psychiatry and Psychological Medicine,Faculty of Medicine, Complutense University of Madrid, SpainThere is large scientific evidence of efficacy of cognitive-behaviouralpsychotherapy for the treatment of social phobia, either alone or incombination with psychotropic drugs. On the contrary, there is notenough available information on the efficacy of psychodynamic orientedtherapy for this disorder, nor the data is conclusive on the efficacyof interpersonal therapy in comparison to other treatments.Among the various methods of cognitive-behavioural therapy, the“exposure” techniques, preferably “in vivo”, especially those associatedto behaviour restructuring techniques, are key elements of an efficientpsychological treatment. Relaxation or the training in socialabilities have proved their usefulness when associated to the abovementioned techniques. In those cases in which social phobia is thefirst diagnosis, the response to cognitive-behavioural therapy is positive,even in the presence of other disorders. However, comorbiditywith other psychiatric disorders and the clinical subtype of generalisedsocial phobia tend to predict a worse response with respect toglobal functioning. Although many efficacy studies at short and mediumterm have been carried out, more research on the effectivenessand long-term efficacy of the treatments is necessary. Furthermore,there is a need for further knowledge about the differences of therapeuticresponses in the different clinical forms of social phobia.WO6.4.CHILD AND ADOLESCENT ISSUES INSOCIAL PHOBIAE. BelfortUniversidad Central de Venezuela, Caracas, VenezuelaAnxiety disorders in children and adolescents are a group of frequentpsychiatric disorders that tend to continue in the adult life and oftenleave psychological, social, familiar and academic consequences.Nevertheless, these disorders frequently are not perceived, for the followingreasons: a) children with anxiety do not have severe behaviorproblems; b) frequently these disorders are accompanied by otherpsychiatric disorders (e.g., depression), that hide the anxiety symptoms;c) often these disorders manifest themselves with somaticsymptoms, leading to physical and laboratory evaluations, sometimesunnecessary; d) a denial of the symptoms frequently occurs. The generalfeatures of anxiety disorders in children and adolescents, speciallythe social phobia, are visible in a wide spectrum, from feelinghumiliated or ashamed facing social situations, to experiencingsomatic and neurovegetative changes. In children the disorder cansometimes take the form of selective mutism.WO6.5. SOCIAL PHOBIA:RESEARCH PERSPECTIVESF.T. AntunWPA Zonal Representative, Zone 12, Beirut, LebanonNowadays, social phobia has become a psychiatric disorder whereevidence-based treatments have shown beneficial responses. Up torecently, benzodiazepines were the most commonly used treatmentapproach in the management of social phobia. Currently, however,new treatment approaches are being considered as a result of theresearch efforts that have been applied vis-à-vis this psychiatric disorder.These research approaches have focused not only on the psy-120 World Psychiatry 3:S1 - October 2004

chopharmacotherapy but also on the behavioral techniques. Theseresearch efforts have led to the current use of selective serotoninreuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs),beta-blockers, and also cognitive-behavioral therapy. In view of thesenew discoveries, social phobia is nowadays more accessible to treatment,offers a better prognosis, and is much better understood. In thispresentation a review of the most current and promising researchefforts will be undertaken. Additionally, potential future researchefforts will also be addressed and discussed.WO7.COMPARING MENTAL HEALTH AND RISK FACTORSACROSS EUROPEAN UNION COUNTRIESWO7.1.PSYCHOSOCIAL WELL-BEING AND PSYCHIATRICCARE IN THE EUROPEAN COMMUNITIES:ANALYSIS OF MACRO INDICATORSM.G. Carta 1 , V. Kovess 2 , M.C. Hardoy 11 Division of Psychiatry, Department of Public Health,University of Cagliari, Italy; 2 MGEN Foundation for PublicHealth, Paris, FranceThe study aimed to investigate the well-being in European countriesand the availability of psychiatric care by means of available macroindicators. A review of macro indicators capable of providing a syntheticdescription concerning the mental health status and the availabilityof psychiatric care and collected routinely from sources suchas the World Health Organization, the Organization for EconomicCo-operation and Development, the Statistical Office of the EuropeanCommunities (EUROSTAT) and the Intercontinental MarketingServices (IMS) was carried out. The evaluation of temporal trends ineach nation permits the carrying out of a subsequent comparisonbetween countries. In all European countries a decreasing trend ofsuicides was observed in the period 1980-2000, with the exception ofIreland and partially of Spain. In Ireland the increase was of 130%,with a particularly high risk in young people and adults. Portugal andGreece presented respectively the highest and the lowest rates ofundetermined causes of death. A general increase during the mid1980s in mental disorder mortality was shown. Psychiatrists per100,000 inhabitants ranged from 3.6 in Spain to 17.5 in Finland, childpsychiatrists from 0.9 in Germany to 5.1 in Portugal. Psychiatric bedsranged from 0.4 per 1000 inhabitants in Italy and Spain to 1.3 in Ireland.IMS data indicated a trend towards an increase of consumptionfor antidepressants and antipsychotics in all European countries. Abetter coordination in the collection of data concerning mentalhealth status in the European Union and an improvement of the qualityof services available is necessary.Supported by the Project “The status of mental health in Europe”.WO7.2.RISK FACTOR COMPARISONS ACROSS SOMEEU COUNTRIES: ESEMED AND EUROBAROMETERCOMPARISONSV. Kovess 1 , V. Lehtinen 21 MGEN Foundation for Public Health, Paris, France;2 STAKES, Helsinki, FinlandMental health comparisons between countries are quite hard to conduct.Most European Union (EU) countries have some epidemiologicaldata, but methodologies, specially design and instruments, are toodiverse to make comparisons. However, two recent EU surveys havebeen conducted in diverse countries using identical instruments (theComposite International Diagnostic Interview and the Short Form-12for the first one and the Mental Health 5 Item Scale for the second)and the same design in national representative samples: the EuropeanStudy of Epidemiology of Mental Disorders (ESEMeD) and the Eurobarometer.These studies collected sociodemographic variables, thusallowing to compare at least the relative risk for the major risk factors,such as gender, age living arrangement, foreigner/native and employmentstatus. The presentation will compare relative risk (odd ratios)for these risk factors across the diverse countries as well as care utilisation.The presentation will for example show that South Europeanwomen have a higher relative risk than their male counterparts, whilein Northern countries there is no higher risk for females. In some ofthe countries the youngest (those less than 25 years) have more problemsthan the adults. French young people have a higher risk formood disorders and German and Spanish young people for anxietydisorders; taking any disorders French and German young peoplehave a higher risk than their adult counterparts in their own country.In most of the countries, people aged over 65 years have some lowerrates than adults, except for Italy where this never happens. Concerningmood disorders, in all countries except Italy and Netherlandsthose who are unemployed have a higher risk than those who are inpaid employment (corrected by sex and age). In most of the countriespeople who live with a partner have a lower risk for mood disordersthan those living in other situations; however, in France, Germanyand Netherlands there is a higher risk. The results will be discussed aswell as their implications for fostering prevention policies.WO7.3.COMPARING THE POSITIVE MENTALHEALTH IN EUROPEV. Lehtinen 1 , B. Sohlman 1 , V. Kovess 21 STAKES, Helsinki, Finland; 2 MGEN, Paris, FranceThe Eurobarometer survey 58.2, conducted in Autumn 2002, includeditems to measure the state of positive and negative mental healthas well as social support and help seeking behaviour due to mental illhealth.The main aim of this paper is to compare aspects of positivemental health across the 15 'old' European Union (EU) memberStates. The dependent variables analysed in this paper are the following:the mean Energy and Vitality Index (EVI) from the Short Form-36 (SF-36) questionnaire and the perceived social support measuredby the 3-item Oslo scale. The Eurobarometer survey covers the populationof the EU member States aged 15 years and over. The samplesizes are about 1000 per country/region, except Luxembourg (about600) and Northern Ireland (about 300). The response rates variedfrom 23% to 84%. Countries where the response rate was lower than45% are excluded from the present analyses. The mean EVI for the 11selected countries together was 62.4, with the score ranging from 58.8(Italy) to 66.3 (Spain). The mean EVI was generally higher for men(65.3) than for women (60.0). The percentage of people experiencingstrong social support varied similarly between countries (from 9.1%for Italy to 35.1% for Spain). High EVI score (indicating good mentalhealth) was also associated with younger age, being single or married,and being employed.121

WO7.4.SOCIAL INEQUALITIES AND THE COMMONMENTAL DISORDERST. FryersUniversity of Leicester, UKThis paper discusses the evidence for associations between markersof social position and the prevalence of the 'common mental disorders'(mostly non-psychotic depression and anxiety, separately ortogether). It presents a recent major systematic review of the publishedevidence for general populations in developed countries, andan extended analysis of the British National Psychiatric Survey of1993. Additional evidence is drawn from surveys using the GeneralHealth Questionnaire, the Composite International Diagnostic Interviewor the Short Form-36 from the 'Survey of Surveys' undertakenfor the European Union (EU) project The Mental Health Status ofEurope. Issues of causation are addressed, including evidence fromthe limited longitudinal studies available. In Western European andsimilar populations, people of lower social position are generally disadvantagedin health and illness. This includes the common mentaldisorders, higher frequencies of which are associated with poor education,material disadvantage and unemployment. Their large contributionto morbidity and disability, and their social consequences inworking age adults, would justify substantial priority being given toaddressing mental health inequalities within social and economicpolicy in Europe. Disadvantaged people tend to live in communitiesand cultures that are disadvantaged by noxious environments, poorhuman services, high levels of smoking, drinking, drug taking, andviolence. These are almost certainly causally associated with high levelsof psychiatric morbidity found in these populations, probablymediated or enhanced by individual disadvantages. They may affectduration as well as onset and thus increase prevalence. There are wellknown policy implications relating to social exclusion and deleterioussocial environments. It does not need population surveys to showthat poverty, deprivation, environmental degradation and socialstress should be high on the political agenda.WO7.5.THE STATE OF MENTAL HEALTH IN OLD AGEACROSS THE “OLD” EUROPEAN UNIONM.C. Angermeyer, S.G. Riedel-HellerDepartment of Psychiatry, University of Leipzig, GermanyAging and the special circumstances of older people are taking anincreasingly central place in public health across Europe. The paperprovides the first syllabus on the occurrence of mental disorders inold age focusing on surveys conducted in the 15 countries whichcomprised the “old” European Union. A systematic search of the literatureon the prevalence of mental disorders in old age in Englishand German was conducted, using Medline and Psyndex databases.Mental disorders in old age are common. However, the pattern differsfrom that in younger cohorts. The most serious threats to mentalhealth in old age are posed by dementia and depression. It is a clearcut finding that dementia exponentially increases with age. The basicissue whether depression increases or decreases with age remainsunsolved. Databases on other mental disorders in old age are muchsmaller. Although among the most prevalent conditions across the lifespan, decreasing rates of anxiety disorders and alcoholism have beenfound with increasing age. No firm conclusion can be drawn aboutthe occurrence of drug-related disorders and somatoform disorderswith increasing age. Psychotic syndromes in late life appear toincrease with age. Unfortunately, variation among studies conductedin different European regions seems to reflect mainly methodologicaldifferences rather than real differences. A concerted action in improvingthe methodology of epidemiological research in old age, producingcomparable data across Europe, is needed to meet the challengesof an aging population.WO7.6.IMMIGRATION AND MENTAL HEALTH IN THE EUM. Bernal 1 , J.M. Haro 1 , M.G. Carta 21 Sant Joan de Deú-Serveis de Salut Mental, Sant Boi deLlobregat, Barcelona, Spain; 2 Division of Psychiatry, Departmentof Public Health, University of Cagliari, ItalyMigration during the 1990s in Europe has been high. Besides themigration from developing to developed countries, there has been arise of new migrations, especially from the Eastern and Central Europeancountries and from the Commonwealth of Independent States.Some countries in Europe, like Spain, Italy or Portugal, that havebeen traditionally exporters of migrants, have shifted to becomeimporters. Political and socio-economic instability in and aroundEurope has significantly increased the number of refugees and asylumseekers arriving in European countries. The presence of undocumentedimmigrants is a well-established fact in most European countries.Among all the changes a human being must face throughout his live,few are so wide and complex as those which take place during migration.Practically everything that surrounds the person who emigrateschanges. The singularity of the migratory experience lies in the factthat it is a psycho-social process of loss and change, which is knownin the psychiatry of migration as a grief process. In the case ofrefugees, who have to flee their country for fear of being persecuted,the grief process is even more complex. In Spain, research has beencarried out about conditions which points to mental and psychosomaticdisorders in the immigrant population. This research came upwith the following factors affecting the mental health of immigrants:labour and economic instability, cultural and social marginalisation,family estrangement, pressures to send money to their families, racialdiscrimination and lack of statutory documentation. The particularlyhard conditions of today’s migration seem to be propitiating a worseningin the mental health of the newcomers. Current situations aremaking of the migratory experience an extremely hard and unbearableprocess. An example of this is the situation in the South of Europe,particularly Spain and Italy. Psychiatrists from the Psycho-pathologicaland Psycho-social Assistance Service (SAPPIR) team, located inBarcelona, have described a common syndrome called chronic andmultiple stress syndrome in immigrants (or Ulysses syndrome).Despite migrants represent a vulnerable population with respect tohealth problems, in many European countries there are migrants whofall outside the existing health and social services, something which isparticularly true for asylum seekers and undocumented immigrants.They are usually only entitled to emergency health services. Somestates have done efforts to universalise the right to access nationalhealth care services, therefore including undocumented migrants.Nevertheless, the health care gaps that are being left by the authoritiesare being covered by the informal work of doctors at the health systemand by non-governmental organizations, which provide medical and,specially, mental health assistance together with health promotionand prevention programs among other services. Our aim should be toprovide specific mental health care services for migrants. It is necessaryto highlight the importance of adopting an integrated approach tomental health care that moves away from psychiatric care only, as ithas been stressed in a recent report of the World Health Organizationin collaboration with Red Cross and Red Crescent organizations.122 World Psychiatry 3:S1 - October 2004

WO8.INTERNATIONAL PERSPECTIVES ONCOERCIVE TREATMENT IN PSYCHIATRYWO8.1. INTERNATIONAL RESEARCH ONCOERCION IN MENTAL HEALTH CAREL. KjellinPsychiatric Research Centre, Örebro, SwedenCoercion in psychiatric care has been subjected to an increasinginternational research interest during the last decades. In the firststudies, formally legally involuntarily admitted patients were regardedas exposed to coercive measures, while formally legally voluntarilyadmitted patients were not. Legally committed and voluntary patientswere compared with regard to socio-demographic and clinical characteristics.Great variations in civil commitment rates were foundbetween countries, as well as between regions within jurisdictionswith the same mental health legislation. In later studies, a wider conceptof coercion has been used, since several studies had shown alack of congruence between the formal legal status of the patients andthe patients’ perceptions of being coerced to admission and exposedto coercive measures during care. Instruments to assess perceivedcoercion have been developed, and perceived coercion has beenstudied. Ethical conflicts in the use of coercion from the perspectivesof different actors involved have been studied empirically, the situationof the patients’ relatives has been given attention as well as experiencesand attitudes of staff and people in the community. Ongoingstudies focus on international comparisons of civil commitment legislation,the use of coercive measures, perceived coercion in psychiatricinpatient care and pressures to adhere to outpatient treatment, as wellas on the outcome of coercive care. However, knowledge is still missingregarding under what conditions and in what way the use of coercionin psychiatric care may produce a more positive outcome of carethan if coercion had not been used.WO8.2.CIVIL DETENTION AND FORENSIC PLACEMENTOR TREATMENT LEGISLATION FOR MENTALLYILL – ARE THERE COMMON APPROACHES INTHE EUROPEAN UNION?H.J. Salize, H. DressingCentral Institute of Mental Health, Mannheim, GermanyTwo recent European Commission-funded studies analysed the legalframeworks for compulsory admission of mentally ill persons (civildetention) as well as for the placement and treatment of mentally illoffenders across the former 15 European Union (EU) Member States.Major results from both studies will be presented. Rules and regulationsfor civil detention as well as the actual practice in caring formentally ill patients on an involuntary basis differ widely across theEU Member States. Time series on civil detention quotes or rateswhich could be assessed for most of the 15 Member States confirm awide variety (e.g. ranging in 2000 from 218 involuntary placed mentallyill per 100,000 population in Finland down to 6 per 100,000 populationin Portugal) and suggest that differing legal traditions, nationalmental health care systems or other factors determine strongly thecurrent practice. The legislation in the field of placement and treatmentof mentally ill offenders, which in some Member States partlyoverlaps civil detention law, is similarly divergent, constituting amajor obstacle for a future European harmonization to overcome.WO8.3.MANDATED COMMUNITY TREATMENT IN THEUNITED STATESJ. MonahanSchool of Law, University of Virginia, Charlottesville, VI, USAA growing array of legal tools is being used to mandate adherence tomental health treatment in American community settings. In thesocial welfare system, benefits disbursed by money managers and theprovision of subsidized housing have both been used as leverage toassure treatment adherence. Similarly, in the judicial system, adherenceto mental health treatment may be made a condition of probation,and favorable disposition of a criminal case by a newly-createdmental health court may be tied to treatment participation. In addition,under outpatient commitment statutes, judges have the authorityto order patients to comply with treatment in the community. Inresponse to these uses of leverage, a patient may attempt to maximizepersonal control over treatment in the event of later deterioration byexecuting an advance directive that specifies his or her treatment preferences.In this presentation, the Director of the MacArthur Foundation’sResearch Network on Mandated Community Treatment willpresent the first data from a five-site study of 1,000 patients on howoften given forms of leverage - singly or in combination - are imposedon people with mental disorder to get them to adhere to treatment inthe community.WO8.4.FIRST RESULTS ON LEGALLY INVOLUNTARILYADMITTED PATIENTS IN 12 EUROPEAN STUDYCENTRES PARTICIPATING IN THE EUNOMIAPROJECTT.W. Kallert, and the EUNOMIA study groupDepartment of Psychiatry and Psychotherapy, Universityof Technology, Dresden, GermanyPrevious (mostly national) research has shown significant variation ofdifferent aspects of coercive treatment measures. Therefore, clinicalpractise and outcome of these measures should be assessed at aninternational level facilitating cross-national comparisons. This is thegeneral research objective of the European Commission-fundedongoing EUNOMIA project, whose naturalistic and epidemiologicalstudy design has been implemented in 12 regions in 12 Europeancountries. Using a standardized battery of instruments (e.g. coveringpsychopathology, perceived coercion, satisfaction with treatment,quality of life), each centre assesses two groups of patients for a threemonthfollow-up period (time-points of assessments: within the firstweek after hospital admission, 4 weeks and 3 months after hospitaladmission): legally involuntarily admitted patients (aimed at figure ofcomplete cases in each centre: n=140) and legally voluntarily admittedpatients who – according to a screening procedure – feel coercedto admission (aimed at figure in each centre: n=40). This preliminaryanalysis will include the subgroup constituted in the first 12 monthsof the recruitment period (ca. 800 – 1000 patients) and focus on theinitial assessment of these patients (within the first week after hospitaladmission) covering their socio-demographic and clinical characteristics,legal status, perceived coercion and satisfaction with treatment.The results will be embedded in standardized information onthe organization of mental health care in the participating catchmentareas. In particular, consequences for the clinical practice of involuntaryhospital admissions across Europe will be demonstrated.123

WO8.5.CULTURES OF PSYCHIATRY AND THEPROFESSIONAL SOCIALIZATION PROCESS:THE CASE OF CONTAINMENT METHODS FORDISTURBED PATIENTSL. BowersSt. Bartholomew School of Nursing and Midwifery,City University, London, UKAcute mental disorder necessitating admission to hospital is oftenaccompanied by disturbed behaviour that threatens the health of theperson concerned or that of those around them. A range of containmentmethods are used by psychiatric professionals to keep patientsand staff safe. These strategies are strongly emotive and attract strongmoral valuations, yet differ sharply between countries. This paperreports a study to investigate the relationship between attitudes tothese containment methods, and exposure to psychiatric educationand practice. It was hypothesized that the culture of psychiatry in thestudy country would socialise students' views towards the locallydominant pattern of relative evaluations. Nine cohorts of student psychiatricnurses at different stages of their training at one UK Universitywere asked to complete ratings on 11 containment methods. Containmentmethods fell into five groups, with mechanical restraint andnet beds attracting the most severe disapproval. Neither the relativeevaluation of methods, nor the intensity of those evaluations,changed systematically with duration of training. The findings supportthe interpretation that the relative evaluations of psychiatric containmentmethods are a property of wider national cultures, ratherthan an isolated tradition of professional psychiatric practice.WO9.RECENT ADVANCES IN BRAIN IMAGINGOF DRUG ABUSEWO9.1.MAGNETIC RESONANCE SPECTROSCOPYSTUDIES OF COCAINE DEPENDENCE:IMPLICATIONS FOR NEUROBIOLOGYAND TREATMENTP.F. Renshaw, C.C. Streeter, Y. Ke, D.P. Olson, E.D. Rouse, L.E.Nassar, D.A. Ciraulo, S.E. LukasBrain Imaging Center, McLean Hospital, Harvard MedicalSchool, Belmont, MA, USAMagnetic resonance spectroscopy (MRS) provides a non-invasivewindow on human brain chemistry. Over the last five years, we havecompleted several hydrogen (proton, 1H) and phosphorus (31P)MRS studies of cocaine dependent (CD) subjects. Using 1H MRS, wehave demonstrated that there are no reductions in the neuronal markerN-acetylaspartate (NAA) in CD but that there are changes in thetransverse relaxation time (T2) of NAA in frontal cortex. This reductionin T2, which tends to normalize with treatment, is most consistentwith a reduction in neuronal volume and may reflect changes indopaminergic transmission as dopamine is a critical modulator ofNa/K ATPase activity. We have also noted 15-20% reductions infrontal lobe GABA levels. GABA levels are elevated in CD subjectswho are treated with adjunctive pharmacotherapy. Using 31P MRS,we have demonstrated increases in brain phosphomonoesters (PME;phospholipids precursors) and decreases in brain nucleoside triphosphates(beta-NTP; primarily adenosine triphosphate) in CD subjects.Based on these observations of stimulant-induced alterations in brainchemistry, we have completed preliminary studies on the efficacy ofcytidine diphosphocholine (CDP-choline) as a potential treatmentfor CD. CDP-choline administration stimulates phospholipid synthesis.Initial clinical trials suggest that CDP-choline can reduce not onlycocaine use, but also nicotine, alcohol, and marijuana use in CD subjectsduring early abstinence.WO9.2.FUNCTIONAL MAGNETIC RESONANCE IMAGINGAND DIFFUSION TENSOR IMAGING IN COCAINEDEPENDENCEJ.L. Steinberg 1 , F.G. Moeller 1 , K.M. Hasan 1 , P.A. Narayana 2 ,D.M. Dougherty 1 , L. Kramer 2 , P.F. Renshaw 31 Department of Psychiatry and Behavioral Sciences, Universityof Texas Health Science Center, Houston, TX; 2 Department ofRadiology, University of Texas Health Science Center, Houston,TX; 3 McLean Hospital and Harvard Medical School, Boston, MA,USAPrevious studies report changes in brain function and structure incocaine-dependent individuals compared with healthy controls usingpositron emission tomography (PET), single photon emission computedtomography (SPECT), and structural magnetic resonanceimaging (MRI). Functional magnetic resonance imaging (fMRI) is awidely accepted technique to measure brain function that few studieshave used to date to compare cocaine dependent subjects and nondrugusing controls. In the present study, subjects with currentcocaine dependence were compared to non-drug using controls onblood oxygen level dependent (BOLD) fMRI activation while performinga delayed matching to sample task (Delayed Memory Task,DMT), relative to a continuous performance baseline (ImmediateMemory Task, IMT). Subjects also underwent diffusion tensor imaging,from which a measurement of fractional anisotropy (FA) can becalculated that provides information regarding neuronal white mattertract integrity in the brain. In a preliminary analysis, cocaine dependentsubjects showed differences in BOLD activation compared tocontrols in the prefrontal cortex, and differences in FA. Results ofthese studies will be discussed in light of what is known about FA andthe BOLD effect in relation to cocaine dependence.WO9.3.CORTICAL CHANGES AFTER A 28-DAYWASHOUT PERIOD IN CHRONIC MARIJUANASMOKERS: A BOLD fMRI STUDYD.A. Yurgelun-Todd, S.A. Gruber, J. Rogowska, H.G. Pope Jr.Cognitive Neuroimaging Laboratory, McLean Hospital,Belmont, MA, USATo examine the underlying neurobiological substrates related to marijuanasmoking and abstinence, we measured relative changes in corticalactivation using blood oxygen level dependent (BOLD) magneticresonance imaging (MRI) techniques on twelve current, long-termadult marijuana users before and after a supervised 28-day abstinenceperiod. Imaging data was also acquired in 12 healthy comparison subjects.Marijuana smokers were scanned on days 1 and 28 of the studyusing a 1.5 Tesla scanner retrofitted with a whole body echo-planarcoil and a quadrature head coil. A combined protocol, applying conventionalMRI and functional MRI, was used to assess changes incortical signal intensity. BOLD images were acquired every three secondsusing a gradient echo pulse sequence (TE = 40 msec, flip angle= 75 deg.). Subjects completed three subtests of the Stroop ColorWord Test while being scanned. Compared to control subjects, smok-124 World Psychiatry 3:S1 - October 2004

ers demonstrated decreased anterior cingulate activation andincreased dorsolateral prefrontal activation during the interferencetask at Day 1. At Day 28, smokers continued to display reduced activationin the anterior cingulate, although activation in the dorsolateralprefrontal cortex approached levels similar to control subjects.These findings are consistent with the hypothesis that, in some subjectswith a history of chronic heavy marijuana use, there is an alterationof frontal cortical function associated with attentional processingability. Moreover, our results indicate that changes in BOLD signalin heavy marijuana smokers extend beyond an acute washoutphase, raising the possibility that functional deficits are the result ofeither neurodevelopmental or neurotoxic effects.Supported by NIDA grants DA12483 and DA10346.WO9.4.SEROTONIN, IMPULSIVITY, AND FUNCTIONALMAGNETIC RESONANCE IMAGING IN ECSTASYABUSEF.G. Moeller 1 , J.L. Steinberg 1 , P.A. Narayana 2 , D.M. Dougherty 1 ,L. Kramer 2 , P.F. Renshaw 31 Department of Psychiatry and Behavioral Sciences, Universityof Texas Health Science Center, Houston, TX; 2 Department ofRadiology, University of Texas Health Science Center, Houston,TX; 3 McLean Hospital and Harvard Medical School, Boston,MA, USAMethylene-dioxymethamphetamine (MDMA) is known to causedegeneration of serotonin nerve terminals after acute doses in animals,and behavioral studies in human MDMA users regularly findabnormalities in memory, mood, and impulse control. The purpose ofthis study was to determine whether individuals with a self-reportedhistory of MDMA use would differ from non-MDMA using controlson blood oxygen level dependent (BOLD) functional magnetic resonanceimaging (fMRI) activation while performing a working memorytask. Fifteen MDMA using subjects and 19 non-MDMA using controlsunderwent an fMRI scan while performing the immediate anddelayed memory task (IMT/DMT). The study was a block design inwhich the Delayed Memory Task (DMT) alternated with the ImmediateMemory Task (IMT), which served as a control condition. Randomeffects SPM99 analysis showed a significant increase in activationon fMRI in the MDMA subjects compared to the control subjectsin the medial superior frontal gyrus in vicinity of Broadman’s areas9,10, the pulvinar in the thalamus extending into putamen, and thehippocampus. These results will be discussed in light of behavioralproblems which have been found in MDMA users, such as increasedimpulsivity and memory impairments.WO10.SUCCESSFUL IMPLEMENTATION OFEVIDENCE-BASED FAMILY TREATMENT FORMENTAL DISORDERSWO10.1.EVIDENCE-BASED FAMILY TREATMENT INPRACTICE: THE AGONY AND THE ECSTASYI.R.H. FalloonUniversity of Auckland, New Zealandprovide more than brief education, mainly focused on pharmacotherapy.An international collaborative group, the Optimal Treatment Project(OTP), has been developed to promote the routine use of evidence-basedstrategies for mental disorders. A field trial was started toevaluate the benefits and costs of applying evidence-based biomedicaland psychosocial strategies for schizophrenic and other major disordersover a 5-year period. The cognitive-behavioural family approachhas been a core component of this project. More than 80 centres haveattempted to implement these methods in more than 20 countries.Unfortunately all but 13 centres either failed to complete the initialphase of the implementation programme, or abandoned the projectwithin two years. The main feature that distinguished successfulimplementation was assertive and committed management that consideredevidence-based approaches as the basis for all treatment andensured that continued supervision and quality improvement auditsand annual training updates were conducted routinely within the services.More recent developments of consumer guidebooks have facilitatedthe training and fidelity of application of these methods. Preliminaryresults will be presented that suggest that the continued applicationof these methods may have a major impact on the rates of clinicaland social recovery of schizophrenic disorders, particularly in thosecases who have received family-based treatment from their firstepisodes.WO10.2.FAMILY INTERVENTION IN SEVERE PSYCHIATRICDISORDERS: RECENT OUTCOMES, NEW MODELSAND FUTURE PROSPECTSW.R. McFarlaneCenter for Psychiatric Research, University of Vermont,Burlington, VT, USAFamily interventions that are based on educational principles haveemerged as a front-line indicated treatment for schizophrenia andother major psychiatric disorders. Over twenty controlled clinical trialsof long-term treatment have documented an unprecedented consistencyand scale of effectiveness. The effect sizes achieved are equivalentto those for antipsychotic medication: relapse risk and intensivehospital care is reduced by at least 50% in almost all studies to date.Psychoeducational family treatments are one of the most cost-effectivetreatments in psychiatry. Yet, this approach is still relativelyunknown and not applied in routine practice in the US. We reviewthe evidence that underlies this new status, focusing mainly on newapplications and promising outcomes. Outcomes from new studiesand especially those showing greatly improved outcomes in employment,social functioning and family health and well-being are presented.In particular, methods for combining family psychoeducationwith evidence-based practices, such as supported employment andassertive community treatment, are described and illustrated withnew evidence for effectiveness. Also included are brief descriptionsand outcomes for new versions for bipolar disorder and major depression.The more comprehensive applications of family strategiesappear to have advantages over those that have focused only on anarrow range of select cases, and have been poorly integrated withinthe mainstream services.Despite strong scientific support for the routine implementation of“evidence-based” cognitive-behavioural family strategies, few services125

WO10.3.FAMILIES AS PARTNERS IN MENTAL HEALTHSERVICESR. RonconeDepartment of Psychiatry, University of L’Aquila, ItalyTraining courses, controlled research trials and implementation projectshave been conducted for more than ten years throughout Italy.More recently cognitive-behavioural family approaches have beenincluded in many University training programmes for psychiatrists,psychologists, rehabilitation technicians, social workers, and morerecently for nurses. The University of L’Aquila and the University ofNaples SUN have been the two centres that have contributed substantiallyto this important development. One important factor in thedevelopment and maintenance of family treatment strategies is thesupport of local family associations and consumer groups. A successfulexperience was conducted in Molise, a region of CentralItaly: a one-year psychoeducational intervention training thatincluded members of the local family association as well as professionalsfrom the mental health services. Relatives expressed greatsatisfaction with the training and their own application of the interventions.They reported improved quality of life and enhanced abilityin achieving their individual goals, as well as improved interpersonalcommunication skills and problem-solving abilities. Theyestablished a better relationship with the mental professionals andthey were able to collaborate with them in the planning of innovativerehabilitation services and other developments, e.g. organization ofa congress, creation of a cooperative work programme and developinga sheltered work laboratory. It is apparent that the flexibility oftreatment that is possible when the interventions are conducted notonly in “experimental” protocols and research settings may providebetter engagement and cooperation with families and possibly betterclinical and social outcomes.WO10.4.NEVER GIVE UP! PERSISTENCE IN THE FACEOF OBSTACLES TO THE IMPLEMENTATION OFFAMILY WORKG. FaddenUniversity of Birmingham, Birmingham and Solihull MentalHealth Trust, UKThe focus in recent years in relation to family interventions is toensure their implementation in routine services. Various obstacleshave been identified consistently, including lack of management support,service systems that do not facilitate the provision of family-sensitiveservices, lack of training for staff, attitudes of clinicians andheavy workloads. Faced with such a wide range of diverse obstacles,a similarly wide range of imaginative strategies must be employed inorder to progress the implementation of family work. These includepolicy, training, and strategies aimed at organisational change. Oftenthese strategies have to be repeated over time as key individualschange and move into different roles. The author will draw on experiencesfrom a large-scale programme, which has been underwaysince 1997 in the West Midlands of England, called the Meriden Programme.It covers a population of 5 million. It has two main components.The first element is staff training, with 1,500 therapists havingbeen trained to work with families since its inception. The second elementis employing a range of strategies to bring about organisationalchange, including training for managers, integrating family work intoexisting policies, and ensuring that audit and performance managementstrategies are in place to ensure implementation in practice.Four key strategies emerge as being significant: persistence; establishingclose and trusting relationships with managers; identifying championsat local level; and working closely with carer and family organisations.Of these, persistence and recognising that change takes timeis probably the most important. This presentation addresses the issueof how those charged with ensuring the implementation of familywork can persist in the face of opposition and disappointment, andcan continue to come back ‘to fight another day’.WO11.SUICIDE PREVENTION IN MAJOR PSYCHOSES:RISK FACTORS AND ROLE OF LONG-TERMTREATMENTWO11.1.CAN GENETIC FACTORS PREDICT SUICIDALBEHAVIOR IN MAJOR PSYCHOSES?J. MendlewiczDepartment of Psychiatry, Erasme Hospital, Brussels, BelgiumSuicide remains a major public health challenge. Worldwide, nearlyone million people die of suicide each year. Suicide accounts forabout 10% of deaths among psychiatric patients and up to 15%among bipolar patients. Besides the diagnosis itself, different environmentalrisk factors have been identified, including age, gender, lifeevents, climate and societal attitudes. These factors could explain, inpart, wide national and regional variations in the rate of suicide andsuicidal attempts. It has been demonstrated for decades, in familial,twin and adoption studies, that suicide may cluster in families, suggestinga genetic vulnerability in the occurrence of suicidal behavior.In particular, different studies involved a familial pattern in violentsuicide behavior. This observation is consistent with several neurobiologystudies showing a specific biological pattern in violent suicidebehavior, including a hypothalamo-pituitary axis hyperactivity and alow serotonergic activity, independent of underlying psychiatric diagnosis.Recent progress in molecular genetics and genomics has identifiedpromising candidate genes possibly linked to suicidal behavior.Genes from the serotonergic pathway have been targeted in case-controlassociation studies. Tryptophan hydroxylase (TPH) gene, codingfor the rate-limiting enzyme in the synthesis of serotonin, and serotonintransporter (5-HTT) gene have been largely studied and showedassociation with violent suicide attempt in different reports. Conflictingresults have been found with monoamine oxidase gene and serotoninreceptor genes. More recent studies have focused on the linkbetween genetics and aggression, impulsivity and borderline personalitydisorder. These traits have been related to a higher rate of suicidalbehavior and suicide attempt but also to a low serotonergic activity,as demonstrated by a 5-hydroxyindolacetic acid (5HIAA, mainserotonin metabolite) decrease in cerebrospinal fluid. It becomes thusmore and more obvious that suicidal behavior is related to a constellationof biological, including genetic, environmental but also personalityfactors. It could be hypothesized that a serotonergic geneticdysfunction might lead to low cerebral serotonergic activity, underlyingpersonality and temperament characteristics, predictors of futurepotential suicidal behavior. Further studies are needed to elucidatethe direct or indirect links between neurobiological disturbances,temperament traits and suicidal behavior, in order to comprehend thevulnerability factors of this complex behavior and to early detecthigh-risk patients.126 World Psychiatry 3:S1 - October 2004

WO11.2.PSYCHOTIC SYMPTOMS AND SUICIDAL BEHAVIORIN MAJOR PSYCHOSESH.-J. MöllerPsychiatric Department, University of Munich, GermanyIt is well known that functional psychiatric disorders are one of themain causes of suicidal behavior. Epidemiology and risk factors forsuicidal behavior in functional disorders as well as prevention strategieswill be presented. For example, about 60-70% of patient withacute depression experience suicidal ideas. There is a high incidenceof suicide (10-15%) in depressive patients. There are some predictorsof the risk of suicide, among others the severity of depression, a familyhistory of suicide behavior, a high score in the hopelessness scale.The complex causation of suicidality has to be borne in mind whenconsidering methods of suicide prevention. In order to obtain the bestresults, psychosocial, psychotherapeutic and psychopharmacologicalapproaches should be combined, depending on the risk factors ofeach individual patient.WO11.3.DEPRESSION, COGNITIVE DETERIORATIONAND SUICIDAL BEHAVIOR IN THE ELDERLYP.H. Robert, M. Benoit, E. Caci, E. MichelCentre Mémoire de Ressources et de Recherche, Université deNice-Sophia Antipolis, Nice, FranceDepression and more specifically depressive symptoms are the mostcommon mental health problem of later life. Apathy is not depression,but the two types of symptoms can commonly co-occur. Apathy,defined as a lack of motivation, is also very frequent in elderly subjectswith mild cognitive disorders, Alzheimer’s disease and relateddisorders. Even if not all older depressed patients are suicidal, thegreat majority of older patients who report suicidal ideation or whocommit suicide experienced depression. This is an important informationbecause, among adults who attempt suicide, the elderly aremost likely to die as a result. This paper will stress the relationbetween the cognitive, behavioral, and emotional aspects of the problemin order to give some therapeutic recommendation.WO11.4.IS DURATION OF UNTREATED PSYCHOSISA RISK FACTOR FOR SUICIDE ATTEMPTS INSCHIZOPHRENIA?A.C. Altamura, R. Bassetti, E. MundoChair of Psychiatry, Department of Clinical Sciences Luigi Sacco,University of Milan, ItalyThe duration of untreated psychosis (DUP) has been considered oneof the major outcome determinants in schizophrenia, particularlybecause the latency between the onset of psychotic symptoms and thefirst antipsychotic treatment is a potentially modifiable factor. Resultsfrom previous studies associated a longer DUP to a worse outcome,but to our knowledge no studies were performed to investigate theeffect of DUP in influencing suicidal behavior. In this retrospectivestudy we investigated the possible association between different clinicalvariables, including DUP, and suicidal behavior in a sample of103 chronic schizophrenic or schizoaffective disorder patients. Thesample was subdivided in two subsamples according to the presence/absenceof suicidal attempts lifetime. The main demographicand clinical variables were analyzed and compared between the twogroups. Interestingly, we found a significant association between aDUP ≥ 1 year and the presence of suicide attempts (p

in GABAergic neurons of post mortem brains of patients with schizophreniaand bipolar disorder with psychosis is firmly established.We have shown that methionine injection into mice decreases reelinexpression through a mechanism that likely involves methylation ofthe Reln promoter. Among DNA methyltransferases (Dnmt), Dnmt1is highly expressed in post-mitotic neurons. Along with reducedexpression of Reln, Dnmt1 mRNA is increased in GABAergic neuronsof the prefrontal cortex of patients with schizophrenia. This suggeststhe possibility that Dnmt1 may possess functions in regulatingDNA methylation patterns in post-mitotic neurons. To examine thisin more detail, we are using a mouse cortical interneuron preparation.We have used an antisense oligonucleotide to block Dnmt1 mRNAexpression and translation in these cortical neuron cultures. Dnmt1antisense transfection is accompanied by an increase in Reln mRNAand an attenuation of the methionine-induced down-regulation. Ourfindings are consistent with the hypothesis that one target of Dnmt1may be the reelin promoter. This is likely related to a change in promotermethylation or to the recruitment of co-repressors to thisregion by Dnmt1. Recently, we have been able to show site selectiveincreases in methylation of cytosines in the Reln promoter in genomicDNA isolated from patients, indicating that the down-regulation ofgenes in GABAergic neurons of schizophrenia brain may be the resultof promoter hypermethylation.WO12.3.THE CLINICAL EFFECTS OF ANXIOLYTICS ANDMOOD STABILIZERS ON SCHIZOPHRENIAJ. Davis, E. Costa, A. Guidotti, D.R. GraysonDepartment of Psychiatry, Psychiatric Institute, Universityof Illinois at Chicago, IL, USAThe dominant transmitters postulated to be involved in the therapeuticaction of antipsychotics are dopamine and serotonin. The neuropathologicalevidence indicates that a GABAergic defect is presentin schizophrenia. Anxiolytics or mood stabilizers effect GABAergicmechanisms directly or indirectly through epigenetic control via genesilencing mechanisms. Therefore, it is pertinent to examine their clinicalefficacy. Drugs with these mechanisms may also aggravate schizophrenia.We will present a systematic review and meta-analysis ofthe efficacy or negative effects of benzodiazepines, other minor tranquilizers,and the mood stabilizers as treatment for schizophreniaboth as monotherapy and in augmentation. We will integrate thisclinical evidence with what is known about the biology of schizophreniathrough postmortem studies and what is known about themechanism of action of the benzodiazepines and mood stabilizers.WO12.4.SIMILARITIES AND DIFFERENCES IN NEURALCIRCUITRY CHANGES IN THE LIMBIC LOBE OFSCHIZOPHRENIC AND BIPOLAR SUBJECTSF.M. Benes, R. Burke, J. Walsh, S. Berretta, D. Masilovich,M. MinnsProgram in Structural and Molecular Neuroscience, McLeanHospital, Belmont, MA; Program in Neuroscience andDepartment of Psychiatry, Harvard Medical School, Boston,MA, USAA compilation of results from postmortem studies of the anterior cingulatecortex over the past 12 years revealed both similarities and differenceswhen schizophrenic and bipolar groups have been compared.For markers of the GABA system, there is a great deal of overlapin the findings for the two patient groups when compared to normalcontrols. On the other hand, results obtained from analyses of theglutamate system and apoptosis have suggested that intracellular signalingand metabolic pathways may behave differently in schizophrenicand bipolar subjects. Taken together, these results are consistentwith a “two factor model” of psychotic disorders in which environmentalfactors common to schizophrenia and bipolar disordermay affect the GABA system, while specific susceptibility gene(s) forthe respective diagnostic groups may be reflected in the differencesobserved for the regulation of apoptotic cascades. Overall, these findingsraise the possibility that the development of novel pharmacologictreatments that are uniquely effective in the treatment of schizophrenicversus bipolar disorder may find a basis in the transcriptionalregulation of complex intracellular signaling that mediate theresponse to oxidative stress.Supported by MH00423, MH42261, MH62822 and MH60450.WO12.5.IMIDAZENIL, AN IDEAL PHARMACOLOGICALPROFILE FOR AN ANTIPSYCHOTIC DRUGA. Guidotti, E. CostaDepartment of Psychiatry, University of Illinois at Chicago,IL, USAGABAergic inhibition is increasingly considered one of the mostimportant factors in controlling the mode of operation of telencephalicglutamatergic pathways that are substrates for the regulationof complex brain function. It is now well established that schizophrenia(SZ) patients express a downregulation of telencephalic GABAergiccircuits. This GABAergic dysfunction may act as a vulnerabilityfactor in the etiopathogenesis of psychosis and may contribute to thecognitive/attention deficits and social withdrawal signs characteristicof SZ morbidity. As a general strategy, our studies on SZ are directedat testing whether drugs that normalize a deficient telencephalicGABAergic system may also be beneficial in correcting SZ symptomatology.To this end we are proposing the use of imidazenil, a newgeneration of benzodiazepine recognition site ligands, that is a partialagonist at alpha1 containing GABA-A receptors but acts as a full agonistspecifically at alpha5 subunit containing GABA-A receptors. Differentlyfrom the classically used benzodiazepines, imidazenil isdevoid of sedative and amnestic actions and of tolerance and dependenceliabilities. In rodent models of GABAergic deficiency, imidazenilameliorates anxiety, seizures, and behavioral defects (prepulse inhibitiondeficit, social interaction deficit) related to SZ without having adetrimental effect on attention, cognition, muscle tone and locomotoractivity. The unique pharmacological properties of imidazenil mayprove a superior efficacy of this drug over full allosteric modulatorssuch as diazepam, alprazolam or triazolam, which are sedative,amnestic and induce tolerance and dependence, in the treatment ofpsychosis.128 World Psychiatry 3:S1 - October 2004

WO13.INTERNATIONAL PERSPECTIVES ON MENTALHEALTH SERVICES FOR YOUTH IN PRISONWO13.1.QUALITY OF JUVENILE FORENSIC DIAGNOSTICASSESSMENT IN THE NETHERLANDSN. DuitsForensic Psychiatric Service, Juvenile Department, Ministryof Justice, Amsterdam, The NetherlandsJuvenile forensic diagnostic assessment and decisions of the court canhave far reaching consequences for juvenile delinquents and Dutchsociety. Improvement of quality and guidelines are therefore needed.Quality management is only possible if one has considered the conceptsof quality and the organizational framework of the juvenileforensic diagnostic system. In the Netherlands we developed a uniquequality framework for the juvenile forensic diagnostic assessment. Ithas typical ‘polder model’ characteristics, such as cooperation andnetworking with forensic partners. Organizational and practicalaspects will be presented in the light of the Dutch juvenile juridicalcontext. Empirical research stood at the basis of this unique qualityframework. The concept of quality has been investigated by means ofa concept mapping among ‘users’ and ‘makers’ of juvenile forensicdiagnostic assessment in the perspective of Dutch juvenile penal law.Methodology and results will be presented and consequences onquality management will be discussed.WO13.2.MEETING THE MENTAL HEALTH NEEDSOF “HARD TO REACH” YOUNG OFFENDERSS. BaileyBolton Salford and Trafford Mental Health NHS Trust,Manchester, UKWe discuss the development, validation and implementation of asemi-structured interview to help identify key mental health symptoms(SIFA) for all young people entering the Youth Justice System inEngland and Wales. Based on the Salford Needs Assessment Schedulefor Adolescents (SNASA), the screen covers alcohol misuse, substancemisuse, depressed mood, deliberate self-harm, anxiety symptoms,post traumatic stress problems, hallucinations, delusions andparanoid beliefs and hyperactivity. This screen has from November2003 been incorporated into the universal screening interview for allyoung offenders, carried out by all professionals working with thisgroup. We also introduce the Mental Health Provision for youngoffenders, a study of 300 young people in order to establish: a) thelevel of mental health needs among this population and b) the currentmodels and effectiveness of service delivery and the comparativeneeds of young offenders in the community and those in custody.Implications for practice parameters, service delivery and an integratedmultiagency approach to young offenders by health, education,social care and justice will be discussed in the context of long-termcosts to this group as they present to adult services in the future,bridging the transition of service delivery.WO13.3.PRACTICE PARAMETER FOR THE ASSESSMENTAND TREATMENT OF YOUTH IN JUVENILEDETENTION AND CORRECTIONAL FACILITIESC. ThomasUniversity of Texas Medical Branch, Galveston, TX, USAOver the past decade, the number of youth held in correctional facilitiesin the United States has grown considerably. Up to 75% of theseyouth have a diagnosable mental disorder according to some estimates,but many do not have adequate mental health services. Inaddition, psychiatrists providing treatment for these youth face a myriadof challenges and pitfalls: potential role conflicts; confidentialityissues; working with families, social services, law enforcement andcourts; negative perceptions of delinquents; and the complex, multipleneeds of these youth. In response to the lack of standards andguidance in addressing these problems, the American Academy ofChild and Adolescent Psychiatry developed a practice parameter concerningmental health services for youth held in correctional facilities.The parameter sets forth 14 specific recommendations on the organizationand delivery of mental health care, including initial evaluation,ongoing monitoring of mental health problems, assessment of violentor suicidal youth, and use of medications. Particular attention isfocused on the difficulties encountered in treatment planning andimplementation for these youth. The research on which the recommendationsare based, the process of creating the parameter and theimplications for policy and practice will be reviewed. The parameterwill serve as a guide to individual practitioners as well as a model forpolicy makers and leaders.WO13.4. EXAMINING THE EFFECTS OFMATERNAL INCARCERATIONT. GunterPsychiatry Research 2-204, University of Iowa, Iowa City,IA, USAWomen are entering prisons at unprecedented rates. The number ofwomen in prisons increased 500% from 1980 to 1999. In 1998 therewere 3.2 million arrests of women (22% of all arrests). Approximately950,000 women (1% of the adult female population) were undercorrectional supervision. With fewer diversionary programs availableto women, they are more likely to be confined than men with a similarcharge. The majority (78%) of women in state prisons are mothersand more women than men are custodial parents at the time of arrest.Over one million children are impacted by the incarceration of a parent.In addition to feeling abandoned, children of incarcerated mothersexperience changes in care providers, residence, and schools leavingthem vulnerable to social isolation, inattentiveness, and behavioraldifficulties. Once incarcerated, rehabilitation opportunities forwomen are meager compare to those available to incarcerated men.Women enter incarceration with more medical and mental healthproblems, and receive fewer services. The lack of equivalent employmentand educational programs in women’s prisons leaves womenunprepared to enter the work force upon release. Social services programmingin women’s prisons is limited and often does not addressimportant issues concerning family life. For example, when counselingand legal advice are available, a woman has a lesser chance ofautomatically re-entering an abusive relationship. We will describeissues unique to incarcerated women and their children, explicate theethical and legal issues related to maternal-child contact during incarceration,and will review model programming.129

WO14.EUROPEAN GUIDELINES ON PRIVACY ANDCONFIDENTIALITY IN HEALTHCAREWO14.1.TOWARDS EUROPEAN STANDARDS ONPRIVACY AND CONFIDENTIALITYR. McClellandQueen’s University, Belfast, UKThe need to safeguard the confidentiality of information thatpatients share with clinicians is as fundamental as the principle ofconsent. This issue has come to the fore in the context of the rapiddevelopments and applications of information and communicationtechnologies within society in general and within the health sectorin particular. In addition to the impact of new technologies, considerationalso needs to be given to the impact of changes in healthcare organisation and practice, for example multi-disciplinary andmulti-agency working. Mental health services are in many respectsat the vanguard of these changes where the ideals of communitycare, shared care and seamless care depend fundamentally on goodcommunication and information sharing. There is a tensionbetween the needs for patient information to optimise the quality ofcare and the expectation of patients that information about themwill be kept confidential. Confidentiality and privacy are also legalconcepts and the relationship between healthcare professionals andtheir patients carries with it legal obligations of confidence as wellas moral ones. In addition, doctors have a professional duty formaintaining confidence and the misuse of confidential medicalinformation is likely to be regarded as serious professional misconduct.Medical consultants have responsibility for the confidentialityof patient information and a vested interest therefore in both theculture and the processes, both human and technical, which ensurethe security of the information held on our patients. In this paperthe present ethical and legal framework will be reviewed and principlesfor good practice presented.WO14.2.IS THE DOCTOR ONLINE?HEALTH INFORMATICS AND RESPECTFOR CONFIDENTIALITY IN PSYCHIATRYE. MordiniCentre for Science, Society and Citizenship, Rome, ItalyThe rapid growth of computer-based information technology is transformingthe delivery of health care. Not only does the new technologyaffect clinical practices and the delivery of health services, but it alsoenables consumers to assume more responsibility for their own healthcare. This development represents a cultural change in psychiatry. Theimportance of electronically collecting, storing, analysing and usingpsychiatric information is undisputed. Patients need information tomake informed choices; psychiatrists need evidence to provide qualitycare; health systems need data to assess outcomes, control costs, andassure quality. Yet, while info technologies in psychiatry hold considerablepromise, they raise ethical concerns. How can we provide therequired data while at the same time protecting the privacy ofpatients? Unless a policy framework is developed, future developmentsand private investments in information technology will deepenthe conflict between individual privacy concerns and the need formore effective health care in psychiatry. Especially difficult debatesaccompany the use of unique identifiers to track the patients, the secondaryuses of health information and the so-called “function creep”,violation of security by authorised users and conflict of interest. Thefirst challenge we are going to face is thus to set the agenda for futurediscussion.WO14.3.VALUES-BASED PRACTICE (VBP)K.W.M. FulfordUniversity of Warwick, UKValues-based practice (VBP) is the theory and skills-base of balancedhealth care decision making for situations in which legitimately different(and hence potentially conflicting) values are “in play”. VBP issimilar to evidence-based practice (EBP) to the extent that both areresponses to complexity: EBP is a response to the growing complexityof the evidence bearing on clinical decisions; VBP is a response tothe growing complexity of the corresponding values. VBP differs fromthe dominant quasi-legal form of bio-ethics in emphasising theimportance of good process in clinical decision making rather thanseeking to prescribe right outcomes. This paper will explore VBP inrelation to confidentiality.WO15.COURT-ORDERED PSYCHIATRIC TREATMENTIN NEW YORK CITYWO15.1.OUTPATIENT COMMITMENT IN MANHATTAN:DIAGNOSIS AND HOSPITAL RECIDIVISMG.R. Collins, A.M. Kleiman, M. MageraManhattan Assisted Outpatient Treatment Program; Departmentof Psychiatry, Bellevue Hospital; Department of Psychiatry,New York University School of Medicine, New York, NY, USAThe purpose of this study was to evaluate the effectiveness of Manhattan’sAssisted Outpatient Treatment (AOT) program, an involuntaryoutpatient commitment program, in reducing number of hospitaladmissions, and total number of inpatient hospital days, from NewYork City’s mentally ill population, with a focus on the impact of psychiatricdiagnosis. The authors examined the first 46 clients alphabeticallycourt ordered in Manhattan under AOT. Of the forty completecharts, twenty one clients were diagnosed with schizophrenia, tenwith schizoaffective disorder, and nine with bipolar disorder. AOTclients, regardless of DSM-IV diagnosis, were significantly less likelyto be hospitalized and were hospitalized for significantly fewer daysin the year following AOT enrollment compared to the year prior toAOT enrollment. AOT was effective in patients with schizophrenia,schizoaffective disorder, and bipolar disorder. This initial study suggeststhat the court ordered AOT program was clinically beneficial toits clients, across a range of DSM-IV diagnoses.WO15.2.COURT-ORDERED TREATMENT FOR PSYCHIATRICPATIENTS: A NEW YORK LAWYER’S EXPERIENCEJ. CorrealeAssisted Outpatient Treatment Program, Bellevue HospitalCenter, New York, NY, USASection 9.60 of the New York State Mental Hygiene Law establishes aprocedure for obtaining court orders for assisted outpatient treatment(AOT) for those mentally ill individuals who meet certain criteria. The130 World Psychiatry 3:S1 - October 2004

statute, enacted in 1999, is commonly referred to as “Kendra’s Law” -named after Kendra Webdale, a woman pushed to her death in front ofa New York City subway by Andrew Goldstein, a mentally ill individualwho had deteriorated after failing to take prescribed psychiatricmedications. The law, amongst other things, calls for monitoring thoseindividuals who, like Andrew Goldstein, have a history of failing tocomply with outpatient treatment, becoming a danger to themselvesand/or others. The goal of the AOT program is to help keep thepatients, and members of the community, safe. At the same time, wehope that, through the intervention of structured services and monitoring,the patients will develop insight into their condition and needfor treatment, such that they can one day function safely in the communitywithout our assistance. Besides obvious benefits to the noncompliantpatient population, Kendra’s Law has provided benefits tothose physicians treating non-compliant patients. And, as the programgains momentum, physicians have, at least in the New York City area,become expected to refer their non-compliant and potentially dangerouspatients to the AOT program. The notion is that such referral willlikely lessen physician liability in the event a patient commits a violentaction toward himself or another. This presentation will share with theaudience the impact of AOT on the practice of psychiatry in New YorkCity. Court-ordered treatment in the context of medical malpracticeissues will, amongst other things, be discussed.WO15.3. MANHATTAN’S OUTPATIENTCOMMITMENT: PSYCHOPHARMACOLOGICALTRENDSG.R. Collins, A.M. Kleiman, M. MageraManhattan Assisted Outpatient Treatment Program; Departmentof Psychiatry, Bellevue Hospital; Department of Psychiatry,New York University School of Medicine, New York, NY, USAThe purpose of this study was to evaluate the most common psychopharmacologicalagents prescribed to mentally ill clients under anoutpatient commitment order in the Manhattan’s Assisted OutpatientTreatment (AOT) program. The authors randomly examined charts of50 clients receiving intensive psychiatric services under a court orderand calculated total numbers and proportion of medications prescribedby class and type. The largest proportion of AOT clients, 80%,were prescribed atypical antipsychotic medication. Traditionalantipsychotics were prescribed to 61% of clients, and decanoatepreparations were prescribed to 40% of clients. 59% of clientsreceived mood stabilizing medication. Antidepressants and anxiolyticswere prescribed to 8% and 3% of clients surveyed, and antiparkinsonianagents were prescribed in 39% of cases. Thus, the vast majorityof the client sample in an urban outpatient commitment programin New York City were prescribed antipsychotic medication, with asignificant number of clients being treated with mood stabilizing andantiparkinsonian agents.WO15.4.SUBSTANCE USE DISORDERS AND MANHATTAN’SASSISTED OUTPATIENT TREATMENT PROGRAMM. MageraManhattan Assisted Outpatient Treatment Program; Departmentof Psychiatry, Bellevue Hospital; Department of Psychiatry,New York University School of Medicine, New York, NY, USAThis study evaluates the effectiveness of outpatient commitment inreducing the frequency and duration of hospitalizations of chronicallymentally ill patients with and without co-morbid substance disorders.The authors examined a random sample of 48 clients treated inManhattan under an assisted outpatient treatment (AOT) order.Complete data for forty charts revealed twenty-two dually diagnosedclients and eighteen clients with a major Axis I disorder and no substance-relatedillness. Data for the year prior to and one year followinginitiation of court-mandated treatment indicated a substantialreduction in the number and duration of hospitalizations for bothgroups. A more pronounced decrease in overall frequency of hospitalizationsoccurred in those without a co-morbid substance disorder,while a greater decrease in the total number of hospital days wasfound among dually diagnosed clients. Further investigation willexplore the differential effectiveness of court-mandated treatment inboth groups.WO16.THE PREVALENCE OF MENTAL DISORDERSIN EUROPE AND ITALY: RESULTS OF THEEUROPEAN STUDY OF EPIDEMIOLOGY OF MENTALDISORDERS (ESEMeD)WO16.1. THE PREVALENCE OF MENTALDISORDERS IN EUROPE: RESULTS FROMTHE EUROPEAN STUDY OF EPIDEMIOLOGY OFMENTAL DISORDERS (ESEMeD)G. de GirolamoDepartment of Mental Health, Local Health Unit, Bologna, ItalyThe study aimed to assess the 12-month and lifetime prevalence ratesof mood, anxiety and alcohol disorders in six European countries. Arepresentative random sample of non-institutionalized inhabitantsfrom Belgium, France, Germany, Italy, the Netherlands and Spainaged 18 or older (n=21185) were interviewed between January 2001and July 2003. DSM-IV disorders were assessed by lay interviewersusing a revised version of the Composite International DiagnosticInterview (CIDI-2000). Fourteen percent reported a lifetime historyof any mood disorder, 13.7% any anxiety disorder, and 5.2% a lifetimehistory of any alcohol disorder. More than 6% reported any anxietydisorder, 4.3% any mood disorder, and 1.0% any alcohol disorderin the last year. Major depression and specific phobia were themost common individual mental disorders. Women were twice aslikely to suffer 12-month mood and anxiety disorders as men, whilemen were more likely to suffer alcohol abuse disorders. ESEMeD isthe first study to highlight the magnitude of mental disorders in thesix European countries studied. Psychiatric disorders were frequent,more common in female, younger, single, or divorced subjects, indicatingan early age of onset for mood, anxiety, and alcohol disorders.WO16.2.THE PREVALENCE OF MENTAL DISORDERS INITALY: RESULTS FROM THE EUROPEAN STUDYOF EPIDEMIOLOGY OF MENTAL DISORDERS(ESEMeD)P. Morosini 1 , G. de Girolamo 21 National Institute of Health, Rome; 2 Department of MentalHealth, Local Health Unit, Bologna, ItalyThis study aims to present 12-month and lifetime prevalence rates ofmood, anxiety and alcohol disorders in Italy. A representative randomsample of the general population of Italy, aged 18 or older(n=4712), was interviewed using a revised version of the CompositeInternational Diagnostic Interview (CIDI-2000). In the interviewedsample, about one in six met DSM-IV lifetime criteria for any mental131

disorder, while in the past year one in ten subjects met the same criteria.Eleven percent reported a lifetime history of any mood disorder,10.3% of any anxiety disorder, and 1.2% of any alcohol disorder. Inthe last year about 6% of the sample met criteria for any anxiety disorder,3.3% for any mood disorder, and 0.2% for any alcohol disorder.Major depression and specific phobia were the most commonindividual mental disorders. Women were respectively twice andthree times as likely to suffer from 12-month mood and anxiety disordersas compared to men, while men were more likely to suffer fromalcohol abuse disorders. Compared to other European countriesinvolved in the same project, Italian prevalence rates for any mentaldisorders were lower, and this finding is consistent with the few previousstudies realized in Italy. The ESEMeD is the first study whichhas evaluated the magnitude of mental disorders in Italy. Psychiatricdisorders were frequent, more common in female, younger, single,unemployed or housewives. Moreover, this study seems to confirmfor Italy a lower prevalence rate of any mental disorders as comparedto other European countries. The reasons of this lower prevalencerate warrant further investigations.WO16.3.USE OF MENTAL HEALTH SERVICES IN ITALY:RESULTS FROM THE EUROPEAN STUDY OFEPIDEMIOLOGY OF MENTAL DISORDERS (ESEMeD)G. Polidori, P. MorosiniNational Institute of Health, Rome, ItalyComprehensive information about access and patterns of use of mentalhealth services in Italy is lacking. We present data about the use ofhealth services for mental disorders in Italy drawn from the ESEMeDproject. Individuals aged 18 years and over who were not institutionalisedwere eligible for an in-home computer-assisted interview. The4,712 participants were asked to report how frequently they consultedformal health services due to their emotions or mental healthproblems, the type of professionals they consulted and the treatmentthey received as a result of their consultation in the previous year. Anaverage 3.0% of the total sample consulted formal health services inthe previous 12 months because of their mental health problems.Among those who met criteria for a mental disorder, the percentagerose to 17%; this proportion was higher for individuals with a mooddisorder (20.9%, 95% CI 14.3-27.4) than for those with anxiety disorders(17.5%, 95% CI 12.1-22.8). Among individuals with a mentaldisorder who had contacted any health services in the previous 12months, approximately half had contacted a mental health professional.Among those subjects with a 12-month mental disorder consultingformal health services, 14.9% received no treatment. TheESEMeD results suggest that the use of health services is limitedamong people with mental disorders in Italy. Moreover, rates of serviceuse are lower in Italy as compared to other European countriesinvolved in the ESEMeD project. The factors associated with this limitedaccess and their implications deserve further research.WO16.4.THE CLINICAL REAPPRAISAL STUDY IN THEEUROPEAN STUDY OF EPIDEMIOLOGY OF MENTALDISORDERS (ESEMeD)F. Mazzi, G.P. GuaraldiUniversity of Modena and Reggio Emilia, Modena, ItalyIn three of the countries involved in the ESEMeD project (France,Italy and Spain), a sub-sample of subjects assessed by the CompositeInternational Diagnostic Interview (CIDI) has been re-evaluatedwith the Structured Clinical Interview for DSM-IV (SCID) by experiencedclinicians. The clinical reappraisal study has two objectives:a) to calibrate the diagnostic thresholds in the CIDI and in the SCIDinterviews; and b) to assess the inter-rater reliability among SCIDinterviewers. In this presentation we report the data obtained in theItalian sample of re-interviewed subjects (n=192). The Cohen’skappa concordance values between the CIDI and the SCID are:major depression: 0.36 (C.I. 0.13-0.58); any mood disorder: 0.27(C.I. 0.07-0.47); panic disorder: 0.34 (C.I. 0.2-0.9): any anxiety disorder:0.5 (C.I. 0.33-0.66); any disorder: 0.39 (C.I. 0.23-0.54). Thesensitivity and specificity values are: major depression .33 and .96;any mood disorder .25 and .96; panic disorder .24 and .99; any anxietydisorder .48 and .95; any disorder .42 and .91. In general terms,CIDI interviews generally under-diagnosed milder forms of disorders.These preliminary data suggest that the CIDI generally underdiagnosesdisorders and can produce false negatives in milder casesof mental disorders.WO17.PSYCHIATRIC THERAPIES IN MOVIESWO17.1.HEALING MOVIESI. SenatoreDepartment of Neuroscience and Behavioural Sciences,University of Naples Federico II, Naples, ItalyHollywood cinema is one of surfaces and deceptions. It is a cinema ofstrong emotions, pregnant with blood, violence, fantastic and sweatysex. A cinema of those who do not shiver, do not stutter and neverstop before danger. A cinema made up of held back words, hiddensobs and tears in handkerchiefs. A cinema of denied love, of brokendreams and of whispers in silence. A regressive, placental and uterinecinema bringing us back in time. An introspective cinema (it makesus cry, laugh, become sad or cheerful) which leads us to reflect onwho we are and who we were. A cinema that makes us sick sufferingand hurting. A cinema of illusions and disillusions, a cinema for thosewho believe in stories told and imagined. A cinema that digs deepinto you and scratches your body and soul. A cinema that takes careof us. A cinema for those who want to nourish their eyes for thedreams of the night. A cinema that has sherazade as its ispiring muse.WO17.2.WHAT EUROPEAN MOVIES MAY TEACH ABOUTPSYCHIATRIC THERAPEUTIC RELATIONSHIPSR. Dalle LucheDepartment of Mental Health, Local Health Unit, Massaand Carrara, ItalyUnlike the majority of hollywoodian filmography, some high-qualitycontinental movies offer less conventional representations of deeppsychotherapeutic interactions. Some filmmakers are able intuitivelyto enlighten how the involvement of the therapists in the therapeuticprocesses, often outside well defined clinical settings, develops necessarilyinto a mutual transformation of both members of the relationship(the best example is Ingmar Bergman’s “Persona”, 1966). Inother cases the same processes are staged with more abstract,metaphorical or theatrical modalities, without any reference to psyinstitutions(a very recent example is Lars von Trier’s “Dogville”,2003). An Italian filmmaker, Marco Bellocchio, used both kinds ofrepresentations of psychotherapeutic processes in about ten of his132 World Psychiatry 3:S1 - October 2004

movies. These continental movies reveal strong links with some earlytwentieth century dramas (Strinberg, Cechov, Pirandello, Schnitzleretc.), as if they were a natural extension of them in the direction of an“inner (dreamed) world theatre”. In order to correctly understandwhat the filmmaker wants to say, a member of the audience who possessespsychopathologic and psychotherapeutic competences has todevelop specific interpretations which involve him/herself in thedynamic represented on the screen: he/she becomes part of themovie, being embraced in a sort of “hermeneutic circle” which mayincrease and improve his/her own professional abilities. Therefore aconfrontation with this high-quality European filmography may begreatly recommended for didactic and training purposes.WO17.3.PILLS OR WORDS?PSYCHIATRIC THERAPIES IN THE MOVIESE. Marchiori, M. De MariPsyche ad Image Association, Padova, ItalyPsychiatric disorders, therapies, therapists and their relationshipswith patients have been variously represented in movies, from thewell known “Spellbound” (Alfred Hitchcock, 1945) to the recent“The soul keeper” (Roberto Faenza, 2002). The authors emphasize,on one side, the risk of excessive simplifications, stereotypes or amusingeffects, and, on the other, how the movies can show in a realisticand convincing way the mental disorders and the different ways totreat them. This work offers a starting point for discussion about thevarious effects of this kind of representations on the audience.WO17.4.MOVIES: STIGMA; COMPLIANCE ANDNON-COMPLIANCE; PHARMACOPHILIA ANDPHARMACOPHOBIA IN PSYCHIATRIC THERAPIESV. VolterraSection on Arts, Movies and Mass Media of the ItalianPsychiatric Association, Bologna, ItalyPart of the “stigma” against psychiatry is related to the cruel andemarginating conditions of mental hospitals; the perverse, aggressive,sometimes criminal behaviour of some psychiatrists; and the dramaticand violent therapies sometimes implemented in the past. Theexasperated representation of such aspects in movies may rise thisstigma and generate suspicion and hostility in the general public,patients and their families about psychiatric therapies. This may contributeto produce non-compliance to psychiatric treatments or, onthe contrary, an excessive and incorrect pharmacophilia.WO18.THE ATYPICAL PSYCHOSES: FROMPSYCHOPATHOLOGY TO NEUROBIOLOGYWO18.1.THE CONCEPT OF ATYPICAL PSYCHOSES INVIEW OF DIFFERENTIATED PSYCHOPATHOLOGYE. FranzekDelta Bouman, Rotterdam, The NetherlandsThe concept of “atypical” psychoses dates from Kraepelin´s dichotomyand refers to endogenous psychoses which could be assigned neitherto schizophrenic psychoses nor to manic depressive illness dueto their atypical clinical pictures. Within the differentiated psychopathologyalong the lines of Karl Leonhard the problem of “atypical”psychoses was accommodated by the idea that there might be anindependent group of endogenous psychoses in addition to schizophreniasand manic-depressive illness, i.e. the cycloid psychoses.Main features of cycloid psychoses are a phasic remittent course withoutresidual states and a bipolarity of the polymorphous clinical syndromes,which occur in three characteristic subforms, the anxietyhappinesspsychosis, confusion psychosis and motility psychosis. Thecycloid psychoses have to be differentiated mainly from the unsystematicschizophrenias, which also show bipolarly structured polymorphousclinical syndromes, but run a progressive course with exacerbationsand incomplete remissions leading to residual states ofvarying degrees of severity. Clinical studies have shown that a reliableclinical differentiation of cycloid psychoses and unsystematic schizophreniasis possible if a comprehensive exploration is carried out by asufficiently trained examiner.WO18.2.THE GENETICS OF CYCLOID PSYCHOSES.RESULTS OF A CONTROLLED FAMILY ANDTWIN STUDYB. PfuhlmannDepartment of Psychiatry and Psychotherapy, Universityof Würzburg, GermanyCycloid psychoses represent a clinical category which can be reliablydifferentiated from schizophrenic and affective psychoses regardingsymptomatology and course. To further clarify aetiological and nosologicalquestions concerning cycloid psychoses, a controlled familystudy and a systematic twin study were undertaken. In the familystudy, all living and traceable adult first-degree relatives of 45 cycloidpsychotic, 32 manic-depressive and 27 control probands were personallyexamined by an experienced psychiatrist blind to the indexproband´s diagnosis. Information about not traceable relatives wasobtained by the family history method. Age-corrected morbidity riskswere calculated using the life-table method. Relatives of cycloid psychoticpatients showed a significantly lower morbidity risk ofendogenous psychoses than relatives of patients with manic-depressiveillness. The familial morbidity in cycloid psychoses, however, didnot differ significantly from the familial morbidity observed amongcontrols. In the twin study, 22 twin pairs with cycloid psychotic indextwins were systematically recruited in the psychiatric hospitals ofLower Franconia. After establishing the diagnoses of the respectiveco-twins by an independent experienced psychiatrist, concordancerates were compared. Pairwise as well as probandwise rates did notdiffer significantly between the 11 monozygotic and the 11 dizygoticpairs. In this regard the cycloid psychotic twins differed from twinswith unsystematic schizophrenias, who showed significantly higherconcordance rates among monozygotic pairs. Both studies suggest asubordinate role of hereditary influences in the aetiology of cycloidpsychoses. The results point out that cycloid psychoses have to bedistinguished from manic-depressive illness as well as from schizophrenicpsychoses regarding clinical genetic aspects, and that cycloidpsychoses therefore could be integrated neither into a spectrum ofschizophrenic psychoses nor into a spectrum of affective disorders.133

WO18.3.SCHIZOPHASIA: AN ATYPICAL PSYCHOSISWITH STRONG GENETIC BACKGROUNDB. JabsDepartment of Psychiatry and Psychotherapy, Universityof Würzburg, GermanyThe term schizophasia was used by Kraepelin for a psychosis withaccelerated and incoherent speech. Leonhard discovered the bipolarstructure of this disease, which he termed cataphasia, characterizingit as an unsystematic type of schizophrenia. He clarified the nature ofthe thought disorder as incoherent, with logical, semantical and syntacticalfaults. With the design of a controlled family study, we aimedto examine personally all living first degree relatives of 30 patientswith cataphasia. Therefore, a semistructured interview on their historywas used as well as a set of blindly analysed verbal tasks to detectformal thought disorder. We personally examined more than 70% ofthe living and accessible relatives. We found a very high risk for theserelatives for need of psychiatric treatment in the life-time course, ahigh risk for endogenous psychoses and considerable risk for cataphasia.Interestingly, some healthy relatives exhibited clear thoughtdisorder without other psychic or social disturbances. Upon theseresults, we can confirm the diagnostic validity of cataphasia, whichshows a substantial homologous familial loading, but a wide variabilityin course and severity of the disease. Thus, cataphasia might be aninteresting object for molecular genetics in the future.WO18.4.PERIODIC CATATONIA: AN ATYPICALSCHIZOPHRENIC SUBTYPE WITH A MAJORDISEASE LOCUS ON CHROMOSOME 15q15G. Stöber 1 , A. Ekici 2 , A. Reis 21 Department of Psychiatry and Psychotherapy, Universityof Würzburg; 2 Institute of Human Genetics, University ofErlangen, GermanyPeriodic catatonia is characterized by qualitative hyperkinetic andakinetic psychomotor disturbances through acute psychotic episodes,and debilitating psychomotor symptoms in the long term. In genomewidelinkage studies on multiplex pedigrees segregating for periodiccatatonia, we recently identified a major disease locus on chromosome15q15, and replicated the chromosomal locus in an independentset of pedigrees. The results satisfied Lander and Kruglyak’s rigorouscriteria for “significant and confirmed evidence for linkage”.Linkage and haplotype analysis in three exceptionally large pedigreeslinked to chromosome 15q15 disclosed an 11 cM critical regionbetween markers D15S1042 and D15S659. In our efforts in revealingthe disease gene we perform linkage disequilibrium mapping andhaplotype analyses in multiplex pedigrees and parent-offspring triosin new sets of microsatellite markers, and concurrently complete systematicmutation scans of candidate genes annotated in that region.The single nucleotide polymorphisms are included in ongoing linkage-disequilibriummapping and family-based and case-control associationstudies.WO19.EPIDEMIOLOGY, CLINICAL PICTURE ANDTREATMENT OF CHILDHOOD DEPRESSIONWO19.1.EPIDEMIOLOGY, CLINICAL PICTURE ANDTREATMENT OF CHILDHOOD DEPRESSIONH.I. EistMontgomery Child and Family Health Services Inc., Bethesda,MD, USACase reports on despondency in children date to the early 17th century.Melancholia was reported in the middle of the 19th century. A1970 meeting of European pedopsychiatrists concluded that childhooddepression represented a significant proportion of mental disordersin children and adolescents. In 1976 Eist reported on 248 consecutivechild and adolescent consultations done in a Washingtoninner city clinic. The incidence of depressive disorders was 15%. In1999 Harrington in the UK reported that 1 in 4 referrals to child psychiatristssuffer from depression. Epidemiological studies indicatethat both incidence and severity of childhood depression are increasingand that care is urgently required. Adult DSM-IV diagnostic criteriaapply to children and adolescents, though there are some differences.For example weight loss when not dieting can be an adultsymptom of major depression. This could be expressed in childhoodas a failure to thrive. Crying, whining, sulking and irritability arecommoner in children than in adolescents and adults, and somaticsymptoms are commoner in children. Suicide attempts are commonin children and are often violent. There is a high rate of nonfatal suicidalbehavior in children aged 6-12, with 1/2 of attempters makingmultiple attempts. While suicide ideation is common in depressedyoungsters, the frequency of attempts increases with age. There is astrong family history of major depression or other mood disorders infirst degree relatives of depressed children and adolescents. Twinstudies document a significant genetic element. Depression commonlyco-occurs with generalized anxiety disorder and childhood medicalconditions such as diabetes and rheumatoid arthritis. Generally, theyounger the age of onset, the worse the disorder. Biopsychosocialtreatments with early intervention and sufficient duration are criticalfor recovery and prevention across the life span. Treatment focuses onrelief of symptoms, prevention of suicide and the fostering of normaldevelopment. Given the long duration of depressive disorders, thehigh recurrence rates, the profound morbidity and high mortality,treatment must be of adequate duration and intensity. There is a highrisk of relapse with short term treatments, with potentially tragic consequences.Studies tracking selective serotonin reuptake inhibitorsusage in children and adolescents through the 1990s indicate that forevery 1% increase in the prescription of antidepressants there is a0.27% reduction in suicides.WO20.HOW TO ORGANIZE A SCIENTIFIC CONGRESSWO20.1.HOW TO ORGANIZE A SCIENTIFIC CONGRESSP. RuizDepartment of Psychiatry and Behavioral Sciences, Universityof Texas at Houston, TX, USAThe organization of scientific meetings such as congresses, conventions,conferences and annual meetings has become quite difficult134 World Psychiatry 3:S1 - October 2004

and challenging. This is particularly true for scientific meetings thatare directed to international and regional audiences. The globalizationprocess that has taken place in recent years has certainlyincreased the demands for global and international communicationprocesses, including scientific events. This situation, however, hasgreatly impacted the organization of these scientific events. Forinstance, scientific presentations need to be translated in several languages,the venue of these scientific events needs to offer airlinetransportation to several key cities and countries at a worldwide level,the official language of these scientific events sometimes is differentthan the native language, and the like. From a different point of view,the financial support from industry no longer comes from the local orregional representatives but from the international headquarters ofthese corporate organizations. Additionally, these types of mega-scientificmeetings often require the contractual services of a professionalcongress organizer (PCO). Undoubtedly, the current demands forthe organization of scientific meetings have become more complex.Moreover, the lack of skills and expertise in this respect can lead tofinancial disasters. Thus, as a service to the field, and particularly toWPA Member Societies and WPA Sections, the members of the WPAOperational Committee on Scientific Meetings are offering theirassistance to the organizers in the development of the necessary skillsand tools to successfully design and implement scientific congresses.WO20.2.THE ROLE OF THE PROFESSIONALCONGRESS ORGANIZERF.T. AntunWPA Zonal Representative, Zone 12, Beirut, LebanonIn the organization of scientific meetings, especially congresses, therole of the professional congress organizer (PCO) is a critical and significantone. In every scientific congress, the financial aspects areessential for the successful planning, design and operation of such anevent. In this respect, it is the PCO the one that provides the initialfinancial support that is required to start all the necessary activitiesrelated to the congress. Likewise, the PCO is the one that preparesthe congress’ budget and monitors all the revenues and expenses ofthe congress. Additionally, the PCO is the one that negotiates withindustry as a way of generating revenues for the congress. Besides, itis the PCO the one that assists the scientific committee with the processingof all the abstract proposals. At the end of the congress, thePCO is the one that prepares the final financial report and analysis ofthe congress. In this presentation all of the factors pertaining to thefunctions of the PCO will be addressed and fully discussed.WO20.3.THE EVALUATION PROCESS IN SCIENTIFICMEETINGSE. BelfortUniversidad Central de Venezuela, Caracas, VenezuelaThe number of psychiatric conferences, congresses and meetings isincreasing everywhere in the world, as well as the complexity of theirorganization. Better knowledge, expertise and technology are thereforerequired. A very important aspect is how to evaluate a meeting,in order to achieve all projected and expected objectives. In this context,we will address a series of evaluation features, including needsand gaps in the scientific program, gaps in the financial support andissues concerning continuing medical education. Various parametersare required, in a continuing process, to successfully plan and organizescientific meetings.WO20.4.THE ROLE OF THE SCIENTIFIC COMMITTEEM.I. López-IborDepartment of Psychiatry and Psychological Medicine,Faculty of Medicine, Complutense University of Madrid, SpainOne of the key factors in the organization of scientific meetings is therole and functions of the scientific committee. This committee is theone that plans and designs all scientific presentations and, thus, theentire scientific program of the meeting. In this respect, the success orfailure of a given congress depends in many ways on the successfulplanning and implementation of the scientific program. A scientificprogram is composed of a series of presentations with different formats.For instance, lectures, symposiums, workshops, posters,forums, satellite symposiums, plenaries, and others. Appropriate balanceamong all of these scientific formats is essential in every congress.Likewise, the selection of the faculty and/or presenters in everycongress is also crucial, as well as the balance of the topics selectedfor presentation. In many ways, the attendance and participation incongresses depend on the quality and balance of the scientific program.Similarly, the overall theme of the congress is also of majorimportance with respect to the goals and objectives being pursued forthis purpose. In this presentation, all of the aspects related to the roleand functions of the scientific committee in congresses will beaddressed and fully discussed.WO20.5.HOW TO ORGANIZE A CONGRESS - ROLE OFFELLOWSHIPSJ. RabochPsychiatric Department, First Medical School, Charles University,Prague, Czech RepublicMany WPA member societies have expressed interest in promotingthe professional development of their young members and in beingcentrally involved in WPA initiatives. WPA shares this view as thetop institutional commitment to the future of our field. In August1999 the WPA General Assembly established the Institutional Programto Promote the Professional Development of Young Psychiatrists(WPA-IPYP). Young psychiatrists in this context include psychiatristsin training and those less than 40 years of age or practicingless than five years since completion of residency training. Since theWorld Congress in Hamburg in 1999, the WPA has been running theWPA Congress Fellows Network to stimulate participation, personalcontacts and scientific contributions from young psychiatrists. Asthe first contact with a psychiatric congress will impact on the use ofcongresses by young psychiatrists in the future, it is essential that thisexperience be a good one. A well-prepared fellowship program isone of the possibilities. The executive committee of member societies,considering the regional economic and geographical aspects aswell as the professional career of the applicants, should do the selectionof candidates. It is necessary to raise adequate funds to be ableto cover travel expenses, unexpensive accommodation and the conferencefee. The program of participants should be as structured aspossible, including a get-together session before the opening of theconference, special scientific sessions, meetings with experts, socialevents, etc. A congress guide should be printed. Final evaluation ofthe program by the young psychiatrists is a valuable source of information.135

WO21.TREATMENTS IN PSYCHIATRY:YOUNGPSYCHIATRISTS' KNOWLEDGE AND ATTITUDESIN VARIOUS COUNTRIESWO21.1TRAINING IN PSYCHIATRIC TREATMENTS: THEAUSTRALASIAN EXPERIENCER. TannaFremantle Hospital and Health Service, Fremantle, AustraliaThe aim of this presentation is to give an overview of the structureand process of psychiatric training in Australasia taking a broadapproach to psychiatric treatments. Specifics of both basic andadvanced training are expanded upon, and the author uses his ownpath through training to illustrate the aimed acquisition of eclecticskills in specialisation. Australasian training in psychiatry aims atdevelopment of multimodal skills to treat mental health problems/illness,to decrease distress experienced by individuals, carers and communities,utilising a broad biopsychosociocultural model whichappreciates the diversity of each person’s experience. In basic training,trainees acquire skills to assess and manage a wide range of mentalhealth problems and illnesses in adult, child and adolescent, oldage, consultation-liaison and addiction psychiatry. Learning to implementtreatments using psychosocial and biomedical approaches isundertaken under a clear process of supervision. Additional experiencesinclude completion of a range of psychological therapies,involvement with carers, general practitioners, community organizationsand non-governmental organizations, and training in the specificneeds of a multicultural population, including indigenous peopleand communities. Examinations complete basic training after a minimumof 3 years. Advanced training involves 2 years of supervised subspecialtytraining with a greater emphasis on adult, self-directedlearning and processes used in continuous medical education.Mandatory experiences include psychological, biological, social andcultural aspects of management in psychiatry. In addition, traineesmust demonstrate development and experience in application of consultativeskills, leadership and management. Participation in anapproved ethical activity for each training year aims at a sophisticatedappreciation of the potential ethical complexities within psychiatrictreatments.WO21.2.NEW TREATMENTS IN PSYCHIATRY: A SURVEYFROM NON-EU EUROPEAN COUNTRIESA. Mihai 1 , A. Danyelan 2 , C. Damsa 31 University of Medicine and Pharmacy Tg. Mures, Romania;2 Association of Child Psychiatrists and Psychologists ofArmenia, Republic of Armenia, and Children’s Hospital MedicalCenter, Cincinnati, OH, USA; 3 Department of Psychiatry,University Hospital, Geneva, SwitzerlandBecause of huge political, social, economical and cultural differencesamong non-EU European countries, we believe that it is important tohave not only a continental overview of training in psychiatric treatments,but also to have some specific reports from different Europeancountries. We tried to receive and present information about psychiatrictreatment from these countries. We have developed and used aquestionnaire about the new treatments in psychiatry, and we havesent it to 50 psychiatrists from different non-EU countries. Wereceived data about treatments and prescriptions in some of the formerSoviet Union republics, such as Armenia, Moldavia and Belarus,and also in other non-EU countries like Romania, Albania, Croatia,Montenegro, Macedonia, Serbia, Turkey, Switzerland. We present acomparison among these countries, underlining the access to trainingin new therapeutic approaches. Moreover, we present some countryspecific reports; in particular, in the former Soviet Union republics,particularly in Armenia, many psychiatrists are still prescribing onlytricyclics and typical antipsychotics, since the patients cannot affordthe costs of selective serotonin reuptake inhibitors or of atypicals. Incountries closer to the border with EU, the governments are makingseveral efforts to support the implementation of these new treatmentsinto clinical practice.WO21.3.PSYCHIATRIC TRAINING AND PRACTICE:PERSPECTIVES OF YOUNG INDIAN PSYCHIATRISTSS. Malhotra 1 , N. Gupta 21 Department of Psychiatry and National Drug DependenceTreatment Centre, All India Institute of Medical Sciences,New Delhi, India; 2 South Staffordshire Healthcare NHS Trust,Burton upon Trent, UKPsychiatry, as a medical discipline in India, has seen a rise in recentyears in the backdrop of significant developments in psychiatrictraining over the last 5 decades. Psychiatric training is provided tomedical students at undergraduate and postgraduate (specialisttraining) levels. The latter includes structured and rigorous involvementin clinical, academic and research activities. The training incorporatesmanagement of a variety of psychiatric disorders across arange of population choosing from a range of treatment modalitiesbest suited for the patient. International classificatory systems andguidelines are followed. Being a developing country with a rich cultureand a large population, there is a need to balance psychiatricservices with available resources in a rational and acceptable way.Also, there is a need to balance the growth in biological developmentsand availability of a range of new psychopharmacologicaldrugs with the role of psychotherapies and traditional practices.There is a need to spread psychiatric awareness amongst populationand psychiatric training amongst the undergraduate medical students.The presentation shall additionally focus on perspectives oftrainees towards liaison psychiatry and highlight the need-based recommendationsfor the future. Alongside their respective regionallearning, a global view of psychiatry through improving communication,collaborations, travel and short term courses shall help inbroadening the horizons and aid in the overall understanding andgrowth of young psychiatrists world over.WO21.4PSYCHIATRY TRAINING IN IRANM.R. SargolzaeeUniversity of Medicine, Mashad, IranThe duration of psychiatry training in Iran is 3 years. General physiciansparticipate in an examination for entering the specialty course.In the last decade, in Iran the interest for psychiatry has increasedenormously, therefore the scientific threshold of psychiatry trainingand practice has been elevated in the last years. The specialty trainingcourse in Iran is governmental. Residents spend their courses in thehospitals. In some universities psychiatric wards are placed in generalhospitals, in other universities the psychiatry department is in apsychiatry hospital. Consultations from different wards about generalmedicine patients with psychiatric problems are more common ingeneral hospitals. Daily works are participation in lectures, morning136 World Psychiatry 3:S1 - October 2004

eports, case reports, case problems and free discussion sessions, visitof in-patients and out-patients and night-shift works. Usually traineesspend some time in other wards, such as child and adolescent psychiatry,neurology and electroencephalography, clinical psychology.Every year all the residents participate in a national examination,which contains 150 four-level questions. Trainees have to answer to90 questions correctly at first year, 100 at second year and 110 at thirdyear. After having passed all the exams and having discussed theirthesis, trainees are approved for clinical practice in Iran (so called“pre-board graduation”). For academic places or for going to subspecialtyin Iran, the graduated psychiatrists should participate in theNational Board of Psychiatry, which is constituted of a theoreticalexam, similar to the pre-board examination but more difficult, and apractical exam (an interview with a patient followed by a discussion).Some obstacles reported by trainees are the following. First, sincethey spend most of their time in hospital settings, they are usuallyexpert in the treatment of patients with severe disorders, such as psychoticdisorders and mood disorders, but they are not well trained inanxiety disorders, somatoform disorders, dissociative disorders andpersonality disorders. This problem is even more significant in thefield of addiction; substance abuse is very common in Iran andaddicted patients are usually treated in out-patient clinics. Second,psychiatric residents do not receive enough training in psychotherapy.Due to the inability of most people to pay psychotherapy fees, thisis limited to relatively rare cases of Iranian rich people. Therefore inmost cases the only available treatment is the prescription of psychotropicdrugs. This is causing the growth of non-professional consultantsworking in the field of consultation, spirituality and alternativemedicine.WO21.5.PSYCHIATRIC CHALLENGES IN NORTH AFRICA:AN ARAB EGYPTIAN PERSPECTIVER.S. Abdel AzimUniversity Hospital, Cairo, EgyptIn Egypt, depression is the most frequent neuropsychiatric disorder,according to a recent World Health Organization (WHO) epidemiologicalsurvey in the Middle East. About 5% of the Egyptian populationsuffers of depression, and the numbers are expected to increaseby year 2020. Schizophrenia is estimated to involve about 2% of theEgyptian population. Medical universities, psychiatric departmentsand hospitals are located in Cairo and in other Egyptian cities likeAlexandria, Mansoura, Tanta, Menoufia, Assiout, El Menia, Banha,Bani Soueif. Still in some Egyptian cities, like Oasis and New Valley,there are no psychiatric wards, mental health hospitals or trained psychiatricprofessionals. The population living in these cities benefit alot from medical troops’ visits, which usually comprise a psychiatrist.In Cairo, there are four public medical universities with a psychiatricdepartment/institute: Ain Shams University, Azhar University (girls),Azhar University (boys), and Cairo University. There is also one privatemedical school. Training in psychiatry differs from one school toanother, both at undergraduate and postgraduate levels. As regardsthe postgraduate level, some schools rely on pharmacotherapy andelectroconvulsive therapy (ECT) more than psychotherapy, othersstress all kinds of psychotherapy training more than pharmacotherapyand ECT, while the integration of the different modalities is thetrend in Cairo University Hospital. In public hospital, conventionalneuroleptics like haloperidol and tryciclics like imipramine andamtriptyline are widely used along with the new generation drugs(both atypical antipsychotics and serotonin selective reuptakeinhibitors, SSRIs), whenever these are available. Until recently, therewas no substantial communication among Egyptian young psychiatrists.In March 2004, the Egyptian Psychiatric Association hasacknowledged the Egyptian young psychiatrists’ section as part of itsgrowing structure, and in this presentation I will bring the achievementsof this promising section among the other above highlightedtopics.WO21.6.TRAINING IN PSYCHIATRIC TREATMENT IN ANEXPANDED EUROPE: TOWARDS HARMONIZATIONJ. Beezhold 1 , A. Fiorillo 21 European Federation of Psychiatric Trainees; Norfolk andWaveney Mental Health Partnership Trust, Norfolk, UK;2 Department of Psychiatry, University of Naples SUN,Naples, ItalyDespite the attempts of the main European psychiatric organizations,such as the Association of European Psychiatrists (AEP), the Boardof Psychiatry of the European Union of Medical Specialties (UEMS),and the European Federation of Psychiatric Trainees (EFPT) to harmonizeEuropean psychiatric training, the delivery of training stillvaries in the different European countries in terms of length, contentand style. In particular, length of training varies from 2 years (Armenia)to over 6 years (UK). In most European training courses psychiatrictrainees have to spend a rotation period in other branches suchas child and adolescent psychiatry and other specialties such as neurology,internal medicine and endocrinology. Selection criteria forentry to postgraduate specialist training vary between countries, andinclude national examination, local examination, university selection,and waiting list. In some countries, there is no selection – trainingis available to all doctors. As regards training in psychiatric treatments,psychotherapy is not part of training everywhere; in fact, it isvoluntary in most European countries and trainees often have toacquire such skills in free time and at very high cost. Other differencesinvolve biological treatments. Some new psychotropic drugs are notavailable everywhere, in particular in Eastern European countries.Moreover, some somatic interventions (e.g., electroconvulsive therapy)are the mainstay in some contexts, while they are almost frownedupon in others. Of course, this reflects great variability in trainingprograms for young European psychiatrists. In view of the enlargementof the European Union, the harmonization of training inEurope must be a priority at a decision-making level both nationallyand at European level. In this presentation, we will provide updatedinformation on European postgraduate psychiatry training, as well asan overview of the current strategies for harmonization.WO22.STRATEGIES FOR PSYCHOTROPIC DRUGSOF THE FUTUREWO22.1.TRANSCRIPTIONAL FACTORS AS A TARGETFOR THE ANTIDEPRESSANTS OF THE FUTUREN. BrunelloDepartment of Pharmaceutical Sciences, University of Modenaand Reggio Emilia, ItalyCurrent treatments for depression, although effective, often producepartial symptomatic improvement, rather than symptom resolutionand remission. Currently available antidepressants target monoaminergicsystems, however different symptoms of depression may have a137

distinct neurobiological basis and other neurobiological systems arelikely involved in the pathogenesis of depression. Recent work hasshown that monoamines and other neurotransmitters initiate a cascadeof events within the post-synaptic neuron. This cascade caninclude effects on a variety of second messenger systems, that in turncan trigger a wide range of biochemical events within the stimulatedcell. Stimulation of some of these pathways is necessary for the actionof currently available antidepressants. Consequently, medicationsthat act directly on second messenger systems may be effective antidepressants.Chronic antidepressant treatment increases the activityof the cyclic adenosine monophosphate (cAMP) cascade in the hippocampusand cerebral cortex, suggesting that agents that activatethis pathway could be useful for the treatment of depression. Oneenzyme – cAMP-specific phosphodiesterase (PDE4) – degradescAMP in the brain, raising the possibility that inhibitors of thisenzyme might have antidepressant efficacy. Another important intracellularsignaling pathway that may be involved in depression is themitogen activated protein (MAP) kinase cascade. Antidepressantsappear to interact with brain derived neurotrophic factor (BDNF), animportant molecule in the brain that activates MAP kinase and otherintracellular cascades. Stress reduces BDNF expression in the hippocampus,whereas chronic antidepressant treatments cause neuronsto increase their expression of BDNF genes. Antidepressant therapyalso appears to prevent the stress-induced reductions of BDNF innerve cells. In addition, BDNF has antidepressant efficacy in certainbehavioral models of depression, suggesting that the BDNF-MAPkinase pathway may play an important role in some of the deleteriouseffects of stress on the hippocampus and that one mechanism bywhich antidepressants work may include increasing the activity ofthis pathway. Although speculative, this hypothesis forms the frameworkof preclinical antidepressant discovery efforts aimed at identifyingsmall molecules that might promote the activity of BDNF and theMAP kinase pathway. Corticotropin releasing hormone (CRH) is amajor neuropeptide mediator of stress responses in the central nervoussystem. Preclinical studies indicate that CRH plays an importantrole in a variety of behaviors relevant to anxiety and depression. Levelsof CRH are increased in the cerebrospinal fluid of individuals withdepression. Neuroendocrine studies are suggestive of increased CRHdrive in the hypothalamus, and postmortem investigations havereported an increase in CRH neurons and a likely compensatorydown-regulation in CRH receptors. This evidence suggests that aCRH antagonist might be useful for the treatment of depression oranxiety. CRH antagonists capable of reaching the brain have beendeveloped, thereby allowing in the near future for an adequate investigationof their clinical utility in the treatment of depression and anxiety.WO22.2.DOPAMINE D3 RECEPTORS AS A TARGET FORNOVEL TREATMENT OF DRUG ADDICTIONB.J. EverittDepartment of Experimental Psychology, University ofCambridge, UKDopamine D3 receptors have a restricted distribution in the brain,being especially prevalent in the nucleus accumbens core and shelland the amygdala. These areas have been implicated not only inmediating the reinforcing effects of drugs of abuse, but also in rewardrelatedlearning, including the associations between envirnmentalstimuli and self-administered drugs. Using a model of cocaine-seekingbehaviour, in which the contingent presentation of drug-associatedstimuli acting as conditioned reinforcers are critical, we have studiedthe impact of manipulating dopamine D3 receptors. Administrationof the selective D3 receptor antagonist SB-277011-A dosedependentlyand selectively decreased cocaine-seeking behaviour.The drug had no effect on food-seeking behaviour, nor did it affect theprimary reinforcing effects of cocaine. Infusions of SB-277011-A alsohad no effect on the locomotor activity. These data indicate that drugswith antagonist efficacy at the D3 dopamine receptor may have therapeuticpotential in the treatment of addictive behaviour. In humandrug addicts, cocaine-associated stimuli induce drug-craving and precipitaterelapse. Treatments that minimise or even prevent thesebehaviourally activating effects of drug cues may aid abstinence andeffectively prevent or reduce the risk of relapse.WO22.3.NEUROPEPTIDES IN MENTAL ILLNESST. HökfeltDepartment of Neuroscience, Karolinska Institutet, Stockholm,SwedenNeuropeptides represent a large group of putative messenger moleculesin the nervous system. They range in size from a few up to morethan 40 amino acids. Over the last fifteen years at least one, sometimesfive or even more receptors have been cloned for each neuropeptide,and they are almost exclusively of the seven transmembrane,G-protein coupled type (GPCRs). Thus several hundred suchreceptors are potential targets for drug development. The neuropeptidesand their receptors are distributed in all parts of the nervous system,primarily in neurons, but various types of glial cells can also produceneuropeptides and express neuropeptide receptors. The neuropeptidesdiffer from classic transmitters in several respects, forexample they are exclusively stored in so called large dense core vesiclesand are in some systems released when neurons are firing at highrates or are burst firing, and only into the extrasynaptic space. It istherefore likely that neuropeptide antagonists mainly act on stronglyactivated and deranged systems, which should minimize the sideeffects. Animal experiments suggest involvement of neuropeptides inseveral mental and neurological diseases, including depression, anxiety,schizophrenia, eating disorders and neurodegenerative diseasessuch as Alzheimer’s and prion diseases. Also, distinct changes in neuropeptideexpression have been demonstrated in post mortem brainsfrom patients afflicted by several mental diseases. Numerous drugsacting on neuropeptide receptors have been developed, mainly by thepharmaceutical companies. They have been tested in animal experimentsas well as in human trials of various disorders such as depression(substance P and corticotropin releasing factor antagonists),schizophrenia (cholecystokinin and substance P antagonists), eatingdisorders (melanocortin, neuropeptide Y and orexin antagonists) andsleep disorders (orexin agonists). However, up till now none of thesecompounds have been approved for treatment of any of these diseases,although an NK1 (substance P) antagonist is now in use fortreatment of chemotherapy-induced emesis. Moreover, many of thesedrugs are in various stages of clinical trials, and the future will show ifthey have efficacy in diseases such as those mentioned above.138 World Psychiatry 3:S1 - October 2004

WO22.4.ROLE OF CB1 CANNABINOID RECEPTOR IN THEREGULATION OF ANXIETY-RELATED BEHAVIOURSAND THE EFFICACY OF ANXIOLYTIC DRUGSL. Urigüen, S. Pérez-Rial, T. Palomo, J. ManzanaresDepartment of Psychiatry, Neuropsychopharmacology Unit,Hospital Universitario 12 de Octubre, Madrid, SpainRecent reports suggest that cannabinoid CB1 receptors, through theirbalanced interaction with opioids, the hypothalamic-pituitary adrenalaxis (HPA), gonadal steroids and GABAergic neurotransmission,may represent a key element in the control of emotional behaviours.However, the role of the endogenous cannabinoid system in theaction of anxiolytic drugs such as benzodiazepines is still unknown.By using mice deficient in cannabinoid CB1 receptors, the aim of thisstudy was to determine the role of this receptor in anxiety-like behavioursand the anxiolytic efficacy of benzodiazepines. To examine themechanisms underlying the anxiety-like behaviours related tocannabinoid CB1 receptors, a number of behavioural assays (openfield,light dark box, elevated plus maze, social interaction test, forcedswimming test) were carried out in wild type and mutant animals. Theresults revealed that deletion of CB1 receptors induced a profoundspontaneous anxiety-like state. Interestingly, behavioural studies carriedout in intact and gonadectomized male and female wild type andmutant mice suggest that this anxiety-like behaviour occurs only inmale rats and appears to be independent of the presence of testosterone.Corticosterone levels and stress responses were also studiedin wild type and mutant intact male mice. Under basal conditions,CB1 mutant mice exhibit low basal corticosterone plasma concentrationsand low proopiomelanocortin gene expression in the anteriorlobe of the pituitary gland. When mice were submitted to 10 minutesof restraint stress, a hypersensitive response was detected in mutantmice compared to wild type. Pharmacological blockade of CB1 receptorswith SR141,716A increased anxiety-like behaviours in wild typeanimals. Low and high doses of bromazepam produced a significantanxiolytic response in wild type animals in the light/dark box testwhereas neither dose was effective in CB1 mutant mice. To explorewhether the lack of anxiolytic effect of bromazepam in these micewas related to alterations in GABA receptor function, we examined,using in situ hybridisation, GABA-A alpha2 receptor gene expressionin areas of the hippocampus. The results revealed that mutant micedisplay higher GABA-A alpha2 receptor gene expression in CA1(70%), CA2 and CA3 (30%) fields of the hippocampus than wild typemice. In summary, our findings revealed that CB1 receptors play apivotal role in the regulation of emotional responses. Interestingly, itappears that the presence of cannabinoid receptors is necessary forbromazepam to achieve complete anxiolytic action. Overall, thesefindings strongly suggest that functional alterations in cannabinoidreceptors may affect the efficacy of anxiolytic drugs in the treatmentof mood-related disorders.Supported by Grant FISS 03/216 to J. Manzanares.WO22.5.ROLE OF NEUROSTEROIDS IN ETHANOLDEPENDENCE AND GABA-A RECEPTORPLASTICITYG. BiggioCentre of Excellence for the Neurobiology of Dependence,University of Cagliari, ItalyProlonged exposure to and subsequent withdrawal of ethanol areassociated with marked, specific, and opposite changes in GABA-Areceptor subunit gene expression as well as in receptor function andpharmacological sensitivity in cultured rat hippocampal neurons.Downregulation of GABA-A receptor and a reduction in the efficacyof various benzodiazepine receptor ligands induced by prolongedethanol treatment are associated with a reduced expression of alpha1,alpha3, gamma2L, and gamma2S subunits. In contrast, an increase inalpha4-containing receptors induced by ethanol withdrawal may bean important determinant of withdrawal syndrome and is blocked bydrugs that are effective in the treatment of ethanol dependence. Wenow show that, in isolated rat hippocampal tissue, ethanol increasesthe concentration of allopregnanolone as well as the amplitude ofgamma GABA-A receptor-mediated inhibitory postsynaptic currentsrecorded from CA1 pyramidal neurons. This latter action is biphasic,consisting of rapid, finasteride-insensitive and delayed, finasteridesensitivecomponents. These observations suggest the ethanol maymodulate GABA-A receptor function through an increase in de novoneurosteroid synthesis in the brain that is independent from hypothalamic-pituitary-adrenal(HPA) axis. This novel mechanism mayhave a crucial role in mediating the short and long term effects ofethanol on GABA-A receptor and brain function.WO23.CURRENT APPROACHES TO SEVEREPERSONALITY DISORDERSWO23.1.BEYOND THE ICD AND DSM: DIAGNOSIS,CO-MORBIDITY, AND THE THERAPEUTIC ALLIANCEIN SEVERE PERSONALITY DISORDERSA. TasmanDepartment of Psychiatry and Behavioral Sciences, School ofMedicine, University of Louisville, KY, USAIn recent years there has been substantial criticism of symptom clustersystems of diagnosis of personality disorders. A more comprehensiveapproach would include a more dimensional analysis of personalitytraits such as neuroticism, introversion, conscentiousness,antagonism, and openness to experience. Negative aspects of such anapproach include the length of time it takes a skilled clinician toassess these factors, which would be difficult in most settings. Further,diagnosis is complicated by substantial co-morbidity with othermajor psychiatric disorders. Once a diagnosis is made, difficulties inestablishing an early therapeutic alliance, and maintaining it throughouttreatment, are significant in this patient population. Modificationsof usual approaches are often necessary to engage and maintaina treatment relationship.139

WO23.2.ACUTE AND LONG-TERM TREATMENT OFTHE SEVERE PERSONALITY DISORDERSA. AndreoliService d'Accueil, d'Urgences et de Liaison Psychiatriques,Geneva, SwitzerlandThis presentation will summarize the different ways and the differentlevels of care for severe personality disorder patients: acute and longtermtreatment in the outpatient clinic, in the partial hospital, in thehospital ward, in the residential facility. The first goal of the treatment,with outpatient or inpatient clinical management programs, isthe containment and care of the affective instability and impulsiveness.The tools for this goal are individual and group psychotherapy(dialectical behavioural therapy), work with the families, medicationfocused on the symptoms at the moment. The staff should be workingevery time on the assertive case management guidelines. The secondgoal is the risk management and the tools for this goal are the emergencyinterventions in the community mental health or in the generalhospital setting, the crisis units or the temporary intensive programsin the residential facility setting. The particular value of intensive outpatientcare and the effects of psychotherapy will be highlighted.WO23.3SEVERE PERSONALITY DISORDERS:HOW TO ORGANIZE THE CLINICAL FRAMEWORKFOR COMMUNITY MENTAL HEALTH CENTERSM. BassiDepartment of Mental Health, Local Health Unit, Bologna, ItalyItalian psychiatrists are finding on an increasingly more frequent basisthat they must diagnose and treat a particular type of patients. Theseare not the traditional patients of public mental health services, suchas people with psychotic, severe and persistent mental disorders,which these structures have by now been able to pinpoint and towhom they have been able to offer a series of solutions to the problem,having to become “responsible” for their care on an intensive or prolongedbasis, both in terms of pharmacological and psychosocialtreatment. These patients meet with psychiatrists when they areurgently admitted or in the emergency room, whether they are examinedat a community mental health center or in the emergency room ofa general hospital in a big city. More frequently, psychiatristsencounter these “new patients” while providing psychiatric consultingservices at so-called “borderline areas”. These are patients which havebeen examined for the first time by services for substance-related disorders,social services for homeless people or health services whichare responsible for treating prisoners. The health and social workerswhich come into contact with these “new patients” soon realize thatthe difficulties in establishing a relationship in order to help thepatient, the impulsivity with frequent return to the negative behavior,and the disturbed, aggressive or frankly antisocial behavior suggestthat these patients should undergo a psychiatric evaluation. In manyof these cases, when a request is made for a timely evaluation, psychiatristsfind themselves faced with young people, prevalently male,affected by an “impulsive cluster” personality disorder (in the majorityof cases a borderline personality disorder or an antisocial personalitydisorder, which are alone or in comorbidity), with a history of variousduration of substance dependence or abuse, with previous episodes ofclear antisocial behavior and consequent problems of a legal or penalnature.WO24.TARGETED COMBINATION OF DRUGS ORPOLYPHARMACY? EVIDENCE FOR AND AGAINSTCOMBINED DRUG TREATMENTWO24.1.THE CARE-STUDY: INITIAL DATA FROM ADOUBLE-BLIND RANDOMISED CONTROLLEDSTUDY OF AUGMENTING CLOZAPINE WITHRISPERIDONEW.G. HonerCentre for Complex Disorders, Vancouver, CanadaPoor response to clozapine remains a considerable clinical problemin a substantial number of patients. One response is to attempt augmentationof clozapine with another antipsychotic drug. Case reportsand open-label studies support the efficacy of this approach. However,there is only one double-blind study, which demonstrated reducedsymptoms following addition of sulpiride to clozapine. We have carriedout a placebo-controlled, double-blind study of risperidone augmentationof incomplete response to clozapine. A total of 72 subjectsenrolled, with 90% completion of the 8 week double-blind phase.The minimum clozapine dose was 400 mg/day for 12 weeks prior tostudy entry. Risperidone 3 mg/day was used for augmentation. Atpresent, results from the open-label extension phase suggest reductionin total Positive and Negative Syndrome Scale scores of approximately15%, from a mean of 97 to 83. The results of the double-blindphase will be presented.WO24.2.COMBINING ANTIPSYCHOTICS WITH ANEUROPROTECTIVE AGENT: A CAUSAL WAYOF TREATING SCHIZOPHRENIA?H. EhrenreichMax-Planck-Institute for Experimental Medicine, Göttingen,GermanyErythropoietin (EPO) is a candidate compound for neuroprotectionin human brain, capable of combating a spectrum of pathophysiologicalprocesses that operate during the progression of neuropsychiatricdisorders. Over the last years we have been preparing the ground forits application in a first neuroprotective add-on strategy in schizophrenia,aiming at improvement of cognitive brain function as well asprevention/slowing of degenerative processes. Using rodent studies,immunohistochemical analysis of human post mortem brain tissueand nuclear imaging technology in man, we demonstrate that: a)peripherally applied recombinant human (rh) EPO efficiently penetratesinto the brain; b) rhEPO is enriched intracranially in healthymen and more distinctly in schizophrenic patients; c) EPO receptorsare densely expressed in hippocampus and cortex of schizophrenicpatients but distinctly less in healthy controls; d) rhEPO attenuatesthe haloperidol-induced neuronal death in vitro, and e) peripherallyadministered rhEPO enhances cognitive functioning in mice in thecontext of an aversion task involving cortical and subcortical pathwaysbelieved to be affected in schizophrenia. These observations,together with the known safety of EPO, render it an interesting compoundfor neuroprotective add-on strategies in schizophrenia andother human diseases characterized by a progressive decline in cognitiveperformance. A multicenter proof-of-principle trial on EPO inchronic schizophrenia has been started in April 2003.140 World Psychiatry 3:S1 - October 2004

WO24.3.COMBINATION TREATMENT IN BIPOLAR DISORDERG.M. GoodwinWarneford Hospital, Oxford, UKRelapse is a frequent event in the course of bipolar disorder. For thatreason, its prevention is a primary goal for treatment. Optimizing ourapproach to this problem requires relevant clinical evidence. In fact,I will argue that it is currently limited by the quality of that clinicalevidence. While we must be guided by the evidence we do have –mainly monotherapy data – and the inferences we can draw byextrapolation and experience, there is a pressing need for more pragmaticdata from large simple trials. Lithium still provides the goldstandard for long term treatment of bipolar disorder. The placebocontrolledevidence to support its use has been superior to that forthe alternatives. However, we must now distinguish between its efficacyagainst manic relapse and its weaker, although probably still significant,effect against depressive relapse. Alternative monotherapiesinclude valproate, olanzapine, carbamazepine and lamotrigine. Theiruse, alone or in combination with each other, and perhaps earlier inthe illness course, are the subject of current debate. The need for furtherlong term studies of prophylaxis, to compare new drugs head tohead with lithium and in combination with it, is increasingly pressing.To be useful such studies will have to be large and if they are to belarge they must be designed in a way that makes them extremely userfriendly for busy clinicians. A culture needs to be established in ordinaryclinical practice to facilitate the entry of patients with bipolardisorder into simple trials that can determine moderate but worthwhilebenefits for one treatment or treatment combination. A relativelyneglected route to optimal effectiveness is also suggested by formaltrials of psychological intervention. These studies all demonstrateimportant advantages over ‘treatment as usual’, except where thecomparator treatment is, itself, enhanced. In other words, we canimprove outcomes independent of pharmacological innovation bybetter structuring and directing routine care – a further example of acombination treatment.WO24.4.IS THE COMBINATION OF ANTIPSYCHOTICS ORANTIDEPRESSANTS WITH BENZODIAZEPINESSUPPORTED BY EVIDENCE? WHAT ARE THEBENEFITS AND RISKS?J. KaneZucker Hillside Hospital, Glen Oaks, NY, USACombining antipsychotics and antidepressants with benzodiazepineshas a long-standing tradition, but is done in a somewhat unreflectivemanner. Studies are quoted in which the combination with a benzodiazepinehas a beneficial effect on the short-term outcome in psychoticdisorders and severe depression. Furthermore, some studiesseem to suggest that the long-term outcome in both conditions isimproved if benzodiazepines are added in the early phase of treatment.A meta-analysis was performed aiming to verify these assumptions.It was found that adding a benzodiazepine to antidepressant orantipsychotic treatment is not beneficial compared to the addition ofa low-potency antipsychotic. The meaning of this study has to be discussedon the background of our current clinical practice.WO25.PERSPECTIVES IN PSYCHIATRIC TRAINING:IMPLICATIONS FOR TREATMENTWO25.1.PSYCHIATRIC TRAINING FROM A CULTURALPERSPECTIVEM. KastrupCentre for Transcultural Psychiatry, Copenhagen, DenmarkPsychiatric services in the Northern European region are faced withnew challenges related to the immigrant population. In Denmark,persons of a non-Danish background comprise about 8-10% ofpatients in psychiatric care. This proportion varies greatly, as communitymental health services in certain areas of Copenhagen have about25% immigrant patients, and in forensic services the proportion mayamount to 40%. No explicit health policy has been formulated withrespect to immigrants. They have access to the same health services asthe rest of the population once they have been granted a residencypermission, implying that psychiatrists will meet patients from otherethnic background in their daily clinical practice. Till now undergraduatesreceive little training on cultural issues in psychiatry. On apost-graduate level, the curriculum comprises training in transculturalaspects of psychiatry. With increased globalization there is howevera need to pay more attention to cultural aspects at all levels anddevelop strategies to increase the cultural competence of mentalhealth professionals. The paper will discuss the content of a culturesensitive curriculum and strategies to implement it.WO25.2.CLASSIFICATION SYSTEMS AND PSYCHIATRICTRAININGL. KüeyPsychiatry Department, Beyoglu Training Hospital; PsychologyDepartment, Istanbul Bilgi University, Istanbul, TurkeyThe current categorically based classification systems had a greatimpact on diagnostic practice, research and training in psychiatry.These “atheoretical” systems, by increasing reliability of diagnosis,proved to be “user friendly” tools mainly in research. In clinical practice,these descriptive and syndrome based approaches to diagnosishave contributed to correct the chaotic terminology of the past, whilegenerating an ongoing debate, especially on the issues of validity anddiversity. Their effect on psychiatric training has been of mixed benefit.These systems give too little attention to deep meaning of thediversity of the subjective experiences as well as to the life history ofthe patient, in the sake of objectivity. Although classification systemsclassify disorders, not patients, in the daily clinical praxis of heavyburden, for most of the trainees these classification systems turnedout to be used as labelization, categorization and delimitation toolswhich classify people, not disorders. While psychiatric trainingshould focus on improving the ability of the trainee to make a comprehensivediagnostic assessment of the patient, overreliance on diagnosticmanual derived data is diminishing the trainee’s comprehensionof the importance of understanding a patient and establishing atherapeutic alliance. The use and misuse of these classification systemsin psychiatric training will be discussed in this presentation.141

WO25.3.THE IDENTITY OF PSYCHIATRY AND TRAININGA. LindhardtPsychiatric Clinic, University Hospital of Copenhagen, DenmarkTraining has a great impact on the identity formation of the youngpsychiatrists. This is done through theoretical training, role modelling,clinical experience under supervision, participation in internationalevents, psychotherapy training - to name some of the contents.During a number of years the European Union of Medical Specialists(UEMS) has developed a training curriculum to be adopted by allEuropean training institutions. The standards of training are reflectingthe state of art of psychiatry and the continuous development ofthe speciality. A number of competences are needed to “create” amodern psychiatrist. In the presentation this will be explored, andissues of the psychiatric profession as such, the needed competencesand the necessary training will be discussed.WO25.4.PHILOSOPHICAL PERSPECTIVES IN PSYCHIATRICTRAININGM. MusalekAnton Proksch Institute, Vienna, AustriaOne of the major questions in the field of training in psychiatry is:how should psychiatrists look like in the next decades, is there a needto change their profile, and what will be their tasks and needs in thefuture? In the last decades we became confronted more and morewith various interesting and important results of studies carried out indifferent research fields, e.g. neurosciences, genetics, neuroimmunology,neurochemistry, sociology, psychology, psychotherapy, philosophy,ethics, anthropology, etc., which led to a high complexity of psychiatricknowledge. This development obviously creates new needs inthe training of psychiatrists, e.g. the need for basic education in philosophy.In order to provide future psychiatrists with the possibility toassess critically new research results, basic knowledge in theory ofscience becomes necessary. Moreover, modern psychiatrists have tomeet extended ethical requirements. Therefore basic knowledge notonly concerning epistemology but also in ethics represents an indispensableassumption for successful work in psychiatry on a high levelof humanity. Last not least it has to be emphasized that philosophy ofeducation itself represents an important tool in developing future psychiatry.Philosophy of education is not so much seeking to solve onlyeducational problems as to study the concepts that structure our educationalthinking, and to lay bare the foundations and suppositions ofour daily work. Philosophical discourse in psychiatry education iswhat happens when our practice becomes self-conscious.WO26.PSYCHOTHERAPY FOR CHILDHOOD DEPRESSION:A CROSS-NATIONAL EUROPEAN STUDYWO26.1.PSYCHOTHERAPY FOR CHILDHOOD DEPRESSION.A CROSS-NATIONAL EUROPEAN STUDYJ. TsiantisDepartment of Child Psychiatry, University Medical School,Athens, GreeceWe present the implementation and preliminary results of a multicenterclinical trial for depressed adolescents aged 10-14 years in whichtwo different forms of psychotherapy interventions are undertaken.The two treatment modalities are brief individual psychodynamicpsychotherapy (BIPP) for a maximum of 30 sessions (once a week)and systemic integrative family therapy (SIFT) for 12 sessions (once afortnight). A random allocation design was used for the two types oftherapy. The total number of cases is 72. All therapists and parent carerswere regularly supervised. Treatment manuals were also used. Avariety of instruments have been used to assess child psychopathology,parental mental health, family functioning, academic achievement,expressed emotion, therapeutic alliance, etc. The assessmentwas made at three time points: baseline, end of therapy and six-monthfollow-up. Observations from the clinical work and some results ofthe treatment outcome will be presented and discussed.WO26.2.PSYCHOTHERAPY FOR CHILDHOOD DEPRESSION:A CROSS-NATIONAL STUDYJ. Trowell 1 , I. Joffe 21 Tavistock Clinic; 2 Great Ormond Street Hospital, London, UKAlthough clinically effective, there is little research evidence of efficacyor systematic study of effectiveness of individual psychodynamicpsychotherapy or family therapy in the treatment of childhooddepression. This study compared these two treatments inthree culturally diverse settings using a manualised approach. Arandomised control trial was conducted in London, Athens andHelsinki with 72 patients aged 10 years to 14 years. Assessment wasdone at baseline, end of therapy and after six months. The subjectsreceived either individual therapy plus parent work or family therapy.Early results will be presented focussing on the presentation ofthe families and then the changes by the end of therapy in depressionand in comorbidity. The cultural differences will also be discussed,with some thoughts on predictive factors, both of depressionand of recovery. The outcomes were good and so there is someevidence for the use of these therapies in moderate and severedepression and/or dysthymia or double depression. Given the currentanxiety about the selective serotonin reuptake inhibitors in thisage range this is an important study.WO26.3.PATTERNS OF CHANGE IN PSYCHOPATHOLOGYAND SYMPTOMS IN DEPRESSED CHILDRENAND THEIR FAMILIES DURING AND AFTERSHORT-TERM PSYCHOTHERAPYF. Almqvist, M. Soininen, E. Korpinen, S. ValleDepartment of Child Psychiatry, University of Helsinki, FinlandDepression in childhood and early adolescence is a common disorder,with a prevalence ranging from 2 to 6% at the population level.Depression is also very common in clinical child and adolescent psychiatricpopulations. Depression in these developmental ages is a seriousdisorder, with extensive co-morbidity, that can persist for longperiods and negatively affect different domains in the development ofthe child and youngster. The rationale for treating depression in developmentalages is therefore recognised. In this project, short-term individualpsychodynamic psychotherapy and family therapy were offeredto depressed youngsters aged 9-14 years. The study was conducted inthree European centres: the Tavistock Clinic in London, the AghiaSophia Children’s Hospital, University of Athens and the Hospital forChildren and Adolescents, University of Helsinki. The children arereferred to the research centres from diverse clinics and services in therespective catchment areas of the centres. After a preliminary screen-142 World Psychiatry 3:S1 - October 2004

ing by the self administered Childhood Depression Inventory, subjectsthat are expected to have a depressive disorder are evaluated by childand parent interviews using the Schedule for Affective Disorders andSchizophrenia for Children (K-SADS). Children who fulfil the diagnosticcriteria for major depression are further extensively evaluated atbaseline by numerous questionnaires and interviews and randomlyallocated to either individual psychotherapy or family therapy. Theindividual psychodynamic therapy consists of up to 30 weekly therapysessions for the child, and 15 parental supportive sessions. The systemsoriented family therapy is provided every second or third week,altogether up to 14 sessions. The therapies last for 6-9 months. Thereis an extensive evaluation both at the end of treatment and at follow up6 months later. The intake of patients is completed, and most ofpatients have completed the course of treatment. In the presentation,the methods, especially the family and individual therapy approach,will be described in greater detail. Different therapy issues and relevantoperational and methodological research issues will be presented anddiscussed. Preliminary results will be presented.WO26.4.FAMILY THERAPY IN A CONTROLLEDCLINICAL TRIALV. TomarasDepartment of Psychiatry, University of Athens, GreeceIn this presentation a theoretical approach to childhood depressionfrom a systemic point of view is attempted. In the cross-nationalEuropean study on the efficacy of psychotherapies in childhood andearly adolescence depression, family therapy had to be adapted tothe research protocol and to the frame of the “systemic integrativefamily therapy manual” which was applied. The supervisory schemeof family therapy was differentiated among the three sites of thestudy. A case-vignette will illustrate the major issues that the therapistsand supervisors had to face during the therapeutic process.Furthermore, results concerning the outcome of family treatmentwill be presented and commented.WO27.TREATMENT OF LIMITS, LIMITS OF TREATMENTWO27.1.HIGH-DOSE PSYCHOTROPIC TREATMENT:THERAPEUTIC AND LEGAL LIMITSE. Marcel 1 , P. Chenivesse 1 , N. Brion 21 Institut Marcel Rivière, Le Mesnil Saint-Denis; 2 Hospital ofVersailles, FranceIn clinical practice, we encounter not rarely psychotic patients whoare resistant to antipsychotic drugs, of both old and new generation.In some of these severe cases, the only way to obtain a therapeuticeffect is to use high doses or atypical associations which are not recommendedin international guidelines. The clinicians have to copesometimes with specific problems such as peculiarities of metabolismin some of these patients. The efficacy and optimal posology of thesedrugs are evaluated in double-blind trials in which several patientswith the above characteristics do not meet the inclusion criteria. Thismay lead to neglect an important fringe of patients which may beresistant to these treatments and need high dose prescriptions,beyond the marketing authorised posology, or associations of drugswhich are usually discouraged.WO27.2.SCARIFICATIONS: FROM RITE TO CARE INBORDERLINE STATESM. De LucaInstitut Marcel Rivière, Le Mesnil Saint-Denis, FranceBorderline states, since the moment they were described, appeared tobe at the boundary of therapeutic possibilities, psychiatric as well aspsychoanalytic. Borderline states are frequently accompanied byscarifications of the patient’s skin. Doing so, the patient expects tolimit or to control his or her massive anxiety and feeling of emptiness.Moreover, scarifications appear as an expression of problems withidentity, a mark of singularity, an attempt of autonomisation, a firststep to subjectification. These attempts to recover one’s control maybe interpreted as a first appeal to a therapeutic relationship; thesemarks are often badly accepted by the patient’s entourage, leading tohospitalisation. When hospitalisation takes place, in order to instigatea process of change, we implement an intervention consisting ofpsychotherapy and body-centered therapy. This double approachmaterializes a containing frame, protecting the subject as a shield.Taking in charge the whole person reduces the split between psycheand soma, and reduces the libidinal conflicts, often masochistic,linked to an early deficient cathexis of the child body by his or hermother. This pattern of treatment reveals another type of relationship:when the patient accepts that somebody might take care of his or herbody in a therapeutic space, protecting him or her from any risk ofimpingement or fusion, he or she may recover a narcissistic reinvestmentwhich, like for the baby, will be a base for his or her ego reconstruction.WO27.3.THE LIMITS IN INSTITUTIONAL CARE OF THEADOLESCENT PATIENTS IN AN ACUTE PHASEC. Brocco, P. VotadoroInstitut Marcel Rivière, Le Mesnil Saint-Denis, FranceThe management of adolescent inpatients in an acute phase needs toharmonize all the therapeutic strategies at work in the patient. Somecharacteristics of the therapeutic relationship may appear like obstaclesto these strategies; they may furthermore become resistanceswhich can lead to a break in the treatment course. Such situations areconsidered by the medical staff as limits of its therapeutic action. Thefirst limit may appear when the clinical intervention is requested bysomebody else than the patient. Narcissistic stakes on the one hand,and a power conflict opposing adolescents to their parents on theother, may act as limits to the access to a therapeutic setting. The secondtype of limit refers to the specific psychopathology of the age ofadolescence, expressing itself with spectacular acting-outs, maskingnarcissistic conflicts which may delay the onset of the therapeuticrelationship. Thus, hospitalization may be altogether perceived as afailure, rejection or punishment, leading the adolescent inpatient totest out the psychiatric team, facing its own expectations and limits.Therefore, the therapeutic relationship may restrict itself to a narcissisticchallenge, with the risk of its interruption. Another difficultyarises when group dynamics of “symptom contagion” occur. Thesemay be considered as iatrogenic effects, limiting the therapeutic benefitsexpected from hospitalisation.143

WO27.4.THE LIMIT BETWEEN ANTISOCIAL PERSONALITYDISORDERS AND SEVERE PSYCHOPATHYY. ThoretL’Evolution Psychiatrique, Paris, FranceIt is important to evaluate clinically the degree of severity of an antisocialpersonality behaviour. In this paper, we will refer to the worksof Meloy and Hare, providing clinical criteria to detect severe psychopathyin patients with antisocial personality disorder. We willanalyse the psychopathology of the psychopath, referring to conceptssuch as grandiose self (Kohut), paranoid regression (Kernberg) andnegative narcissism (Green). This clinical analysis must be done earlyenough to determine what kind of therapeutic program is relevant toeach patient.WO28.INVOLVING PATIENTS AND FAMILIES ININTEGRATED PSYCHIATRIC TREATMENTSWO28.1.FLEXIBLE INTERVENTION STRATEGIES BASEDON THE ELEMENTARY PRAGMATIC MODELP. De GiacomoDepartment of Psychiatry, University of Bari, ItalyA psychiatrist can and should do more than formulating a diagnosisand prescribing a drug therapy. In the course of the first psychiatricvisit, as well as in the follow-up ones, a substantial help can be givento the patient. Flexible intervention strategies, relying on the integrationof the biological and the relational aspect, can be implemented.These include: the prescription of specific activities, to be performedin the period before the following visit (e.g., in the case of anorexianervosa, that the patient and her father make a four week traveltogether); the use of written programs (workbooks); the strategic useof sentences with a strong psychological impact on the patient. Thesesentences may: be given as answers to questions that the same patientasks; be a comment to what the patient expresses; be given as adirect/indirect suggestion to the patient and the relatives who accompanyhim.WO28.2.IMPLEMENTING THE BIO-PSYCHOSOCIALAPPROACHP. PanzarinoCatskill Regional Medical Center, Harris, NY, USAModern clinicians have an array of pharmacological and psychologicalinterventions at their disposal; yet the emphasis in treatment oftenseems to be determined more by the clinician’s preference, philosophyor area of expertise, than on clinical appropriateness based onthe patient's presentation. While most clinicians pay homage toEngel's bio-psycho-social model, few actually embrace it in a meaningfullyway in their daily practice. In addition, many researchershave developed valuable interventions that are targeted and time limited,but there has been little empirical work using the bio-psychosocialmodel. If one approaches each episode of illness as the outcomeof biopsychosocial forces and attempts to quantify the relativeweight of each of these vectors, and develops the treatment planaccordingly with the patient, the episode of illness may be resolvedquicker, and better long-term results may be obtained. We haveattempted to create such a quantified system and utilize it with ourpatients. We will discuss the diagnostic tools, the way the first sessionand subsequent sessions are managed, and the results of our sixmonth pilot study.WO28.3.INVOLVEMENT OF THE FAMILY IN THEMANAGEMENT OF SUICIDAL PATIENTSJ. PriceOdintune Place, Plumpton, UKIt is not current practice to involve children in the management ofadult suicidal patients. A series is described in which children andother family members were invited to join in planning the managementof patients who had informed others of their suicidal intention,either by letter, or words or by suicidal acts. The young people werepleased to be involved, and often contributed useful insights into theparental behaviour. They appreciated the opportunity of facing up topossible parental suicide before the act occurred. The interventionalso short-circuits any communicational function of suicidal behaviour,particularly of an angry variety.WO28.4.THE WISH TO BE CRAZY, OR, IS THERE A RIGHTTO BE PSYCHOTIC?L. JacobssonDepartment of Psychiatry, University of Umeå, SwedenA small, but problematic proportion of patients suffering from psychoticdisorders, mainly schizophrenia and schizoaffective disorders,are extremely non-compliant to treatment. In many cases suchpatients are being forced to treatment and they improve – not completely,but still there is a reduction in psychotic symptoms anddeviant behaviour – but after a short time back home they stop takingtheir medication and they relapse in their psychotic disorder. Some ofthese patients are aggressive and disturbing to their family and neighbourhoodsand sometimes even commit violent acts. When askedwhy they do not want to take drugs, some complain about sideeffects; others, and that is probably the majority of these cases, do notadmit that they are mentally ill and in need of drugs. Instead, theyhave a paranoid perception that they are the victims of other personsor organizations. So, why should they take medications when thecause of their problems is outside themselves and out of their owncontrol? Some of these patients even admit that they are psychotic,but they want to remain in that kind of state. So, the question is: howto deal with this kind of patients? Is there a right to be psychotic or isthere a duty to treat these patients even against their own expressedwill? This question and possible strategies to handle this kind ofproblem will be discussed.WO28.5.HELPING FAMILIES CHANGE: FAMILY MOTIVATIONAND INVITATIONAL ENGAGEMENT IN SUBSTANCEABUSE TREATMENTJ. LandauLinking Human Systems, Boulder, CO, USARecent advances in therapeutic interventions for substance abuserscapitalize on the strengths of families and loved ones. Families can beinfluential in getting substance abusers into treatment and successfullong-term recovery. The interface of “family motivation to change”and individual motivation is a powerful, interactive dynamic for144 World Psychiatry 3:S1 - October 2004

engaging and retaining resistant substance abusers in treatment andmaintaining their long-term recovery. Recent invitational interventionmethods and their results will be explored, challenging beliefsand stereotypes that substance abusers need to “hit bottom” and thatfamily interest is co-dependent, enabling or controlling. ARISE, ARelational Intervention Sequence for Engagement, a successful andcost-effective invitational method for engaging resistant substanceabusers in treatment, will be presented.WO29.MENTAL HEALTH ISSUES IN HIV/AIDSWO29.1.HIV/AIDS AND PSYCHIATRY: TREATMENT ISSUESK. AshleyPeter Krueger Clinic - Beth Israel Medical Center, New York,NY, USAThere are significant mental health issues among individuals withHIV/AIDS and there are important interrelationships between theseconditions. Various aspects of these relationships will be discussed,including: the identification and treatment of psychiatric illness;issues of stigma; potential drug-drug interactions between psychotropicmedications and the highly active anti-retroviral treatments(HAART); the possibility of improved adherence and better generalfunctioning with the treatment of co-morbid psychiatric illnessand/or the provision of psychological interventions; the assessmentand discussion of risk behaviors, including the role of substance use.The use of various modalities of mental health treatment/interventionswill also be discussed.WO29.2.DELIBERATELY AND UNCONSCIOUSLYSEEKING INFECTION BY HIV: PUBLIC HEALTHAND CLINICAL ISSUESR. CabajSan Francisco Community Behavioral Health Services,San Francisco, CA, USACertain people seek to deliberately become infected with the HIV andothers, through their behavior, may be seeking to become infectedunconsciously. The clinical issues will be explored, such as the role ofalcohol and drugs, shame and internalized homophobia, and clinicalinterventions before the person becomes infected. The impact on thepublic health of all people at risk for HIV infection, including peoplewho follow risky sexual practices and those who inject drugs, willalso be explored.WO29.3.LESBIAN, GAY, BISEXUAL AND TRANSGENDERISSUES AT A PSYCHIATRIC HIV/AIDS CLINICV. Contreras, A. ReminajesHIV/AIDS Consultation-Liaison Psychiatry, Albert EinsteinCollege of Medicine, Bronx-Lebanon Hospital, Bronx, NY, USALesbian, gay, bisexual and transgender (LGBT) issues have been overlookedfor some time, especially in the poor inner city setting. We willillustrate prevalent psychiatric diagnoses, the rate of suicidality, andissues of discrimination among LGBT individuals with HIV/AIDSand psychiatric illness at an inner city outpatient clinic in New York.Those psychiatric illnesses with a strong relationship to suicide willbe identified. There will also be a discussion of the recognition andtreatment/management of the suicidal patient.WO30.IMPLEMENTATION OF PSYCHOEDUCATIONALINTERVENTIONS FOR SCHIZOPHRENIA INROUTINE CLINICAL SETTINGSWO30.1.PSYCHOEDUTRAINING STUDY:THE ITALIAN EXPERIENCEA. Fiorillo, L. Magliano, C. Malangone, C. De Rosa,M. Maj and the Working GroupDepartment of Psychiatry, University of Naples SUN,Naples, ItalyThe Psychoedutraining Study has been promoted by the EuropeanCommission within the V Programme for Research and TechnicalDevelopment and carried out in six European countries. This projectaimed to assess the impact of two alternative staff training programmeson the implementation and effectiveness of psychoeducationalintervention for relatives of patients with schizophrenia. Bothtraining programmes included the following core components: a) abasic course on psychoeducational intervention, including sessionson engagement, provision of information on schizophrenia and itstreatments, communication and problem solving skills; b) supervisionsessions on the family work. The “augmented” programme alsoincluded the following components: a) training sessions on the use ofcommunication and problem solving skills to cope with problemsoccurring in the implementation of the intervention; b) supervisionmeetings on implementation problems; c) exercises on the applicationof the psychoeducational techniques in routine work setting. Ineach country, the training programmes have been implemented in aleading centre, which has randomly selected four mental health services(MHS) and allocated them to one of the two programmes. Ineach MHS, two professionals were trained in the intervention protocol,one in the administration of assessment tools. As concerns theItalian experience, the overall impact of the courses on trainees wasimpressive: attendance rates at supervision meetings and frequency ofsessions provided to families were very high; only one trainee fromthe augmented group had significant difficulties in attending the lastsupervision meetings and providing family sessions, due to changes inhis work duties, but no one withdrew. A total number of 15 familieswere engaged; three families from the augmented group dropped out,due to relatives’ guilt feelings, father’s reluctance and patient’srelapse. Service organization and trainees’ motivation were found toplay a major role in the use of the intervention. To overcome difficultiesrelated to case-loads, trainees conducted most sessions outsidethe working hours and at families’ home. Our experience highlightsthat it is possible to provide family interventions in Italian MHS, andthat the implementation of these interventions on a large scalerequires addressing organizational problems at decision-making levels.The impact of the programmes has been evaluated by: a) registeringthe families in which the intervention is started, interrupted orcompleted; b) assessing the trained staff’s adherence to the interventionprotocol; c) assessing family burden, coping strategies, and socialnetwork; d) assessing patients’ clinical status and disability; e) recordingpatients’ relapses and time spent in hospital at follow-up.145

WO30.2.IMPLEMENTING FAMILY WORK IN ANENGLISH CONTEXT: RESULTS FROM THEPSYCHOEDUTRAINING STUDYG. Fadden, F. Gair, C. Morrell, M. BirchwoodUniversity of Birmingham, and Birmingham and Solihull MentalHealth Trust, Birmingham, UKThe Psychoedutraining Study in England was conducted against abackground of a number of policies and guidelines issued by theDepartment of Health stipulating that the needs of families should beaddressed, and that psychoeducational interventions should be widelyavailable to families of those with schizophrenia. In England, thereare a number of centres that have been promoting family work forsome time and conducting research, among them London, Manchesterand Birmingham, as well as some other areas where there are stafftraining programmes focussed on family work. In the random selectionfor participating in the study, these established centres of excellencewere not included, as many therapists in these areas wouldalready have been trained in family work, and many families werealready receiving psychoeducational interventions. The remainingsites available to select from had in common the fact that family workhad not been established in the services, and most of the staff had notreceived training. Another significant feature was that these servicesdid not have an established research ethos. Four sites were recruitedfrom among those willing to enter the randomisation process. All successfullyidentified staff were trained as therapists and researchers.The selection of therapists was made by the centres involved. Frequently,they did not select those who were in the best position torecruit families where one person had schizophrenia, or who had thetime to work with families, because of issues such as the size of theircaseload. There were difficulties post-training with the recruitment offamilies willing to participate in the research. Other problems werelinked to staff changing jobs and roles, families being unwilling toparticipate in the research element of the project, and the identifiedlink people in services not being of sufficient seniority to resolve thedifficulties that arose. The presentation will address factors that influenceddifficulties with implementation, and the attempts made toovercome them.WO30.3.RESULTS OF THE PSYCHOEDUTRAININGSTUDY IN GREECEM. Economou, A. PalliDepartment of Psychiatry, University of Athens, GreeceThe implementation of the Psychoedutraining Study in Greeceincluded the random selection of four mental health services, inwhich eight therapists were trained in the standard or augmentedprogramme. Eight families were treated by the professionals of thestandard group and eight families were treated by the professionalsof the augmented group. All families received the complete interventionsessions as planned in the study. The implementation of thestudy in Greece leads to the following preliminary results: a) mentalhealth services showed interest in applying family interventions; b)mental health service managers were willing to facilitate the mentalhealth professionals of their departments to participate in specializededucational programs; c) in half of the centers participating inthe study, there were more than two professionals initially interestedto attend training on behavioral family therapy; d) the therapiststraineesparticipating in the study were highly motivated to participatein the training and to apply family work; e) the duration andcontent of the training as well as the supervision were particularlyuseful for the trainees, who gained important clinical experience inbehavioral family work and in negotiating with the administrators oftheir services about its integration in everyday work; f) regarding therecruitment of the families, it was much more difficult to engage familiesin the rural regions of Greece than in the cities; g) most of thefamilies did not accept to be tape-recorded; h) most of the mentalhealth centers neither facilitated nor kept back the trainees fromimplementing the family work. In most cases the sessions with thefamilies took place in the afternoons and outside the working hoursof the trainees, a fact that is expected to be a problem in the integrationof family work in the routine of the services; i) the treated relativeshad a tendency to experience less burden, and to apply moreeffective coping strategies after the intervention; j) the clinical statusand the disability index of the patients was the same or had slightimprovements at the 1 year follow-up.WO30.4.GERMAN RESULTS ON IMPLEMENTATIONAND EFFECTIVENESS OF THEPSYCHOEDUTRAINING STUDYT.W. Kallert, J. Schellong, C. Kulke, N. Kernweiss, B. RipkeDepartment of Psychiatry and Psychotherapy, Universityof Technology, Dresden, GermanyAlthough the effectiveness of psycho-educational interventions forfamilies with schizophrenic patients has been assessed in Germanyseveral years ago, the approach of behavioural family therapy is currentlynot provided. Therefore, the research question if therapistshaving received a training programme specifically tailored to practicalproblems of implementing this approach will provide this therapymore frequently and effectively than therapists having been trainedwithin a standard programme is of high relevance. The study phaseswere the following: a) random selection of (at least 4) routine mentalhealth services from three East-German Federal States, b) two staffmembers from each service randomly assigned to one of the twotraining programmes (standard vs. “augmented”), c) continuouslysupervised provision of behavioural family therapy by the trainees toat least one family per trainee in their routine work situation, d)assessment of the treated families and of the therapists over a 12-month period using a battery of standardized instruments. 40% of themental health services (initially selected and informed about the project)refused participation (reasons: lack of staff, time-budget for thetraining). Finally, 8 mental health services sent two staff members tothe training programmes. 3 trainees in each group withdrew duringthe training/supervision period. Results on the therapy of 13 familieswill be presented. Analyses of problems to implement the successful(e.g. in terms of re-admission rates to hospital) approach point tofinancial and administrative issues. Re-funding the costs for thisapproach and its acknowledgement as a training element of the residencyin psychiatry are the main problems.WO30.5DIFFICULTIES REGARDING IMPLEMENTATION OFBEHAVIOURAL FAMILY THERAPY INTERVENTIONS:THE PORTUGUESE EXPERIENCE WITHIN THEPSYCHOEDUTRAINING STUDYM. Xavier, M.G. PereiraFaculty of Medical Sciences, Lisbon, PortugalThe Psychoedutraining Study has been running in Portugal since2002. According to the main schedule, eight therapists from four146 World Psychiatry 3:S1 - October 2004

mental health services (MHS) were allocated to two different trainingand supervision programs for behaviour family therapy (BFT) inschizophrenia. These eight therapists eventually became responsiblefor a total of thirteen families (one or two families each). Results ofthe training course were impressive regarding satisfaction and motivationof the trainees (most emphasised the clinical usefulness of theapproach). Meanwhile, the trainees’ acquisition of BFT skills wasfound rather satisfactory, although a minority expressed significantdifficulties since the beginning (apparently, due to lesser baselinecommunication and problem-solving competence at a personallevel). Eventually, all trainees came to acquire these basic skills, mostof them expressing enthusiasm and confidence about psychoeducationalwork. Nevertheless, the speed at which BFT proceeded insome families was slow. Additional contributing difficulties werementioned, namely conciliating the psychoeducational interventionwith heavy caseloads and personal obligations: none of the therapistsroutinely undertook home sessions with families. Specifically,during the recruitment phase, some trainees have pointed out hiddenprejudices concerning family interventions in their MHS colleagues.It is our experience that continued supervision while applying BFTfor the first time contributes to overcome some (but not all) difficultiesrelated to clinical issues and service organization. It also seemscrucial for ‘treatment integrity’. Outcome measures concerning clinicalparameters, caregiver burden, coping strategies and social networkthroughout the process are still in study. According to ourjudgement, and regarding staff adherence, differences related toattendance of the standard versus augmented programmes will notprove significant. Variables related to each MHS organisation andopenness to family approaches and, last but not least, personal characteristicsof the trainees, seem to play a major role at that purpose.This will have implications in refining selection criteria for individualtraining, but mostly in further efforts contemplating systemicchange of the services.WO30.6EFFECTIVENESS OF A PSYCHOEDUCATIONALINTERVENTION FOR FAMILIES OF PATIENTSWITH SCHIZOPHRENIA AND THE IMPACT OFTHE IMPLEMENTATION OF TWO STAFF TRAININGPROGRAMMESF. Torres-González, A. Jiménez, M.M. MuñozGrupo Andaluz de Investigación en Salud Mental, Universityof Granada, SpainThe study aims to: a) confirm in Spain that the rates of relapses ofpeople with schizophrenic disorders are reduced by psycho-educationalinterventions upon their families, according to the internationalliterature; b) assess the impact of two alternative staff training programmes("standard" and "augmented") on the implementation of awell-known psycho-educational intervention for relatives of patientswith schizophrenia (Falloon et al., 1985). The study is being carriedout in six European countries, Spain among them. Within Spain, thestudy is being carried out in 4 mental health services representative ofthe country as a whole. An experimental group (A), constituted by thefamilies to which the psycho-educational interventions are applied,will be compared with a control group (C) constituted by the samenumber of cases under clinical routine treatment. The treatmentapplied to this second group will not include any kind of psycho-educationalintervention. For the objectives of the European study, theexperimental group will be randomly divided in two subgroups (A-1A-2), to which the two psycho-educational intervention programs ofdifferent intensity will be applied. The dependent variables are: rate ofrelapses, subjective and objective family burden, “adherence" of thetrained therapists to the new technique.WO31THE EVOLUTION OF COMMUNITY PSYCHIATRYIN ITALYWO31.1.ITALIAN PSYCHIATRY AND ITALIANPSYCHIATRISTS: 26 YEARS OF CHANGESM. BassiDepartment of Mental Health, Local Health Unit, Bologna, ItalyItalian psychiatry is probably more debated than known in the internationalarena. The law 180 of 1978, introducing a radical communitypsychiatry system, has drawn worldwide attention, giving space todebates and comments ranging from enthusiastic to frankly disparaging.Even recently, this interest was marked by several well-attendedsymposia on the evolution of the Italian community psychiatry withininternational congresses. Historical analyses of how the reformmovement took momentum, produced a law and how it was enactedcan be found elsewhere. Now the majority of Italian psychiatristswork in the public mental health system. The mental health departmentis the network that provides for outpatient and inpatient care,for emergency and for psychosocial rehabilitation, for drug therapyand for different psychotherapies. In Italy the mental health departmentsare 234; 5,561 psychiatrists are working in the public mentalhealth system (18% of the total number of mental health workers)and 95.7% of them are state employees.WO31.2.INTENSIVE COMMUNITY CARE: IS IT THESAME IN ITALY AND THE REST OF EUROPE?A. FiorittiLocal Health Unit, Rimini, ItalyIt is assumed that descriptions of services such as intensive case management(ICM) and assertive community treatment (ACT) implyrecognised patient groups and processes. We tried to identify whethertwo ACT services in different health care contexts (i.e., Italy, UK andUS) serve patients with similar sociodemographic and clinical characteristics.Different researchers collected data on ACT patients in Italy,UK and US. Sociodemographic data, illness history, use of servicesand of medication were compared. As expected, in Italy patients significantlymore often lived with their family and were employed. UKand US patients were more ethnically diverse. In UK and US a greaternumber suffered from psychotic disorders. Polypharmacy was muchmore frequent in Italy. Service descriptions can be misleading whenused across differing health care contexts and need adequate ‘input’characterisation to draw meaningful conclusions. Background socialvariables, organization and ‘philosophy’ of psychiatric systems of care,as well as professional education, may all differ substantially betweencountries and influence the actual implementation of psychosocialcare programs.147

WO31.3.THE COMMUNITY MENTAL HEALTH SERVICEPROVISION ACROSS ITALYF. StaraceService of Psychiatry, Cotugno Hospital, Naples, Italy26 years after the introduction of the reform law, practically all Italianmental hospitals have been closed. When the law was approved in1978, there were 78,538 mental hospital residents. Three types ofcommunity facilities, alternative to mental hospitals, have been set upfor the management of psychiatric illness. These are: a) general hospitalpsychiatric wards (GHPWs); b) residential, non-hospital facilities(with full- or part-time staff care); c) non-residential, outpatientfacilities, which include day hospitals, half day centers and outpatientclinics. These services are organized through 234 departments ofmental health, covering the entire country. This paper offers a standpointof the evolution and the diffusion of the community mentalhealth services in Italy 26 years after the reform. The mental healthcare in Italy has grown and improved in terms of population coverage,number of available facilities, and capacity to meet patients’needs.WO31.5.RESIDENTIAL CARE IN ITALY: A NATIONAL SURVEYG. de GirolamoDepartment of Mental Health, Local Health Unit, Bologna, ItalyThe “PROGRES” (PROGetto RESidenze, Residential Care) project isaimed to survey the main characteristics of all Italian non-hospitalresidential facilities (NHRFs) (Phase 1) and to assess in detail 20% ofthe NHRFs and the patients who live there (Phase 2). In Phase 1,structured interviews were conducted with the managers of all ItalianNHRFs. In Phase 2, 20% of the surveyed facilities were evaluated bya research assistant who met with staff and then carried out an indepthevaluation of each patient. On May 31, 2000, in Italy there were1370 NHRFs, with 17138 beds, with an average of 12.5 beds each anda rate of 2.98 beds per 10,000 inhabitants. Discharge rates were verylow. Most had 24-hour staffing. In Phase 2, 265 NHRFs have beenevaluated in great detail, as well as 2962 residents. There is markedvariability in the provision of residential places between differentregions; discharge rates are generally low; NHRFs serve a very disabledpopulation who in the past would have been admitted forlengthy stays in mental hospitals. However, the boundary betweenhousing needs and treatment/rehabilitative aims of residential facilitiesseems unclear and needs to be identified.WO31.6.COMMUNITY TREATMENT OF SEVERE ANDPERSISTENT MENTAL ILLNESS IN ITALY:THE OUTCOMESM. RuggeriDepartment of Medicine and Public Health, Universityof Verona, ItalyCare for people with schizophrenia, as in the Italian model of communitycare, should address a wide range of outcomes, including professionaland consumer perspectives, and assess effectiveness of carein various life areas. The aims of the study are: a) to measure changesin psychopathology, functioning, needs for care and quality of lifeoccurring in a three year period; b) to assess the frequency of ‘good’and ‘poor’ outcomes. Data obtained in several studies performed inthe South-Verona Mental Health Service setting will be presented,detailing in particular the results of a three-year follow-up of an annualtreated prevalence cohort of 107 patients with an ICD-10 diagnosisof schizophrenia attending the Service. The mean symptom severity(especially negative symptoms) and some types of needs for care(especially social needs) worsen, while quality of life shows nochange over the study period. The outcome for schizophrenia at 3years depends upon: a) the domain of outcome used, b) whether staffor consumer ratings are used, and c) the degree of stringency of thedefinitions used for good and poor outcome.WO32.PREDICTING RESPONSE TO ANTIPSYCHOTICS ANDANTIDEPRESSANTS BY FUNCTIONAL IMAGINGWO32.1ANTIPSYCHOTIC RESPONSE PREDICTION WITHFDG-PET IN SCHIZOPHRENIAM.S. Buchsbaum, M.M. Haznedar, E. HazlettNeuroscience PET Laboratory, Mount Sinai School of Medicine,New York, NY, USAWe acquired positron emission tomography (PET) with fluorodeoxyglucose-F18(FDG) as tracer and anatomical magnetic resonance imaging(MRI) in 30 never previously medicated psychotic adolescents(age 13-20) and 24 age- and sex-matched normal controls. PET scanswere performed at baseline and after 8-9 weeks of a randomized double-blindtrial of either olanzapine or haloperidol. Patients carriedout a serial verbal learning task during the tracer-uptake period. PETscans were coregistered to the MRI. Of the baseline sample of 30 adolescentpatients, 22 completed the second PET and clinical evaluation.We examined the baseline FDG values in the caudate and foundthat high metabolic rates in the caudate predicted response tohaloperidol as reflected by the Brief Psychiatric Rating Scale totalscore (dorsal right caudate -0.56) while low metabolic rates at baselinepredicted response to olanzapine (r=0.39, z=2.07, p

group found that changes in the slow alpha range, observed six hoursafter the administration of a single test dose of either haloperidol orclopenthixol, discriminated between responders and non-responderswith an accuracy rate of 88.9% (91.3% in chronic and 84.6% in firstepisode patients). More recently the test dose procedure was used toidentify predictors of response to novel antipsychotics. Clozapine orrisperidone were administered to 18 drug-free patients with DSM-IVschizophrenia. EEG findings indicate that, in line with what observedwith standard neuroleptics, changes in the slow alpha band discriminateresponders from non-responders to risperidone. For clozapinethe same pattern of EEG changes (increase of theta and decrease offast alpha and beta activity) was observed in both responders andnon-responders. These preliminary findings indicate that traditionalparameters used by pharmaco-EEG studies may have limited utility inthe prediction of response to novel antipsychotics. A low resolutionbrain electromagnetic tomography (LORETA) study is being conductedto identify topographic parameters contributing more thantraditional pharmaco-EEG parameters to the early identification ofresponders and nonresponders to treatment with novel antipsychotics.WO32.3.TREATMENT RESPONSE TO RISPERIDONEAUGMENTATION IN SRI-REFRACTORY OCDPATIENTS: A STUDY BY POSITRON EMISSIONTOMOGRAPHY IMAGINGS. Pallanti 1 , M.S. Buchsbaum 2 , E. Hollander 2 , N. Baldini-Rossi 31 University of Florence, Italy; 2 Mount Sinai School of Medicine,New York, NY, USA; 3 University of Pisa, ItalyPrevious positron emission tomography (PET) studies of patients withobsessive-compulsive disorder (OCD) have found elevated glucosemetabolic rates in the orbitofrontal cortex (OFC) and caudate nuclei,that normalize with response to treatment. This is the first PET investigationof risperidone augmentation in OCD patients refractory toserotonin reuptake inhibitors (SRIs). We studied 16 OCD patientswho were non-responders to SRIs with an additive trial of risperidone.PET with 18F-deoxyglucose and magnetic resonance imaging wasobtained at baseline and following eight weeks of either risperidone orplacebo in a double-blind parallel group design. Risperidone treatmentwas associated with significant increases in relative metabolicrate in the striatum, cingulate gyrus, the prefrontal cortex, especially inthe orbital region, and the thalamus. Four of nine patients whoreceived risperidone showed clinical improvement (Clinical GlobalImpression, CGI score of 1 or 2 at 8 weeks) while none of the sixpatients who received placebo showed improvement. Patients withlow relative metabolic rates in the striatum and high relative metabolicrates in the anterior cingulate gyrus were more likely to show a clinicalresponse. The metabolic response in the striatum with antipsychoticsand cingulate gyrus with SRIs is consistent with earlier PETstudies showing these effects when these treatments were administeredindividually. Our results are consistent with a fronto-striatial circuitchange related to both dopaminergic and serotonergic systemsand with the presence of subtypes within OCD which can be identifiedby drug response.WO32.4.IMAGING PREDICTORS OF TREATMENTRESPONSE FOR DEPRESSIONH. MaybergDepartment of Psychiatry, Emory University, Atlanta, GA, USAWhile there are many effective options for treating a major depressiveepisode, there are no clinical markers that predict the likelihood ofremission with an initial trial of either an antidepressant medicationor psychotherapy. In prioritizing a role for direct measures of brainfunctioning in the development of new algorithms for first-line clinicalmanagement of depressed patients, a systematic characterizationof pretreatment patterns predictive of unambiguous remission tostandard treatments is a necessary first step. Towards this goal, wehave characterized two distinct brain subtypes using positron emissiontomography (PET) measures of resting state brain glucose metabolism.Building on past findings demonstrating pretreatment rostralcingulate (BA24) activity differences between responders and nonrespondersto selective serotonin reuptake inhibitors (SSRIs), we examinedbaseline differences between patients treated with either an SSRIor cognitive behavior therapy (CBT). Analyzed in the context of aputative, limbic-cortical neural systems model using a multivariateapproach (partial last squares), pretreatment differences involving theinteractions of subgenual cingulate (BA25) with rostral anterior cingulate(BA24), medial frontal (BA10) and lateral frontal (BA9)regions distinguish depressed patients who later respond to SSRIpharmacotherapy or CBT, respectively. These preliminary studiesprovide foundation for prospective investigation of these outcomemarkers in studies of both pharmacological and non-pharmacologicalinterventions.WO33.TREATMENT OF PERSONALITY DISORDERS:NEW PERSPECTIVES (Special Workshoporganized by the International Society for theStudy of Personality Disorders)WO33.1.NIDOTHERAPY IN THE TREATMENT OFPERSONALITY DISORDERSP. TyrerImperial College School of Medicine, London, UKNidotherapy is the collaborative systematic assessment and modificationof the environment to minimise the impact of any form of mentaldisorder on the individual or on society. It is particularly appropriateto consider for chronic and recurring disorders in which there is noprospect of short-term improvement, and many personality disorderscome into this category. It involves five phases of treatment, beginningwith a full environmental analysis (physical and social) with thepatient and the collaborative development of a programme for change,followed by an implementation plan, involvement of an arbiter if thereis disagreement between therapist and patient, and a monitoringprocess with consequent changes in the plan when agreed. Nidotherapyis particularly suitable for those patients who have fought againstall other forms of therapy as they wish to stay the way they are and itsadoption leads to a much better therapeutic relationship.149

WO33.2.INTEGRATING PHARMACOTHERAPY ANDPSYCHOTHERAPY/ PSYCHOANALYSISJ. StevensonWestmead Hospital, University of Sidney, AustraliaThere is increasing acceptance of combining medication and psychoanalyticpsychotherapy, particularly during the past two decades. Theconcerns once expressed about the potential of medication to interferewith the therapeutic process (obscure the transference or thecountertransference resistance) are giving way gradually to a growingacceptance that medication may enhance the therapeutic process,and that the two in fact may work together. Questions such as whatworked and what was responsible for cure are superfluous. In thispaper I will be discussing the indications for and problems with theuse of medication in the context of psychotherapy, how they maywork together, and who should do the prescribing. To integrate psychotherapyand pharmacotherapy, one must believe that in certainpatients, for psychotherapy to be successful, an understanding of thecomplex interrelations between psychology, physiology and biochemistrymust be present. As Kandel put it, “what we conceive of as ourmind is an expression of the functioning of our brain”. Freud himselfviewed all mental disturbances as being fundamentally biological innature. Gabbard reports that this acceptance has been reflected insurveys of analysts in the US: 90% of respondents to a questionnairesaid they prescribed medication. In a study at the Columbia UniversityCentre, pharmacotherapy was combined with psychoanalysis in29% of the candidates’ controlled cases, suggesting that medication isno longer seen as a contaminant that would interfere with certificationof the new graduate. Since the mid 1980s, there has been anemerging literature examining the conceptual and clinical issuesinvolved in combined treatments. As psychotherapists also prescribeor refer to a third party, prescribing has its inherent difficulties. Thispaper will look at the main arguments for and against the psychotherapistalso being the pharmacotherapist to his or her patient.Some factors belong with the patient, some with both patient andtherapist, and some with the therapist alone.WO33.3.TREATMENT OF METACOGNITIVE IMPAIRMENTS INPERSONALITY DISORDERS PSYCHOTHERAPYA. SemerariThird Centre of Cognitive Psychotherapy, Rome, ItalyIn the last years, different authors have supported the hypothesis thatdifficulties in relationship and adaptability of patients with personalitydisorders are maintained and worsened by metacognitive functionimpairments. By “metacognitive function” we mean the ability toprocess and integrate mental state’s representations and, according tosuch knowledge, to predict and explain the overt behaviour. Metacognitiveimpairments in personality disorders are different. In some casesthere is a difficulty to monitor thoughts and emotions which constituteinner states, in other cases there is an inability to think about mentalcontents and mental states in an integrated way, in other cases there isan inability to differentiate between inner world and reality. Up to nowthere are few suggestions about how to improve metacognitive functionsin these disorders. In this contribution some transcribed sessionswith patients suffering from personality disorders will be analysed. Wewill present some examples of metacognitive impairments and therapist’sinterventions improving the function during the session. Interventionsof validation of patient’s experience and interventions inwhich shared aspects of the experience are underlined are followed byan improvement of patient’s ability to recognise and comprehend mentalstates.WO34.BIOLOGICAL CORRELATES AND TREATMENTOF PATHOLOGICAL GAMBLINGWO34.1.FUNCTIONAL MAGNETIC RESONANCE IMAGINGSTUDIES OF PATHOLOGICAL GAMBLINGM.N. PotenzaYale University School of Medicine, New Haven, CT, USADespite associations with adverse measures of functioning and havingsimilar prevalence estimates as schizophrenia and bipolar disorder,pathological gambling (PG) has historically received little attentionfrom the psychiatric community. In particular, little research hasfocused on the brain mechanisms contributing to PG, although animproved understanding of these mechanisms has significant implicationsfor prevention and treatment. Functional magnetic resonanceimaging (fMRI) studies involving subjects with and without PG wereperformed to investigate the neural correlates of gambling urges andimpulse control. A videotape cue exposure paradigm was used toinvestigate gambling urges. In response to gambling, but not happy orsad videotapes, PG subjects reported substantially more intense gamblingurges than did control subjects: on a 0-10 Likert scale, PG subjectsreported mean scores of 5.20±3.43 and control subjects reportedmean scores of 0.32±0.60 (p

WO34.3.MOOD STABILIZERS IN THE TREATMENT OFPATHOLOGICAL GAMBLING AND THE BIPOLARCONNECTIONS. PallantiUniversity of Florence, ItalyWhile selective serotonin reuptake inhibitors are effective for somepatients with pathological gambling (PG), others experience relapse ofgambling during treatment. These patients may suffer from comorbidconditions, such as bipolar spectrum disorders, which influence treatmentresponse and contribute to relapse of impulsive gambling. Systematicand controlled studies with mood stabilizers in PG are limited.We describe the results of a trial of lithium and valproate in PG, and aplacebo controlled treatment study in bipolar spectrum pathologicalgamblers. Forty-two subjects with PG entered a 14-week single-blindtrial with lithium or valproate and a total of 15 subjects on lithium and16 patients on valproate completed the protocol. Forty bipolar spectrumPG patients entered a ten-week double-blind treatment studywith slow release lithium carbonate compared to placebo. At the endof the 14-week treatment period, both the lithium and the valproategroups showed significant improvement on mean PG-Yale-BrownObsessive-Compulsive Scale (PG-YBOCS) score. This improvementdid not significantly differ between groups. Fourteen of the 23 patients(60.9%) on lithium and thirteen of the 19 patients (68.4%) on valproatewere responders based on a Clinical Global Impression (CGI)-Improvement score of very much or much improved. The secondstudy showed that bipolar spectrum PG patients significantlyimproved on sustained release lithium carbonate compared to placeboon gambling behavior as measured by total PG-YBOCS Scale(p=0.002), including both thoughts/urges (p=0.002) and behavior(p=0.034), as well as PG-CGI Severity (p=0.045) and control overgambling behavior (PG self-report scale). A reduction of affectiveinstability (Clinician-Administered Rating Scale for Mania score) andreduction of non-planning impulsivity (Barratt scale) was alsoobserved in the lithium-treated group compared to placebo. Accordingto the PG-CGI Improvement score, 11 out of 12 patients (91.7%) wererated as responders in the lithium group vs. 6 out of 17 (35.3%) in theplacebo group (p=0.002). Of note, improvement in gambling severitysignificantly correlated with improvement in mania ratings (r= .478,p=0.009). Findings from the first study suggest the efficacy of bothlithium carbonate and valproate in the treatment of PG. This is the firstcontrolled trial of mood stabilizers efficacy in PG. A double-blind,placebo-controlled trial is required to confirm these findings. In thesecond study, sustained released lithium appeared an effective treatmentin reducing both gambling behavior and affective instability inbipolar spectrum PG patients. This highlights the need to identify subgroupsof PG patients with bipolar spectrum conditions, since thismay have important treatment implications.WO34.4.PATHOLOGICAL GAMBLING AND THEOCD SPECTRUME. HollanderMount Sinai School of Medicine, New York, NY, USAIn the research planning agenda for DSM-V, a new category of obsessive-compulsivebehaviors spectrum has been proposed. This wouldencompass disorders that share clinical features of repetitive thoughtsand behaviors, comorbidity, family history, brain circuitry, neurobiologyand treatment response. One subgroup of the obsessive-compulsivespectrum would include impulsive disorders, including pathologicalgambling (PG). This presentation will examine whether PG maybe conceptualized within the obsessive-compulsive spectrum, particularlywithin the impulsive subgroup. It will review similarities anddifferences between obsessive-compulsive disorder and PG withregards to phenomenology, family history, brain circuitry, and treatmentresponse. It will also discuss alternative conceptualizations ofPG as a behavioral addiction, and as a classic impulse control disorder.WO35.PSYCHIATRY IN THE COUNTRIES OF EASTERNEUROPE AND THE BALKANS: SIMILARITIES ANDDIFFERENCES (Organized by the WPA InstitutionalProgramme for Eastern Europe and the Balkans)WO35.1.WPA INSTITUTIONAL PROGRAM FOR EASTERNEUROPE AND THE BALKANS: INTRODUCTIONG.N. Christodoulou 1 , D. Lecic-Tosevski 2 , V. Kontaxakis 31 Hellenic Psychiatric Association; 2 Institute of Psychiatry,Belgrade, Serbia and Montenegro; 3 Department of Psychiatry,University of Athens, GreeceThe area of Eastern Europe and the Balkans is characterized by along scientific tradition and a formative contribution to world psychiatry,but also by severe socio-economic deprivation, war conflictsand disasters (mainly man-made). This has had a serious impact onthe population and on mental health professionals. In view of theabove, the World Psychiatric Association has established in October2002 an Institutional Program for Eastern Europe and the Balkans.The goals of the Program, its activities and the steps towards establishmentof a Psychiatric Society of Eastern Europe and the Balkanswill be reported.WO35.2.MULTICENTRIC STUDY ON POST-TRAUMATICSTRESS: FROM RESEARCH TO RECONCILIATIOND. Lecic-Tosevski 1 , A. Kucukalic 2 , T. Franciskovic 3 ,D. Ljubotinja 4 , M. Schützwohl 5 , S. Priebe 61 Institute of Mental Health, School of Medicine, University ofBelgrade, Serbia and Montenegro; 2 School of Medicine, Universityof Sarajevo, Bosnia and Herzegovina; 3 Center for Psychotrauma,Psychiatric Clinic, University of Rijeka, Croatia; 4 InternationalRehabilitation Centre for Torture Victims, Zagreb, Croatia;5 Department of Psychiatry and Psychotherapy, University ofTechnology, Dresden, Germany; 6 Barts and London School ofMedicine, Queen Mary University of London, UKTen years after the armed conflict in ex-Yugoslavia a significant numberof people still suffer from post-traumatic stress. However, the majorityof them have not requested or received any type of specialised psychiatrichelp. In order to better understand these phenomena, empiricalresults are needed about both barriers to treatment and treatment outcomesin specialised psychiatric services. The STOP study (Treatmentseeking and treatment outcomes in people suffering from post-traumaticstress following war and migration in the Balkans), is a multi-centrestudy funded by the European Commission, carried out by six centresin Croatia, Bosnia-Herzegovina, Serbia, Germany and the UK. A combinedquantitative-qualitative method has been developed in order to:a) identify barriers to treatment and coping strategies of people withpost-traumatic stress that have not asked for help, both of the ones that151

took refuge outside the post war area and of those who stayed in theregion and b) assess treatment outcomes in people already engagedwith services. Empirical results will hopefully contribute to betterorganisation of assistance to traumatized people, but also initiate reconciliationin the countries that faced the armed conflict and its severeconsequences.WO35.3.PAST AND PRESENT IN THE ROMANIANPSYCHIATRYT. UdristoiuUniversity of Medicine and Pharmacy, Craiova, RomaniaTraditionally, the psychiatric patients were helped by the churches andmonasteries, among which some small asylums were developed. The“birth” of the Romanian psychiatry was a law issued in 1838, whichenforced the transfer of the patients’ care responsibility to the hospitaladministration. Further, several large psychiatric hospitals have beenbuilt, the last one in Bucharest in 1924. After a short period of progressbetween the two world wars, the era of communism began. During the1960s and early 1970s, some achievements in the health care infrastructurewere noticed, but not in psychiatric care. After 1990, duringthe transition period, the frequency of stress-related disorders, depressionand coping disorders has escalated and generated delinquencyand violence. The offer of psychiatric care remained modest, withoutinfrastructure improvement and under the continuous hegemony ofsomatic medicine. For a country with a population of 21,7 millionsinhabitants, we have at present about 4 psychiatrists/100,000 peopleand 0,7 beds/1000 inhabitants, with insufficient opportunities for daycareand ambulatory care. This situation is far from covering the needsof the people, considering the results of the epidemiological studiesconducted in late 1970s, which revealed that almost one third of thepopulation would need psychiatric help. The policy in psychiatry andmental health is limited to the secondary prevention, with very fewactions towards primary prevention, rehabilitation, and patients’ qualityof life. An important and difficult problem is the development ofnon-biological therapies, which are very little used at the present. Thedomination of the somatic medicine and the almost exclusive use ofbiological therapies are reflected also in psychiatric training, bothundergraduate and postgraduate. On the other hand, some progresshas occurred. New opportunities for information appeared, the professionalassociations were founded, second generation antipsychoticsand antidepressants were approved for marketing and the psychiatristsparticipated in international multicenter trials. In one sentence, thegates to the world have been opened. Currently, we need to highlightthe discrepancy between the efforts of the specialists, who are trying toact according to modern psychiatry, and the mental health policy,which is based on unsuitable and, sometimes, obsolete traditions.WO35.4.BULGARIAN PSYCHIATRY: CURRENT SITUATIONAND TRENDS FOR DEVELOPMENTL. JivkovBulgarian Psychiatric Association, Municipal PsychiatricDispensary, Sofia, BulgariaThe Balkan countries have close historical, economic and socioculturalinteractions. This exerts a considerable influence on the developmentof psychiatric science and practice. This presentation will summarizethe main trends in the development of Bulgarian psychiatry,with emphasis on its situation under the totalitarian regime and thechanges and reforms after 1990. An outline of the similarities and thedifferences in the development of Bulgarian psychiatry compared tothe other countries of the region will be made possible by retracingthe general features of these two periods. An attempt will be made todescribe the current tendencies in psychiatric progress at both the scientificand the practical level in Bulgaria. The National Program forMental Health in force at the present moment, the current changes inthe legislation concerning mental health care, the current state of theeducational system, the present role of psychiatric non-governmentalorganizations such as the Bulgarian Psychiatric Association will beconsidered.WO35.5.PSYCHIATRY IN TURKEY: SYSTEMS IN TRANSITIONL. KüeyPsychiatry Department, Beyoglu Training Hospital; PsychologyDepartment, Istanbul Bilgi University, Istanbul, TurkeyAlthough psychotherapeutic understanding and accordingly humanepractice of caring for the mentally ill have a long history in Turkey,modern forms of practice in mental health have developed in the lastcentury. Being under the effect of continental Europe first and theAnglo-Saxon tradition later on, psychiatric praxis reflects the prevailingsocio-cultural values. Turkey, with a population of about 70 million,is at geographical crossroads of East and West, and this dichotomyis deeply reflected in many facets of life, including psychosocialconstructs. Being a developing country with limited health and mentalhealth resources, the challenge is to manage and adapt to the rapidtransitional processes. In this presentation, the data on the epidemiologyof psychiatric disorders and the mental health personnel will bepresented. Accordingly, areas of service, research, training and publicationsin psychiatry will be reviewed in the context of their regionaland institutional differences. Finally, the issues of developing anational mental health program and the role of psychiatric societiesand the importance of international collaboration in such processeswill be discussed.WO35.6.PSYCHIATRIC REFORM IN GREECEG.N. Christodoulou, M. MadianosAthens University Medical and Nursing Schools, GreeceData indicating reduction of long-stay patients and of the total numberof patients in Greece between 1984 and 2004, coupled withincrease in extramural facilities, are presented. Closure of public mentalhospitals seems to be a realistic goal. However, much remains tobe done in the areas of prevention, primary care, integration of psychiatricand medical services, as well as with respect to the creation ofalliances with the community, mental health promotion and qualityof extramural services.WO36.AUTISM IN SCHIZOPHRENIA, TODAYWO36.1.AUTISM AND SCHIZOPHRENIA: AN INTRODUCTIONFROM A PHENOMENOLOGICAL POINT OF VIEWA. BalleriniUniversity of Florence, ItalyThe image of retreat, of detachment from external reality, of distancingfrom others, of separation from the world that is common and in-152 World Psychiatry 3:S1 - October 2004

common, of closure into a sort of virtual hermitage, whether activelysought or passively submitted to, has from the beginning been centralto the concept of autism and has remained one of its descriptiveaspects. In schizophrenia, the condition described as the autisticmode of life can arise from a person’s being confronted with a pathologicalcrisis of his ontological security, of “basic faith” in the obviousnessof the intersubjective world: a crisis in the intersubjectivefoundation of human presence. In short, from the phenomenologicalpoint of view, autism derives from a difficulty in the “empathic”(Husserl, Stein) primary process that represents in the consciousnessthe Other, as a subject like ourselves. Autism is a concept that goesbeyond psychiatric diagnoses, even if it finds in the sphere of schizophreniasits most complete and persuasive expression and characterization.It can thus be proposed that even if not all forms of autism area schizophrenic disorder, the core forms of the schizophrenic spectrumare unthinkable except as autistic.WO36.2.AUTISM, THE SELF AND SCHIZOPHRENIASPECTRUMJ. ParnasUniversity of Copenhagen, DenmarkOver the past years, we have been studying the issue of disordered selfhoodin schizophrenia as an essential aspect of the autistic vulnerability.We consider this condition both as a generative disorder, definingthe construct validity of schizophrenia spectrum disorders, as well as apurely symptomatic or subsyndromatic entity, potentially useful in differentialdiagnosis. A summary of the relevant data from the followingstudies are presented: a) a pilot study of 18 first admission cases (FAC);b) a systematic study of 155 FAC cases; c) a comparison of remittedbipolar patients with residual schizophrenic patients, and d) casesidentified in a large genetic population. Jointly these studies supportour hypothesis that anomalies in self-experience belong to the cardinalphenomenological aspects of schizophrenia.WO36.3.SCHIZOPHRENIC AUTISM AS A RESTINGPOSITION OF IMPAIRED INTENTIONALITY:THERAPEUTIC APPROACHC. MundtUniversity of Heidelberg, GermanyPsychotherapeutic access to schizophrenic autism requires a psychopathologicalconcept as a pathogenetic tool suitable for psychotherapy.For this purpose this presentation will look at schizophrenicautism from the viewpoint of impaired intentionality in thesense of the ability to constitute intersubjective meaning and keepingup the continuous readjustment of it. In this perspective schizophrenicautism can be looked at as a resting position of intentionalefforts. Functionally this resting position can serve either the preventionof overchallenging intentional efforts during developmentaltasks or coping with fragile and weakened intentionality after theonset of psychosis. Taking schizophrenic autism as a resting positionof impaired intentionality opens two lines of psychotherapeuticaccess: firstly, to tentatively share the patient's world of private meaningsand hence establishing a sort of preliminary intersubjectivity as astarting point for developing topics of future common meaning; secondly,to encourage patients to step out of their world of privatemeanings, to stimulate curiosity for meanings in the social space. Thisshould be safeguarded by creating a social frame in which the vigor ofintentional protrusions from the social other and the weak intentionalefforts of the patients are kept in balance so that the patient is notdiscouraged and forced into retreat again. A clinical case vignette andthe history of an artist suffering from schizophrenia will elucidatethese lines of psychotherapy.WO36.4.NEUROPHYSIOLOGICAL ASPECTS OFINTERSUBJECTIVITYV. GalleseUniversity of Parma, ItalyThe capacity to understand others as intentional agents, far from beingexclusively dependent upon mentalistic/linguistic abilities, is deeplygrounded in the relational nature of action. An implicit form of "understanding"is achieved by modeling the behavior of others as an intentionalaction on the basis of a motor equivalence between what they doand what the observer does. Mirror neurons are likely the neural correlateof this mechanism. New evidence suggests that some of the neuralstructures involved in processing felt sensations and experienced emotionsare also active when the same sensations and emotions are recognizedin others. It appears therefore that a whole range of different“mirroring systems” are present in our brain, their functional mechanismbeing embodied simulation. Simulation is embodied not onlybecause it is neurally realized, but also because it uses a pre-existingbody-model in the brain, and therefore involves a prerational form ofself-representation. Embodied simulation enables individuals to entertaina series of implicit certainties about others, thus constituting ashared manifold of intersubjectivity. I will propose that embodied simulationcould be a basic organizational feature of our brain, enablingour rich and diversified interpersonal experiences. This perspectivemay offer a global approach to the understanding of the vulnerability tomajor psychoses such as schizophrenia.WO37.CLINICAL RESEARCH ON IMPULSIVITY:NEW DEVELOPMENTS AND DIRECTIONS FORPOSSIBLE TREATMENTSWO37.1.IMPULSIVITY, AGGRESSIVENESS, ANDPERSONALITY DISORDERS: LOOKING BEYONDBORDERLINE AND ANTISOCIAL PERSONALITYDISORDERSA. Fossati 1 , E.S. Barratt 21 School of Psychology, “Vita-Salute” San Raffaele University,Milan, Italy; 2 Department of Psychiatry and Behavioral Sciences,University of Texas Medical Branch at Galveston, TX, USAAlthough extensive research has interrelated measures of impulsivityand aggression, identifying the latent structure of these constructsamong patients with selected personality disorders (PDs) has notbeen broached. Starting from these considerations, in this study 380consecutively admitted outpatients were administered the StructuredClinical Interview for DSM-IV Personality Disorders, the BarrattImpulsiveness Scale-11 and the Buss-Perry Aggression Questionnaire.Using a maximum likelihood exploratory factor analysis with aPromax rotation, six latent dimensions were identified. Impulsivityand aggression were identified as independent constructs which wererelated primarily to antisocial and borderline PDs. A less robust relationshipwas found between the aggression and impulsivity dimensionsand narcissistic/passive-aggressive PD dimension.153

WO37.2.NEW RESEARCH ON THE ASSOCIATIONBETWEEN IMPULSIVITY AND SUICIDEA.C. Swann, D.M. Dougherty, M. Pham, S. Abutaseh,F.G. MoellerDepartment of Psychiatry, University of Texas Health ScienceCenter at Houston, TX, USAClinical predictors of suicide risk in bipolar disorder are needed.Impulsivity is a prominent and measurable characteristic of bipolardisorder that can contribute to risk for suicidal behavior. The purposeof this study was to investigate the relationship between impulsivityand severity of past suicidal behavior, which is a robust predictorof eventual suicide, in patients with bipolar disorder. We measuredimpulsivity, using a questionnaire (Barratt Impulsiveness Scale,BIS-11) and a performance measure (Immediate Memory-DelayedMemory Task, IMT-DMT), in subjects with bipolar disorder who hada definite history, or absence of history, of attempted suicide. Diagnosisused the Structured Clinical Interview for DSM-IV (SCID).Interviews of patients and review of records were used to determinethe number of past suicide attempts and the medical severity of themost severe attempt. Subjects with suicide attempts had more impulsiveerrors on the IMT and had a faster latency to respond, especiallyfor impulsive responses. Impulsivity was highest in subjects withthe most medically severe suicide attempts. Effects were notaccounted for by presence of depression or mania. BIS-11 scoreswere numerically, but not significantly, higher in subjects with suicideattempts. A history of alcohol abuse was associated with greaterprobability of a suicide attempt. These results suggest that a historyof severe suicidal behavior in patients with bipolar disorder is associatedwith impulsivity, manifested as a tendency toward rapid,unplanned responses.WO37.3.IMPULSIVITY AND AGGRESSION IN ADOLESCENTSWITH CONDUCT DISORDERD.M. Dougherty, C.W. Mathias, D.A. MarshDepartment of Psychiatry, University of Texas Health ScienceCenter at Houston, TX, USAImpulsivity has been implicated as playing an important role in thedevelopment of aggressive and other maladaptive behaviors in childrenwith conduct disorder. However, the most common measures ofimpulsivity (i.e., questionnaires) are limited by reliance on the accuracyof historical recall by the subjective rater and are only appropriatefor measuring generalized tendencies to respond impulsively across avariety of situations over longer periods of time (trait specific). Wehave recently applied a modified continuous performance task amongadolescents, which demonstrated significantly greater impulsive-typeperformance among those with conduct disorders and oppositionaldefiant disorder than controls. As an extension of that work, the currentdesign explores the role of fighting history in continuous performancetask scores among adolescents with conduct disorder. A modifiedcontinuous performance task (i.e., Immediate and Delayed MemoryTasks) was administered to three groups of adolescents: thosewithout conduct disorder or a history of fighting (control), and thosewith conduct disorder who either exhibit planned (CDfight/plan) orimpulsive (CDfight/nonplan) histories of physical fighting. Impulsivetype performance on the Immediate and Delayed Memory Tasksshowed a significant difference by fighting subtype. The CDfight/nonplangroup exhibited a significantly higher proportion of impulsivetyperesponses than either the control or CDfight/plan groups, whichwere not different from one another. The current findings support thenotion that impulsivity is a characteristic associated with distinct subgroupswithin the conduct disorder population. This unique behavioralprofile has implications regarding biological mechanisms andtreatment prediction/outcome among certain sub-samples of adolescentswith conduct disorder.WO37.4.IMPULSIVITY AS A RISK FACTOR ANDCONSEQUENCE OF PSYCHOSTIMULANT ABUSEF.G. Moeller 1 , J.L. Steinberg 1 , D.M. Dougherty 1 , K.M. Hasan 2 ,A.C. Swann 1 , P.A. Narayana 2 , E.L. Reilly 1 , L.A. Kramer 2 ,E.S. Barratt 31 Department of Psychiatry and Behavioral Sciences, Universityof Texas Health Science Center, Houston, TX; 2 Department ofPsychiatry and Behavioral Sciences, University of Texas MedicalBranch, Galveston, TX; 3 Department of Radiology, University ofTexas Health Science Center, Houston, TX, USAStudies report changes in brain function and structure in individualswho abuse psychostimulants, including cocaine, methamphetamine,and methylene-dioxymethamphetamine (MDMA). There is also agrowing body of evidence that stimulant abuse is associated withincreased impulsivity. This association could be secondary to changesin brain function due to stimulant abuse, or due to personality traitsthat lead to stimulant abuse. This paper will review the literature andpresent new data on the association between psychostimulant abuse,impulsivity, and brain function. Data will be presented that stimulantabusing individuals exhibit increased impulsivity and show changesin brain function and structure relative to controls. There is also evidencethat at least some of these changes in brain function are relatedto impulsivity. Measures of brain function and structure include anauditory-oddball event related potential task, functional magneticresonance imaging (fMRI), and diffusion tensor imaging (DTI).Impulsivity measures include self-report (Barratt ImpulsivenessScale-11) as well as behavioral laboratory measures of impulsivity(Immediate and Delayed Memory Task). The data presented will supportthe hypothesis that changes in brain function seen in psychostimulantabusing individuals are also responsible for processes leadingto increased impulsivity. These results will be discussed in light ofeffects of chronic psychostimulant abuse on the brain, and possiblepharmacologic treatments for impulsivity.WO38.TEACHING AND LEARNING CORE COMPETENCIESOF BASIC CONSULTATION/LIAISON PSYCHIATRYWO38.1.CORE COMPETENCIES FOR PSYCHIATRICTRAINEES: DIAGNOSING AND TREATINGPSYCHOTIC PATIENTS IN MEDICAL SETTINGSA.M. Freeman IIIDepartment of Psychiatry, University of Tennessee Health ScienceCenter, Memphis, TN, USAA number of competencies are required of physicians who evaluateand manage psychosis in consultation-liaison settings. Of perhapsprimary importance is the need to determine the origin of the psychosis.The possibility that the medical or surgical illness is responsiblefor the psychotic phenomena must be addressed. Appropriate history,mental status examination, and laboratory findings will be essen-154 World Psychiatry 3:S1 - October 2004

tial. Awareness of the breadth of illnesses that may produce psychosisis required. These can range from Alzheimer’s disease and other neurologicalillness to several endocrinopathies, tumors (e.g. gastrointestinaltumors), infections such as HIV/AIDS, and sensory disturbancesamong many other disorders. Psychosis may often be presentin the context of delirium or dementia. Another issue is that the treatmentof medical disorders by pharmacotherapy, surgery, radiationtherapy, etc., may cause psychosis. Yet another important clinical discernmentis whether the psychosis is primary as with schizophreniaor bipolar disorder, after underlying medical causation is ruled out.Schizophrenia, for example, has numerous medical co-morbiditiesoften requiring hospitalization. Substance-induced psychotic disordersare also an important consideration in differential diagnosis. Theuse of appropriate psychopharmacotherapy is a central core competency.In general, the newer atypical antipsychotics cause fewerextrapyramidal symptoms, but there are occasions when an older,typical antipsychotic such as haloperidol is necessary to control agitatedpsychotic behavior. The tendency for glucose dysregulation andweight gain to be associated with atypical antipsychotics must be consideredin selecting treatment for psychotic patients with obesity ordiabetes.WO38.2.DELIRIUM AND THE CORE COMPETENCIESL.S. WinsteadUniversity of Colorado Health Sciences Center, Denver, CO, USADelirium is a serious medical condition with a prevalence estimatedto be between 10-30% of medically ill patients in the hospital setting.The prevalence of this condition is even greater in hospitalized elderly,cancer, AIDS and terminally ill patients. Delirium has a significantmorbidity associated with it. Elderly patients with delirium have beenestimated to have a 22-76% chance of death during the hospitalizationwhere the delirium occurs. As many of the symptoms of deliriummimic other psychiatric disorders (i.e. anxiety, apathy, psychomotoragitation, psychosis) it is imperative that the psychiatric trainee havethe ability to recognize, diagnose, and recommend treatment forpatients with this condition. Therefore psychiatric trainees should: a)have knowledge of various subgroups of patients at risk for developingdelirium; b) have knowledge of medications which may putpatients at risk for the development of delirium; c) recognize the signsand symptoms of this condition; d) recognize laboratory tests andphysical exam findings which will aid in the diagnosis of delirium; e)work with various medical/surgical teams in the diagnosis and managementof the patient with delirium; f) recommend appropriate medicaland environmental interventions to the primary team/nursingstaff/family.WO38.3.CORE COMPETENCIES FOR PSYCHIATRICTRAINEES: EVALUATION AND MANAGEMENTOF DEPRESSION IN ADULTS, CHILDREN, ANDADOLESCENTS IN MEDICAL SETTINGSK.F. SherryDepartments of Pediatrics, Adult Psychiatry, Child andAdolescent Psychiatry, University of Utah Health Sciences Center,Salt Lake City, UT, USADepression is a frequent concern in patients of all age groups. Physiciansare therefore required to remain sensitive to the presentingsymptoms of depression. In medical settings, both inpatient and outpatient,the primary physician may feel uncomfortable, or perhapsinadequate, in making the diagnosis of depression and then, in managingthe patient with depression. A simple screening tool with asymptom checklist can prompt the physician to make a referral to apsychiatrist or mental health provider if the patient needs a furtherassessment. Depression can be co-morbid with other medical conditions,often exacerbating the illness, or complicating treatment. Inconsultation-liaison settings, the psychiatrist should be aware of theconfounding medical condition and its contribution to underlyingdepression (or vice versa). Other conditions associated with depression,such as infectious (mononucleosis, HIV), endocrine (diabetes,hypothyroidism, others), or drug and alcohol abuse should also beconsidered. In choosing appropriate treatment, the psychiatristshould guide the primary physician in the choice of psychopharmacotherapy,explaining the possible side effects. Medical therapy indepressed children is not as well studied as with adults, and this hasraised some controversy when treating children. The psychiatristshould be able to relay well-known information. Selective serotoninreuptake inhibitors remain the first choice of treatment for most agegroups, but physicians should be aware of the older medications andother options with newer medications. The consulting physicianshould also be aware of other therapy options appropriate for theindividual patient.WO38.4.SUBSTANCE ABUSE IN THE MEDICALLY ILL:COMPETENCIES FOR TRAINEESD.K. WinsteadDepartment of Psychiatry and Neurology, Tulane UniversityHealth Sciences Center, New Orleans, LA, USASubstance abuse is a common problem both in general society as wellas a co-morbid condition amongst patients hospitalized in the generalhospital. Therefore, the psychiatric consultant must be able to recognize,diagnose and treat those medical/surgical patients who presentwith co-morbid substance abuse problems. Thus, the trainee inpsychiatry must: a) have basic medical knowledge of the pharmacologicactions of the most frequently abused substances; b) be able torecognize the signs and symptoms of both toxicity and withdrawal; c)be able to recommend to the attending physician appropriate managementof the signs and symptoms of toxicity and/or withdrawal; d)be able to recommend to the patient and his/her family appropriateaftercare treatment following discharge from the acute care hospital.WO39.THE CURRENT ROLE OF PSYCHOTHERAPY INGRADUATE PSYCHIATRIC TRAININGWO39.1.PSYCHIATRISTS AS PSYCHOTHERAPISTSP. RuizDepartment of Psychiatry and Behavioral Sciences, Universityof Texas Medical School at Houston, TX, USACurrently, the use of psychotherapy by psychiatrists is facing majorchallenges in the United States as a result of the managed care practicesthat are nowadays prevailing in the health and mental healthcare system in this country. Nevertheless, the training of psychotherapyin all its modalities continues to be one of the requirements forgraduate training in psychiatry in the United States. The ResidenceReview Committee (RRC) in Psychiatry, as mandated by the AccreditationCouncil for Graduate Medical Education (ACGME), not only155

equires appropriate training and clinical experiences in psychotherapyduring the four years of psychiatric residency training in the UnitedStates, but also expects that this type of training will focus on allmodalities of psychotherapy. That is, supportive, cognitive-behavioral,psychodynamic, interpersonal and other modalities. Within thiscontext, this presentation will examine the role of psychiatrists asproviders of psychotherapy in the United States given the prevalenceof managed care in the health and mental health care delivery systemof this country.WO39.2.TRAINING PERSPECTIVES ABOUTPSYCHOTHERAPY CORE COMPETENCIESM.B. RibaDepartment of Psychiatry, University of Michigan, Ann Arbor,MI, USAIn today’s training and educational environment in the United States,directors of psychiatry training are facing major challenges and difficultiesin documenting all of the current accreditation requirementspertaining to core competencies in psychotherapy. Based on the existingaccreditation requirements, as promulgated by the AccreditationCouncil for Graduate Medical Education (ACGME), all residents inpsychiatry must have appropriate exposure to all basic modalities ofpsychotherapy before they are allowed to graduate from graduatetraining programs in psychiatry in the United States. This exposurecalls for clinical experience, supplemented by appropriate supervisionand didactic seminars. Moreover, this requirement extends notonly to supportive, cognitive-behavioral, interpersonal and psychodynamicmodalities of psychotherapy, but is also required for an arrayof diagnostic categories of psychiatric disorders. This required documentationand validation from the supervisors is quite demandingand time consuming. In this presentation, this situation will be fullyaddressed, discussed, and documented.WO39.3.PERSPECTIVES OF ACADEMIC DEPARTMENTS OFPSYCHIATRY ABOUT PSYCHOTHERAPY TRAININGR.W. GuynnDepartment of Psychiatry and Behavioral Sciences, Universityof Texas Medical School at Houston, TX, USANowadays, academic departments of psychiatry in the United Statesare facing major challenges in the provision of appropriate trainingexperiences and supervision in the different modalities of psychotherapyeducation. On one side, we face the reality of the currenttraining requirements that call for the learning in psychotherapy bothclinically and didactically during the four years of psychiatric residencytraining. On the other side, however, we face the fact that clinicalexperiences in individual psychotherapy provided by psychiatricresidents are not reimbursed by medical insurance companies. Thispolicy is based on the fact that faculty supervision on site is requiredfor academic departments of psychiatry to be able to bill for psychotherapyservices provided by psychiatric residents. The availabilityand cost of faculty supervision under this model is rather prohibitiveat the present time. This situation creates a major financial hardshipfor academic departments of psychiatry under the present regulationsfrom both the medical insurance companies and the residencyaccreditation guidelines. In this presentation, these academic andfinancial challenges will be addressed and discussed.WO39.4.CURRENT PATTERNS OF PSYCHOTHERAPYTRAINING IN THE UNITED STATESA.A. MatorinDepartment of Psychiatry and Behavioral Sciences, Universityof Texas Medical School at Houston, TX, USAThe current model of graduate training in psychiatry in the UnitedStates is undergoing a major reconceptualization and restructuring.This re-modeling is not unique of the United States but is also occurringin Canada, the United Kingdom, Western Europe, and otherindustrialized regions of the world. This educational re-shaping is soimportant and novel that it requires examination, reflection and evaluation.With this thought in mind, a study was conducted among allgraduate training programs in psychiatry in the United States. Thegoal was to define the patterns of psychotherapy training that are currentlytaking place in the United States as well as their future trends.In this presentation, the results of this study will be presented, discussedand examined. Hopefully, the outcome of this discussion andexamination will be helpful for educators from other regions of theworld that might face similar situations in the near future.WO39.5.EVALUATION OF THE PSYCHOTHERAPY CORECOMPETENCY MODELE.F. FoulksTulane University Medical School, New Orleans, LA, USAThe core competency model (based on the six basic competencies:medical knowledge, patient care, practice-based learning and improvement,interpersonal and communication skills, professionalism, andsystem-based practice) is nowadays used in several developed nationssuch as the United Kingdom, Canada and the United States. It is, however,in the United States that this model has brought major challengesand dilemmas insofar as its applications to psychotherapy are concerned.The United States have given high priority and relevance to theuse of psychotherapy for several decades. Yet, this emphasis is currentlybeing seriously challenged with the prevalence in the United Statesof the managed care-oriented health and mental health system. Also, asa result of its underpinning, emphasis on evidence-basedmedicine/psychiatry is nowadays prevailing in the field. In this presentation,the impact of this dilemma in the overall educational system ofthis country will be addressed, examined and discussed.WO39.6.RESIDENTS’ PERSPECTIVES ON THE CORECOMPETENCY MODEL OF PSYCHOTHERAPYR. BaileyDepartment of Psychiatry and Behavioral Sciences, Universityof Texas Medical School at Houston, TX, USAIn the last several years, residency training programs in psychiatryacross the United States have adopted the new core competencymodel in the training of psychotherapy. This new model has greatlyimpacted on the perception and conceptualization of psychotherapyon the part of the psychiatric residents. Until recently, the view of theresidents about psychotherapy training was pessimistic at best due tothe impact of the managed care model that was prevailing in the UnitedStates for about two decades. Under this model, the opportunityfor psychiatrists to practice psychotherapy was almost nil. Yet, underthe new core competency model, psychotherapy has been given muchpriority and relevance. This new emphasis on psychotherapy as a156 World Psychiatry 3:S1 - October 2004

treatment modality in psychiatry has led to optimism and interest onthe part of the psychiatric residents. In this presentation, the perspectivesof psychiatric residents in this educational and treatment topicwill be addressed and discussed.WO40.INNOVATIVE APPROACHES TO OUTCOMEASSESSMENT OF PSYCHOSOCIALINTERVENTIONS IN SEVERE MENTAL DISORDERS(Special Workshop organized by the WorldAssociation for Psychosocial Rehabilitation)WO40.1.KEY METHODOLOGICAL ISSUES IN OUTCOMEASSESSMENTA. BarbatoMario Negri Institute, Milan, ItalyThe definition and measurement of outcome in severe mental disordersis a controversial issue in the mental health field and is a majorsource of misunderstanding among clinicians, researchers, consumers,informal caregivers and policy makers. This is particularlytrue for outcome assessment in psychosocial interventions. It is clearthat the complexity of psychosocial interventions requires the use ofinnovative approaches in the design of studies aimed at testing theirefficacy, such as the development of community-based clinical trialsand pragmatic clinical trials incorporating a qualitative approach,and treatments allocation using block randomization, cluster randomization,or patient preference allocation. Moreover, the integrationof various stakeholders’ views is of primary importance in theidentification of care endpoints.WO40.2.USE OF RECOVERY INDICATORS IN OUTCOMEASSESSMENTM. FarkasCenter for Psychiatric Rehabilitation, University of Boston,MA, USAThere are a wide range of recovery outcomes that should be taken intoaccount when assessing the efficacy of psychosocial interventions forpeople with severe mental disorders. Examples include: gaining/regaininga valued role, i.e. student, worker, family member, tenant; experiencingincreased success and satisfaction in these roles; reducing/controllingsymptoms; increased sense of self-efficacy; increased feelings ofwellbeing; increased number or quality of interpersonal connections;increased measures of physical health; increased sense of self-esteem.Research in this field should include those outcomes that consumersbelieve are most critical, and focus on recovery; subjective outcomesand qualitative approaches should assume greater credibility and utilization.Evidence-based psychosocial interventions research shouldcontinue to make the best possible use of quasi-experimental and correlationalresearch.WO40.3.OUTCOME EVALUATION OF WORKREHABILITATIONG. HarnoisMcGill University, Montreal, CanadaIn the last years various approaches to work rehabilitation haveemerged and a research base in this area is being developed. Traditionalmodels of vocational training are being gradually replaced bysocial firms, supported employment and other approaches. Currentstatus of outcome research in the field will be reviewed.WO40.4.OUTCOME ASSESSMENT: A VIEW FROMDEVELOPING COUNTRIESH. ChaudhryDepartment of Psychiatry, University of Lahore, PakistanThe evaluation of psychosocial interventions in developing countriesfaces many difficulties: in general, they are non-standardised; theircontent, duration and delivery depend on the quality and numbers ofpsychosocial care personnel; they tend to be client-specific, with veryfew generalisable models developed – simple, culture-specific andneed-based interventions which are difficult to compare with the evidence-basedpsychosocial interventions included in professionalguidelines. However, a number of strategies to integrate outcomeassessment within the care process in areas with limited resources arebeing identified. Examples will be provided from Pakistan, India andother Asian countries.WO41.HOW TO IMPROVE ADHERENCE TO PSYCHIATRICTREATMENTSWO41.1.THE RELATIONSHIP BETWEEN ADHERENCETO AND EFFICACY OF COMBINED TREATMENTVERSUS MEDICATION ALONE IN DEPRESSIVEDISORDERSG. Tibaldi, C. MunizzaDepartment of Mental Health, S. Giovanni Bosco Hospital,Turin, ItalyWe conducted a systematic overview, by means of weighed regressionanalysis, of sixteen randomised clinical trials comparing pharmacologicaltreatment alone to pharmacological treatment plus a nonpharmacologicalintervention. We measured within trial difference indropout and response rates between drug alone and combined treatmentarms. The weighed average of the differences of response rateswas 12.1% favouring combined treatment. This increase in responsewas made up by an average decrease in dropout rate of 10.7% and innon-response rate of 1.4%. Weighed regression indicates that 65.7%(p=0.008) of any reduction in dropout rate is converted into responseand the remaining is converted into non-response. When the dropoutrate difference is zero, the combined intervention generates an averageincrease in response rate of 5.1% (p=0.141) thus reducing thenon-response rate by the same amount. This study clearly demonstratesthat it is possible to reduce the dropout rate and that a largeproportion of dropouts do indeed respond to therapy. The combinedtreatment appears effective over and above drug alone only thanks to157

the response to the drug of a sizable proportion of patients whowould have otherwise dropped out of a treatment with drugs alone.WO41.2.MAIN ISSUES ABOUT IMPROVEMENT OFADHERENCE IN THE LONG-TERM TREATMENTOF SCHIZOPHRENIC DISORDERSL. Salvador-CarullaUniversity of Cadiz, SpainMany systematic reviews examined interventions aimed at improvingadherence to pharmacological treatment for schizophrenia. Althoughinterventions and family therapy programs relying on psycho-educationwere commonly used in clinical practice, they were often ineffective.Concrete problem solving or motivational techniques were usualcharacteristics of successful programs. Interventions targeted specificallyto problems of non-adherence were more likely to be effectivethan more broadly based interventions. Psycho-educational interventionswithout accompanying behavioural components and supportiveservices are not effective in improving medication adherence in schizophrenia.Specific types of community interventions such as assertivecommunity treatment and motivational interviewing have a goodlevel of efficacy, to be further confirmed. Concrete instructions topatients and problem-solving strategies, such as reminders, self-monitoringtools, cues, and reinforcements, appear useful, as well as sessionsto reinforce gains.WO41.3.INTEGRATING TREATMENT APPROACHESIN PERSONALITY DISORDERS:IMPACT ON ADHERENCE AND EFFICACYA. AndreoliService d'Accueil, d'Urgences et de Liaison Psychiatriques,Geneva, SwitzerlandIn a recent paper, A. Kopelowicz and R. P. Liberman proposed sevenprinciples to guide mental health professionals in their integration ofpharmacological and psychosocial interventions: a) pharmacologicaltreatment almost exclusively improves symptoms and reduces the riskof relapse; b) pharmacological treatment leads to improvements inpsychosocial functioning when the individual has acquired the relevantpsychosocial skills before; c) psychosocial treatments affect primarilypsychosocial functioning (social, vocational, educational, family,recreational, and self-care skills); d) both pharmacological andpsychosocial treatment have dosage related therapeutic effects andside effects; e) psychosocial treatment is most helpful for clients whoare symptomatically stable (states of partial or full remission); f) alleffective psychosocial treatments (individual therapy, group or familytherapy, day hospital, or inpatient milieu therapy) contain elements ofconcrete problem solving; g) continuing positive and collaborativerelationship infused with hope, optimism, and mutual respect isessential. Assuming that these specific principles are fully relevant tothe management of personality disorders, usually based on longerterm therapeutic programs, available data about the adherence to themore effective treatment strategies currently available for these disorderswill be reviewed. Data on the impact of psychosocial interventionson medication adherence will also be presented and discussed.WO42.OBSESSIVE-COMPULSIVE DISORDER:FROM SEROTONIN TO OTHER MONOAMINESAND BACK AGAINWO42.1.OBSESSIVE-COMPULSIVE DISORDER:FROM SEROTONIN TO OTHER MONOAMINESAND BACK AGAINJ. ZoharDivision of Psychiatry, Chaim Sheba Medical Centre,Tel Hashomer, IsraelObsessive-compulsive disorder (OCD) is a common disorder with aworldwide prevalence of about 2% and unique with regard to treatmentresponse. As opposed to other psychiatric disorders, such asdepression, panic disorder, post-traumatic stress disorder etc., inwhich monoadrenergic and serotonergic medications were found tobe effective, it seems that OCD responds primarily to serotonergicmedications. However, there are about 40% of the patients who arenot responding, or who respond only partially to appropriate interventionwith serotonergic medication. In those resistant patients, thepossibility of adding an antipsychotic, and especially the new atypicalantipsychotics, is often raised. There are actually four types of situationswhere intervention with antipsychotics might be considered:obsessive-compulsive patients with poor insight (what was previouslycalled ‘psychotic obsession’), schizophrenic patients with OCD,obsessive-compulsive patients with tic disorder, and obsessive-compulsivepatients who did not respond to intervention with an adequatetreatment (in terms of dose and duration) of antiobsessive medication.With the advances in the study of OCD, it has become apparentthat it is necessary to sharpen the diagnosis and to distinguishbetween subsets of OCD, such as early versus late onset, with tic disorderversus without tic disorder, OCD related to autoimmunepathology versus no autoimmune pathology, comorbidity of OCDand schizophrenia versus comorbidity with other anxiety or affectivedisorders, etc. It seems that an analysis which takes into considerationthese and other subtypes will provide us with better informationthan if they were studied as one group and hence shed a light on thepossible role of other monoamines in OCD.WO42.2.SEROTONINERGIC AND DOPAMINERGICSYSTEMS IN NAÏVE OBSESSIVE-COMPULSIVEDISORDER PATIENTSL. Bellodi, P. Cavedini, A. Gorini, C. Zorzi, D. PeraniVita-Salute University Medical School, Milan, ItalyObsessive-compulsive disorder (OCD) is characterized by intrusivethoughts and ritualized behaviours. Many studies suggest that thepathogenesis of this disorder may be linked to deficits in serotoninergicand dopaminergic neuronal transmission. We investigated in vivoserotonin 2A (5-HT2A) and dopamine (D2) receptors activity in OCDusing positron emission tomography (PET). PET imaging was performedin 9 drug-naïve OCD patients and 8 healthy controls after theadministration of [11C]MDL, a highly selective 5-HT2A receptorantagonist, and 11C-labelled raclopride ([11C]RAC), a potent selectiveD2 receptor antagonist. Statistical analysis was performed usingvoxelwise analysis of spatially normalized parametric maps (SPM99)and region of interest (ROI) analysis. [11C]MDL-PET binding data inOCD patients compared to controls showed significant reductions of5-HT2A receptor density in the dorsolateral frontal cortex bilaterally158 World Psychiatry 3:S1 - October 2004

and in the anterior cingulate cortex, the right insula and the left middletemporal gyrus. The same analyses for [11C]RAC binding revealedan increased D2 receptor activity in OCD patients in the ventral striatumand in the putamen. The study provides evidence of the involvementof serotoninergic and dopaminergic systems in the pathophysiologyof OCD. In particular, a key role for the striatum in the regulationof stereotyped behaviour patterns is highlighted by the increasedventral and dorsal striatal [11C]RAC binding. Behavioural disordersin OCD associated with serotoninergic system dysfunction provide arationale for pharmacological treatment with selective serotonin reuptakeinhibitors.WO42.3.INTRACELLULAR MECHANISMS IN OBSESSIVE-COMPULSIVE DISORDERD. Marazziti, S. Baroni, L. Palego, I. Masala, B. Dell’Osso,L. Betti, G. GiannacciniDepartment of Psychiatry, Neurobiology, Pharmacology andBiotechnology, University of Pisa, ItalyProtein kinase C (PKC) and protein kinase A (PKA) are the final targetsof the pathways mediated, respectively, by the breakdown ofphosphatidylinositol-4,5-bisphosphate and cyclic AMP (cAMP). Preliminaryindications are available on alterations of these intracellularmechanisms in obsessive-compulsive disorder (OCD). Therefore, weinvestigated whether OCD patients differed from control subjects inthe effect of PKC upon the 5-HT transporter, after stimulation of thisenzyme with 4-beta-12-tetradecanoylphorbol 13-acetate (ß-TPA).Basal velocity of adenylate cylase (AC), as well as the effect of thesynthetic catecholamine isoprenaline (ISO), were also examined. Atbaseline, OCD patients showed a significant decrease in the maximalvelocity (Vmax) of 5-HT uptake, as compared with control subjects,with no change in the Michaelis-Menten constant (Km). The activationof PKC with ß-TPA provoked a significant decrease in Vmax valuesin both groups, but the effect was significantly more robust inOCD patients who, in turn, also showed an increase in Km values.On the contrary, with regard to basal AC activity or ISO stimulation,no difference was observed between the two groups: however, OCDpatients showed a leftward shift of the ISO dose-response curve thatdid not reach statistical significance. These results could indicate thepresence of hyperactivity of PKC in OCD that could be the result ofincreased activity of the phosphatidylinositol pathway. The findingsregarding AC might be due to a possible condition of supersensitivityof beta2-adrenoreceptors in OCD. Taken together, the overall findingssuggest that intracellular mechanisms are altered in OCD andmight, perhaps, represent the targets of future drugs.WO42.4.ALTERNATIVE ANTI-OBSESSIONAL AGENTSG. Maina, U. Albert, F. BogettoDepartment of Neurosciences, Anxiety and Mood Disorders Unit,University of Turin, ItalyAlthough treatment with serotonin reuptake inhibitors (SRIs) such asclomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline andcitalopram represents a promise for many patients with obsessivecompulsivedisorder (OCD), still a proportion comprised between 40and 60% fail to adequately respond to such agents or are intolerant toside effects. This underlines the urge to develop other pharmacologicalagents for the treatment of OCD and to develop new strategies forpatients resistant to SRIs. Several compounds have been tested, bothin drug-naïve and in resistant subjects, without satisfactory results.The only compound to date which seems to exert an antiobsessiveaction is venlafaxine. Venlafaxine, a serotonin and norepinephrinereuptake inhibitor, similar to clomipramine but lacking the anticholinergic,antihistaminic, and alpha-adrenergic blocking effects,has been studied in the treatment of OCD. We will present resultsfrom a 12-week, single blind study versus clomipramine in the treatmentof drug-naïve patients and from a 12-week, single blind studyversus clomipramine and citalopram in the treatment of patientsunresponsive to at least two previous trials with selective SRIs(SSRIs) other than citalopram. These studies, together with otherdata coming from different groups of researchers, strongly support theneed of well controlled studies performed in double-blind conditionson the use of this compound in the treatment of OCD.WO42.5.LONG-TERM PHARMACOLOGICAL TREATMENTOF OBSESSIVE-COMPULSIVE DISORDERF. Catapano, M. Masella, F. Perris, F. Rossano, L. Magliano,M. MajDepartment of Psychiatry, University of Naples SUN, Naples,ItalyObsessive-compulsive disorder (OCD) is a chronic lifelong illnesswith a waxing and waning course, that can have a significant impacton the quality of life of the sufferers and their families. Behavioral andpharmacological therapies have been found to be effective in thetreatment of OCD, both alone and in combination. However, the literatureon long-term treatment of OCD is rather controversial, due tothe paucity of studies exceeding a 2 year follow-up. The aim of thisstudy was to evaluate the long-term course of OCD in patients treatedwith serotonin reuptake inhibitors (SRIs) and to identify predictorsof clinical outcome. Seventy-nine patients fulfilling DSM-IV criteriafor OCD were followed prospectively for 3 years. Baseline informationwas collected on demographic characteristics, axis I and IIdiagnosis, family history, and severity of obsessive-compulsive (OC)and depressive symptoms using standardized instruments. During thefollow-up period, the clinical status of each patient was evaluatedmonthly in the first year and bimonthly thereafter by means of theYale-Brown Obsessive Compulsive Scale (Y-BOCS) and the HamiltonRating Scale for Depression (HDRS). Twenty-one patients werelost at various stages of follow-up. At the end of the third year, 24patients (44%) still met full criteria for OCD, 19 (34%) were in partialremission, and 12 (22%) were in full remission. The cumulative probabilityof achieving at least partial remission from OC symptoms duringthe 3-year period was 68%. The probability of full remission was38%. For subjects who achieved at least partial remission, the probabilityof subsequent relapse was 60%. Significant predictors of pooroutcome included an earlier age at onset, a longer duration of illness,and a greater severity of OC and depressive symptoms at intake.WO43.GUIDELINE DEVELOPMENT ANDIMPLEMENTATION IN PSYCHIATRYWO43.1. STEPS FOR GUIDELINE DEVELOPMENTT. KendallRoyal College of Psychiatrists´ Research Unit, London, UKClinical guidelines are systematically developed statements whichenable clinicians and patients to make decisions about appropriatetreatment for specific situations. The initial guideline development at159

the National Institute for Clinical Excellence (NICE) made use of afive-step model to achieve optimised treatment for people with schizophreniain England and Wales. Identifying and refining the subjectarea was the first step in developing the guideline. Then strategies hadto be designed allowing a systematic search for evidence. In addition,aspects concerning cost-effectiveness were examined.WO43.2.GUIDELINE ADHERENCE IN INPATIENTSCHIZOPHRENIA CARES. Weinmann, B. JanssenDepartment of Psychiatry, Heinrich Heine-University, Düsseldorf,GermanyGerman Guidelines for Schizophrenia Care have been developedsince 1996. However, there are few incentives for guideline implementationand practical use. Within the multicenter German ResearchNetwork in Schizophrenia (GRNS), seven psychiatric hospitals participatedin a quality management study with the aim to improve schizophreniatreatment outcomes by implementing guidelines and qualitycircles, and benchmarking relevant processes and outcomes. Baselinedata point to significant differences in patient case-mix and treatmentprocesses between the seven hospitals. Mental state at admission, particularlythought disturbance, and a chronic disease course were bestpredictors for mental state outcomes at discharge. Guideline adherenceamong hospitals was moderate. To correlate guideline adherencewith outcomes, case-mix adjustment models had to be used controllingfor mental state, duration of disease, age, comorbidity and occupationaland residential situation. Overall low guideline adherenceconcerning a variety of treatment domains was associated with pooreroutcomes. However, results differed whether mental state or socialfunctioning was used as primary outcome parameter.WO43.3.THE TEXAS MEDICATION ALGORITHMPROJECT: STEPS FOR OPTIMAL GUIDELINEIMPLEMENTATIONJ.A. Chiles, A.L. MillerUniversity of Texas Health Science Center, San Antonio, TX, USABy transforming clinical guidelines into specific stepwise graphicalsequences (algorithms), strategies and methods arise, which lead tooptimised therapeutic effects. The Texas Medication Algorithm Project,started in 1996, is designed to develop, implement and evaluatea set of medication algorithms in the Texas public mental health sector.It is a public and academic effort that consists of four phases. Amajor result has been the development of medication treatmentguidelines for three major psychiatric disorders: schizophrenia, majordepressive disorder and bipolar disorder. The rationale for using algorithmsis to improve the quality of treatment by reducing unnecessaryvariations in clinical practice. These algorithms go beyond guidelinesby providing a systematic approach to decision making that shouldprovide similar answers when clinicians are faced with similar clinicalsituations. Phase IV of the project focusses on algorithm implementationin clinical care.WO43.4.GUIDELINES AND DECISION SUPPORT SYSTEMSIN OUTPATIENT SCHIZOPHRENIA CAREB. Janssen, R. Menke, D. Geßner-ÖzokyayDepartment of Psychiatry, Heinrich Heine-University, Düsseldorf,GermanyThe positive effect of adherence to evidence-based guidelines hasbeen repeatedly shown. Electronic systems for interactive decisionsupport are new methods of implementing guidelines. The presentstudy evaluates different approaches to optimise schizophrenia outpatienttreatment. Elements of internal quality assurance (documentationsystem, implementation of guidelines and monitoring systems)as well as elements of external quality management (benchmarking)are being established in hospital-associated practice networks of psychiatristsin four project groups. 15 private practice psychiatrists inthe experimental group 1 work with computer-aided documentationand decision support. Various guidelines appear at trigger points (e.g.psychopathological deterioration, relapse). In addition, psychiatristsreceive comparative data feedback focussing on patient outcome variables(benchmarking). A second group of 9 psychiatrists in privatepractice use computer-aided documentation systems without guidelinesand benchmarking, but implement quality circles. Another twocontrol groups in Munich assess patients and treatment using a paperand pencil version without benchmarking data or guideline implementation.583 patients with schizophrenia were recruited by 55 psychiatristsand followed-up for at least 16 months. There were no baselinedifferences in psychopathology between the groups. After 16months, patients in the experimental group had a significant reductionin Positive and Negative Syndrome Scale general, positive andnegative scores; nearly similar results were obtained in the secondgroup working with quality circles. In the control groups no suchchanges were found. Further data with regard to guideline adherencewill be analysed.WO44.THE CURRENT MANAGEMENT OF ALZHEIMER’SDISEASEWO44.1.TREATMENT OF ALZHEIMER’S DISEASE:FROM CHOLINESTERASE INHIBITORS TOANTI-AMYLOIDE. GiacobiniDepartment of Rehabilitation and Geriatrics, Universityof Geneva, SwitzerlandVarious forms of pharmacological treatment are being tested clinicallyin an effort to slow down or block the conversion of mild cognitiveimpairment to Alzheimer’s disease (AD). Experimental and clinicaldata suggest that cholinesterase inhibitors (ChEI) in addition tosymptomatic benefit might have a delaying effect on AD progression.Other approaches being investigated include anti-inflammatories,nootropics, amino-3-hydroxy-5-methyl-4-isoxazole propionic acid(AMPA) receptor agonists. Data from the recent vaccination studywith pre-aggregated A-beta-42 shows that patients who generatedamyloid plaque immunoreactivity over one year period showed a significantlyslower rate of decline of cognitive functions and animprovement in activities of daily living. These preliminary resultssuggest that targeting beta-amyloid with immunization could be ofbenefit to early cases of AD.160 World Psychiatry 3:S1 - October 2004

WO44.2.NON-PHARMACOLOGICAL TREATMENTSIN DEMENTIAO. ZanettiAlzheimer’s Research and Care Unit, S. Giovannidi Dio - Fatebenefratelli Institute, Brescia, ItalyReality orientation (RO) is the only rehabilitative approach for thedemented patients supported by clinical evidence. A recent Cochranereview about RO evaluated 6 randomized controlled trials, with atotal of 125 subjects. Change in cognitive and behavioural outcomesshowed a significant effect in favour of treatment. Cochrane reviewersconcluded that there is some evidence that RO has benefits onboth cognition and behaviour for dementia sufferers. Reminiscencetherapy (RT) is based on the assumption that remote memory remainsintact until the latter stages of dementia and could be used as a formof communication with the patient. RT can be conducted on an individualbasis or in a group and involves the recall of past events withthe use of music, photographs and other aids. RT is usually conductedin weekly sessions by trained staff. The aims of RT include: socialisation,memory stimulation and intergenerational sharing. Specificforms of sensory stimulation (e.g. music therapy, aromatherapy, brightlight therapy) and exercise have been investigated as interventions forbehavioural and psychological symptoms of dementia. The aims ofstimulation therapy are both calming and activating. Music therapyaims to aid communication with patients who can no longer use languageand is based on the observation that musical abilities, includingsinging, remain preserved until the later stages of dementia. Musictherapy aims to provide social stimulation, reduce agitation, encouragereminiscence and help patients cope with emotional problems.Aromatherapy involves the use of essential oils either massaged intothe hand or used in oil burners or baths in order to provide sensorystimulation, reduce agitation and aggressive behaviour. Bright lighttherapy has been found to be effective in the treatment of sleep disturbance.The aim of bright light therapy is to attempt to re-establishcircadian rhythms and reduce sleep disturbance.WO44.3.THERAPY OF ALZHEIMER’S DISEASE:WHAT IS THE FUTURE?F. DragoDepartment of Experimental and Clinical Pharmacology,University of Catania, ItalyThe pathogenesis of Alzheimer’s disease includes, among others,factors such as oxidative stress, inflammation and deficit of thebrain cholinergic system. An example of therapeutic approach to bedeveloped concerns the pharmacological interference with betaamyloid.There is evidence that intracerebroventricular infusion ofbeta-amyloid causes brain dysfunctions similar to those ofAlzheimer’s disease, as evidenced by neurodegeneration andimpairment of learning and memory in rodents. However, themechanisms of neurotoxic effects of beta-amyloid in vivo are notfully understood yet. Neuronal degeneration induced by beta-amyloidaffects subcortical nuclei modulating various physiologicalprocesses and behaviors. Various neurotransmitters are involvedin synaptic connections of these nuclei, including acetylcholine,norepinephrine, dopamine and serotonin. Indeed, beta-amyloidfragments induce a dose-dependent memory deficit in mice. Theireffect on memory retention depends upon the time of administrationand seems to involve cannabinoid CB1 receptors in the brain,as the administration of the cannabinoid CB1 receptor antagonistSR141716A reverts the impairment of cognitive capacity induced bybeta-amyloid fragments. Other therapeutic routes may be the developmentof new drugs acting as antagonists on the N-methyl-Daspartate(NMDA) glutamate receptors. Furthermore, beta-secretaseand gamma-secretase enzymes produce beta-amyloid and drugswhich inhibit these enzymes have entered clinical trials. Scientistsare also researching ways to activate non-neural brain cells, knownas microglia, whose function is to clear away amyloid and preventthe build-up of plaques. While trials for the anti-amyloid vaccineAN-1792 were suspended in 2002, scientists continue to investigatean immune response to remove amyloid plaques. Scientists arestudying ways that may help decrease or prevent neurodegenerationand may help injured neurons to re-grow. One method involves theapplication of nerve growth factors or drugs that mimic their effects.Researchers are also excited at the prospect of replacing lost neuronsby using stem cells derived from bone marrow and other tissues,which have been induced to change into neurons. Finally,studies with estrogens, Ginkgo biloba extract and vitamins/antioxidantsdeserve some interest.WO45.COMING-OUT AND HEALTH CARE FOR YOUNGHOMOSEXUALSWO45.1.ANTI-HOMOSEXUAL RHETORIC AND THECOMING-OUT OF YOUNG GAYSR. KjaerP.O. Box 7090, Homansbyen, Oslo, NorwayAn increasing aggressive media strategy from conservative religiousgroups in Norway exposes young gays in their coming-out process tocondemning and disparaging attitudes. Examples of psychiatrists andmedical doctors supporting this activity are to be found and this createsan unclear and insecure situation among young gays as what toexpect if they go to a psychiatrist or general practitioner with problemsin this potentially vulnerable phase. Based on clinical material andreview of literature, the presentation will describe how this can influencethe coming-out process where internalizing of negative attitudesto homosexuality leads to specific therapeutic challenges.WO45.2.SEXUAL ORIENTATION AND HEALTH-RELATEDISSUES IN ADOLESCENCER. KittsDepartment of Psychiatry, Upstate Medical University,Staten Island, NY, USAThe study attempts to assess and understand physicians’ inadequaciesin the management of sexual health-related issues with adolescentpatients. It places emphasis on sexual orientation to promote theimprovement of healthcare for young homosexuals. Overall improvementin adolescent healthcare by providing further understanding ofa physician’s relationship with such issues is another objective. Howoften physicians address and discuss sexual orientation, how awareare they of issues dealing with sexual orientation, and how preparedare they in dealing with these issues are addressed by the study. Thestudy was conducted by distributing an anonymous survey to residentsand attending physicians in family practice, internal medicine,psychiatry, obstetrics and gynecology, emergency medicine, and pediatricsat Upstate Medical University and the University of Hawaii.161

WO45.3.YOUNG HOMOSEXUALS AND THEIR FEAR OFHOMOPHOBIC ATTITUDESP. SingyPsychiatry Service, Lausanne, SwitzerlandA qualitative study among young gays in the French speaking area ofSwitzerland concentrated on the view that young homosexuals had oftheir medical practitioners. The study further analyzed the relationshipthey had with them and observed that the fear of suffering homophobicattitudes in this treatment relationship and in society in generalrepresents a great preoccupation among the people interviewed.WO45.4.PSYCHIATRY AND SUICIDAL THOUGHTS INYOUNG HOMOSEXUALSP. CochandPsychiatry Service, Lausanne, SwitzerlandThe view that young homosexuals had upon their psychologists andpsychiatrists was highlighted in a qualitative study among young gaysin the French speaking area of Switzerland. One third of the interviewedpopulation reported they had once gone through depressionwith or without the determination of committing suicide. Thesealarming findings should incite psychologists and psychiatrists torethink their clinical practice with this group of patients.WO46.COGNITIVE DYSFUNCTION IN SCHIZOPHRENIA:FROM EVALUATION TO TREATMENTWO46.1.BARRIERS AND OPPORTUNITIES IN THETREATMENT OF COGNITIVE IMPAIRMENT INSCHIZOPHRENIAM. DavidsonDepartment of Psychiatry, Sheba Medical Center, Tel Aviv, IsraelCognitive impairment is often but not invariably inherited. It does notcorrelate with severity of delusions and hallucinations and it is weaklycorrelated with severity of primary negative symptoms, and thoughtprocessing impairment. There is conflicting evidence whether, followingthe first episode, cognitive performance stabilizes or continues todeteriorate. Comparison on cognitive batteries between groups ofschizophrenic patients and population norms or non-schizophrenicindividuals reported differences ranging between 1 and 2 SD on compositescores and inferior performances on at least one specific test in70 to 90% of the patients. Therefore, trials have to include large numbersof patients to detect small and variable effects. Furthermore, toshow that a compound is useful in clinical practice it must be proventhat it benefits not only performance on cognitive tests but also cognitivelyrelated social and vocational performance or at least intermediatesurrogates between it and the tests. Although there exist specificdomains of cognitive performance on which schizophrenic patientsare impaired, there is considerable heterogeneity regarding thedomain and quality of the impairment. Hence, it is difficult to decidewhat kind of schizophrenic patients to enroll into trials and whatscale to use to measure change. Also, the most likely trial designshould be an add-on one, in which the cognitive enhancers or placeboare added to an antipsychotic drug. However, add-on designs areoften difficult to interpret. Moreover, there are currently no clearindications from the regulatory bodies about what trials design andoutcome measurements would be acceptable in order to gain an indication,making the pharmaceutical industry reluctant to invest in thisdirection. Furthermore, several biological hypotheses exist to explainthe cognitive impairment, but none has been proven, making theselection of compounds to be tested in trials difficult. Despite thesedifficulties, the realization that cognitive impairment is a majorsource of suffering and disability to schizophrenic patients is responsiblefor initiatives common to academia, government and industry todevelop an appropriate treatment. A number of such initiatives arecurrently underway.WO46.2.THE REMEDIATION OF COGNITIVE DEFICIT INSCHIZOPHRENIA: THE STATE OF THE ARTA. RossiDepartment of Experimental Medicine, University of L’Aquila, ItalyThe current literature on strategies and methods of cognitive remediationin schizophrenic disorders has been focused on the remediationof executive functions. The possibility of an improvement of the neurocognitivedeficit through specific interventions has been hypothesized.People with schizophrenic disorders have some degree of cognitivedeficit that often precedes the clinical onset, is not secondary tothe symptoms of the disorder and persists even when the positivesymptoms have been resolved. The possibility that the neurocognitivedeficits could be modified by psychological remediation with effectsnot exclusively confined to the cognitive domain has been nowadaysaccepted and numerous studies demonstrate that these interventionsare effective, with a positive impact on social and working abilities,symptomatology and self-esteem.WO46.3.DISTRIBUTION OF WCST REMEDIATION AMONGSCHIZOPHRENIC PATIENTS TREATED WITHTYPICAL OR ATYPICAL ANTIPSYCHOTICSP. Stratta 1 , F. Carusi 1 , A. Di Genova 2 , A. Tomassini 2 , A. Rossi 21 Department of Mental Health, Local Health Unit 4, L’Aquila;2 Department of Experimental Medicine, University of L’Aquila,ItalyTo appreciate the potential of efforts for improving psychiatric careand their impact on opportunities for rehabilitation, we examined theutility of a categorization of a schizophrenic sample on the basis oftheir response to a modified procedure for Wisconsin Card SortingTest (WCST) administration that, through verbalization, has beendemonstrated to be useful to remediate the cognitive performance. Asample of 70 recent onset to long-term schizophrenic patients treatedand clinically responsive to ‘atypical’ (A) or typical (T) antipsychotics(APs), and with relatively good outcome in terms of Global Assessmentof Functioning Scale (GAF, at least 65) were evaluated along anaturalistic observation. Patients were divided on the basis of theWCST remediation pattern through verbalization into ‘good performers’,‘remediators’ and ‘poor performers’. The analysis of the datashows a significant different distribution of subjects responsive to APtreatment, with more ‘good performers’ in the subgroup responsive toAAPs and no ‘remediators’ in the patients treated with TAPs. Subjectson AAPs showed less perseverative errors than those on TAPs, bothwith the standard and the modified administration. Subjects assumingAAPs but not those receiving TAPs reduced perseverative errors withverbalization. These data suggest the potential relevance of the findingsfrom neurocognitive assessment as predictors of AP response.162 World Psychiatry 3:S1 - October 2004

WO46.4.A RANDOMIZED, PLACEBO-CONTROLLED,ADD-ON STUDY OF THE EFFECTS OF COGNITIVEREMEDIATION ON FUNCTIONAL OUTCOMES OFCOGNITIVE-BEHAVIOURAL REHABILITATIONR. Cavallaro 1 , S. Anselmetti 1 , M. Bechi 1 , E. Ermoli 1 , F. Cocchi 1 , A.Vita 2 , C. Mencacci 3 , P. Stratta 4 , A. Rossi 4 , E. Smeraldi 11 Department of Neuropsychiatric Sciences, Vita-Salute UniversityMedical School, Milan; 2 Department of Mental Health, AziendaOspedaliera, Melegnano, Milan; 3 Department of Psychiatry,Fatebenefratelli Hospital, Milan; 4 Department of ExperimentalMedicine, University of L’Aquila, ItalyThere is a growing interest in cognitive rehabilitation of schizophreniadeficits, in particular in what is called ‘cognitive remediation’,where cognitive deficits are treated directly through repeated practiceon cognitive exercises. This approach is mainly hypothesized to overcomethe so-called ‘cognitive limiting factors’ to rehabilitation, gainingthe effect of classical cognitive-behavioural therapy. Nevertheless,generalization of these effects to functional outcomes is still unclear.The aim of this controlled study was to evaluate the efficacy of a programof computer-aided neuropsychological enhancement of cognitivedysfunctions in a sample of chronic schizophrenics participatingin a cognitive-behavioural rehabilitation program, and to assess itseffectiveness on daily functioning and quality of life. The sample consistedof 75 patients with clinically stabilized schizophrenia, whowere tested before and after three months of a single blind, placebocontrolledcognitive enhancement program with the Brief Assessmentof Cognition in Schizophrenia battery, the Wisconsin Card SortingTest (WCST) and the Continuous Performance Task (CPTax) toassess neuropsychological performance change. Psychopathologicaland functional assessment were performed by the Positive and NegativeSyndrome Scale (PANSS) and the Quality of Life Scale (QLS), onthe same occasions. Patients were randomised to placebo or activecomputer-aided cognitive training with multiple weekly sessions,added to a standard cognitive-behavioural rehabilitation program.We observed a significantly better outcome of measures of executivefunction (WCST p=0.04), sustained attention (p=0.02) and of themeasure of daily functioning (QLS p=0.02) at ANOVA analysisamong patients randomised to active treatment in comparison tothose receiving placebo. These results confirm previous studiesreporting positive effects of cognitive remediation therapy on cognitivefunctioning, but demonstrate also a significant effect on functionaloutcomes of rehabilitation programs.WO47.EARLY PSYCHOSIS: NEW STRATEGIES FORPREVENTION AND REHABILITATIONWO47.1.EARLY PSYCHOSIS: PREVENTION ANDREHABILITATIONF. Orsucci, M. Mazza, S. De RisioInstitute of Psychiatry and Clinical Psychology, CatholicUniversity of Rome, ItalySeveral studies conducted worldwide in the past decade have describeda delay averaging 1 to 2 years between the onset of psychosis and accuratedetection, diagnosis, and initiation of treatment. Reported associationsbetween treatment delay and longer time to medication responseand earlier relapse have focused attention on duration of untreated psychosisas a potentially modifiable determinant of illness course. Theprovocative hypothesis that delayed treatment allows disease progressionthat affects long-term morbidity, along with intriguing descriptionsof detection and prevention efforts, has catalyzed a surge of scientificinterest in the early detection, treatment, and prevention of schizophrenia.This interest has grown alongside recognition that despiteprogress in developing medications with fewer side effects, the treatmentof established schizophrenia is very often inadequate to alleviatethe morbidity and disability associated with chronic forms of the illness.Deficit symptoms and cognitive impairments, which appear to bethe greatest determinants of disability in this disorder, remain largelybeyond the reach of current treatments. Scientific interest in the possibilityof altering the course of schizophrenia through early interventionhas generated both enthusiasm and controversy. While there is littledisagreement that timely detection and treatment of those already illwith schizophrenia are important public health priorities, the identificationand treatment of patients prior to full-blown disease onset hasgenerated a significant debate.WO47.2.DEPRESSION AND QUALITY OF LIFE IN THE EARLYCOURSE OF SCHIZOPHRENIAF. Bogetto, P. RoccaDepartment of Neurosciences, University of Turin, ItalyDepression remains poorly understood in schizophrenia, even if thiscondition is common among schizophrenic patients. The reportedrate of depression is 7% to 75%, with a modal rate of 25%. Differencesin cohort status, illness chronicity, and assessment methods allcontribute to the variability of these estimates. The occurrence ofdepression in schizophrenia has often been associated with worseoutcome, impaired functioning, personal suffering, higher rates ofrelapse or rehospitalization and even suicide. The question ofwhether the depressive syndrome could be considered an epiphenomenonof other symptoms of schizophrenia remains unclear. Fewstudies focused on the relationship between depressive and positivesymptoms and this literature showed conflicting results, with somestudies reporting an association between depressive symptoms andpsychotic exacerbation, and others not. The issue of overlap betweennegative symptoms and depressive symptoms has been debated inthe literature, too. We investigated whether depressive symptoms,assessed by Calgary Depression Scale for Schizophrenia, were significantlyassociated with functional outcome in a group of subjectswith recent-onset schizophrenia (n=54). We also analyzed depressionand social functioning in a group of chronic schizophrenicpatients (n=108). In both patient groups, depressive symptoms werestrongly related to quality of life. This finding suggests that depressivesymptoms should represent a focus of attention in schizophrenia,particularly in view of their relevance for clinical treatment andrehabilitation.WO47.3.PROBLEMS OF EARLY INTERVENTION INPSYCHOSISG.M. Galeazzi 1 , K. Elkins 2 , M. Rigatelli 11 Department of Psychiatry, University of Modena andReggio Emilia, Italy; 2 Department of Psychiatry, University ofMelbourne, AustraliaWhile prompt state of the art intervention in cases of full blown psychosisis an important and generally agreed upon goal, importantquestions remain open about indications, potentials and limitations163

(including ethical aspects) of intervention programs for individualsconsidered at very high risk of later psychotic development. Theauthors review problems in this research area and in particular: a)recent epidemiological data that, suggesting that psychotic-like experiencesare common in the general population, may cast doubt on thespecificity of intervention programs targeted on the formal characteristicsof these experiences; b) the issue of predictive power of availableinstruments to evaluate these at risk states; c) controversy about thereal meaning of the reported association between duration of untreatedpsychosis and outcome; d) the persistence of preventive effect oncethe active intervention phase ceases; e) the implications, at the ethicallevel, of adopting both pharmacological and non-pharmacologicaltreatments, in situations not well defined in a psychopathological way;f) the meaning and appropriateness of establishing dedicated centresand programs for first episode psychosis in comparison to treatment ingeneral community mental health centres. The authors suggest thatthese issues deserve wide debate involving not only researchers andpolicy makers but also consumers and the general public beforeextending research models to everyday practice.WO47.4.BOUFFÉE DÉLIRANTE: A FIRST APPROACHF. Tonioni, C. Cuomo, V. Faia, R. Lacerenza, P. Madia, S. De RisioInstitute of Psychiatry and Clinical Psychology, CatholicUniversity of Rome, ItalyThe onset of the psychotic process takes sometimes the form of asudden explosion of fragments of the Self which are almost obliteratedin the Inconscious, where they lie substantially dissociated fromthe rest of personality, in order to provide a delicate, precarious balance.If sky is conscience, the explosion (or eruption) is similar to avolcanoid whirl, incandescent lava, lapilli thrown toward infinity,that gravity brings back to the subtle rifts of the conscience surface.These sudden bouffées can undergo different evolutions; one of themost favourable is a sort of "self-recomposition", which is quite rare,and resolves in the re-establishment of the previous, precarious balance,with the residue of some more or less consistent scar tissue.More frequently, the recovery is tightly related to the "empathic" wayof approaching the patient since the first clinical interview. In fact thetherapist's "retention-comprehension" skills may play a significantrole in determining the evolution of the clinical picture. We arestrongly convinced that the therapist should have a "psychoanalyticmind", considering the content of the fragments of the Self chaoticallyexpelled, typically interrelated by an intimate logic that can berebuilt, stitched up, according to a program of pharmacological-psychotherapeutictreatment for each patient.WO48.THERAPEUTIC FACTORS IN THE DIFFERENTPSYCHOTHERAPEUTIC METHODSWO48.1.THERAPEUTIC FACTORS IN COGNITIVEBEHAVIORAL THERAPY WITH SPECIALEMPHASIS ON INTERPERSONAL APPROACHESJ. BurmeisterSwiss Psychiatric AssociationWe are struggling for effectiveness and appropriate cost managementin the public health services on a global scale. In general, more importanceis attached to immediate economic benefit than to treatmentefficacy. Suboptimal and false treatments, induction of chronicity andpoor health economics contrast with the available beneficial psychologicaltreatments. The second generation of the General Model ofPsychotherapy exhibits a number of well identified therapeutic factorswhich can sufficiently explain the effectiveness of psychotherapeuticinterventions apart from so called unspecific factors: the activityof the therapist, the explanation/understanding of the disorder,the management/positive influence on the disorder and the use ofresources. In cognitive therapy most interventions foster individualself management (empowerment; competence enhancement) by: a)giving information including explanation of symptoms; b) providingways to intervene by monitoring and modifying stressful symptoms; c)putting emphasis on different resources. One of the main targets is theinterpersonal sphere with functional diagnostics and systematicchange programs (family therapy, psycho-education).WO48.2.THERAPEUTIC FACTORS IN PSYCHODYNAMICINPATIENT TREATMENTM. Schmolke, M. AmmonGerman Academy for Psychoanalysis, Berlin, GermanyOur dynamic psychiatric concept of a “healthy person” is not justfreedom from disease and symptoms nor a static consideration of anenduring and stable state of well-being. Our concept of health andhealing aims at a process towards identity formation, developmentalpossibilities and goals and meaningfulness in life. Disease is regardedas one of a person’s possibilities and a momentaneous loss ofhomeostasis of various personality functions. In a state of disease aperson is no longer able to cope with internal and external stress andchallenges. Symptomatology is understood as an important source ofcommunication in the person’s environment and can be used as acommunication bridge in psychotherapy. The treatment goal is thereforenot regaining of an earlier state of well-being but differentiationand strengthening of a person’s identity, regulatory forces and capabilityto establish and maintain human contacts. The followingaspects of psychodynamic inpatient treatment are essential in ourDynamic Psychiatric Hospital in Munich: a) constructive use of thetotal context of the hospital as a transference and counter-transferencefield and as a field of real interpersonal relationships; b) identitypsychotherapy in verbal and non-verbal groups; c) strengtheningthe patients’ non-pathological part of personality in the sense of“alliance with the healthy Ego parts”, such as skills, competences,talents, life experience, knowledge – the so-called internal and socialresources; d) working with reflection and transference/countertransferenceprocesses and group dynamics in case-conferences andteam supervision.WO48.3.THERAPEUTIC FACTORS IN PSYCHODRAMATIC–PSYCHODYNAMIC GROUP THERAPYG. TarashoevaBulgarian Psychiatric AssociationAccording to the 2001 report of the World Health Organization“Mental Health: New Understanding, New Hope”, psychotherapyis one of the main methods of modern treatment of mental illness.This understanding, coming from the bio-psycho-social model ofmental illness, succeeded in entering in Bulgaria in the new law forpublic health. What is, actually, that cures in psychodrama? What isthe target of the therapeutic factors, what do they influence andhow? Which are the therapeutic tools of psychodrama and psycho-164 World Psychiatry 3:S1 - October 2004

dynamic group therapy that we can use for fulfilling the therapeuticfactors? Some of the therapeutic factors in psychodrama are: actingcatharsis; acting insight; corrective emotional experience; re-integrationof the new experience; re-learning (emotional, cognitive,interpersonal).WO49.UPDATE ON RESEARCH IN PSYCHIATRICTREATMENT ISSUES FOR LESBIAN, GAY,BISEXUAL AND TRANSGENDER PATIENTSWO49.1.DIAGNOSIS RELATING TO HOMOSEXUALITYIN ICD-10: TREATMENT IMPLICATIONSG. NakajimaCenter for Special Problems, San Francisco, CA, USAAlthough homosexuality was deleted as a mental illness in ICD-10 in1992, egodystonic sexual orientation, which is defined as "the genderidentity or sexual preference is not in doubt but the individual wishesit were different because of associated psychological and behavioraldisorders, and may seek to change it" remained a diagnostic category.Sexual maturation disorder and sexual relationship disorder werealso added. All three of these diagnoses can be subdivided by sexualorientation to include homosexuality. No published scientific studiessupport the use of any of these diagnoses. However, they have beenused by unethical therapists to justify trying to change gay, lesbian,and bisexual men into heterosexuals. Examples of how these diagnosescan be used in unproven "treatments" will be discussed. Suggestionsfor future changes in ICD-11 and DSM-V concerning homosexualitywill also be provided.WO49.2.SELF HARM IN LESBIAN, GAY AND BISEXUALPEOPLEM. King 1 , E. McKeown 1 , J. Warner 21 University College; 2 Imperial College, London, UKDespite increasing recognition of the rights of lesbian, gay and bisexual(LGB) people to be free of discrimination and prejudice and tohave their relationships accepted in law, LGB people are disadvantagedin modern society and may be vulnerable to mental disorders.Ethnic minority gay men and lesbians bear multiple levels of discrimination.There are worrying levels of suicide and parasuicide amonggay youth and considerable problems of substance abuse in the gayand lesbian communities that go unrecognised. A recent study in theUK compared the mental health of approximately 1285 LBG with1093 heterosexual people, using a computerized interview. Gay menwere 1.24 (95% CI 1.07, 1.43) times more likely, and lesbians 1.34 (CI1.11, 1.52) times more likely to have a current psychiatric disorderthan their heterosexual counterparts. 33% of heterosexual, 52% ofgay or lesbian and 56% of bisexual people had considered harmingthemselves. Of those who had considered it, 44%, 55% and 56%respectively had actually harmed themselves. Attempted suicide inthe LGB population was associated with markers of discriminationsuch as recent physical attack (odds ratio, OD 1.7, CI 1.3, 2.3) andschool bullying (OR 1.4, CI 1.1, 2.0), but not current psychiatric status.In conclusion, LGB people have high levels of mental disorderand self harm, possibly linked with discrimination.WO49.3.ADOLESCENT TRANSGENDER HEALTH CARED. GarzaCallen-Lorde Health Center, New York, NY, USAThe Health Outreach To Teens Program is an institution providingprimary care services in New York City that works with lesbian, gay,bisexual and transgender youth. Particularly transgender youth mayundergo fluctuating identities before reaching stability. Many peopleof transgender experience have been shunned by family and socialsupports, or inadequately serviced by traditional medical care. A profileof this particular program is presented.WO49.4.THE EVALUATION OF HOMOPHOBIA IN ANITALIAN SAMPLE: AN EXPLORATORY STUDYV. Lingiardi, S. FalangaLa Sapienza University, Rome, ItalyHomophobia has not been systematically studied by Italian mentalhealth researchers and social scientists. The purpose of this study wasto conduct an initial investigation of the nature of homophobiaamong Italians, and to investigate personality and other factors relatedto homophobia. We investigated: a) whether a male military personnelgroup would have more homophobic attitudes than a group ofcomparably aged male university students; b) whether some personalityfactors and other personal characteristics would be correlatedwith homophobia, and c) whether there are differences in homophobiabetween male and female university students. In this study, agroup of male officers of the Italian Marine Corps was compared to agroup of male university students of the same age with respect tohomophobia and personality characteristics. Then, we compared asample of female university students with male students. The instrumentsused were the Italian version of the Modern HomophobiaScale and the 16 Personality Factor Inventory. Results showed significantlyhigher homophobia in the military personnel than male students.Consistent with previous research on sex differences in homophobia,males demonstrated more negative attitudes towards gay andlesbian people than females.WO50.PSYCHIATRY IN FORENSIC SETTINGSWO50.1.CONSULTATION PSYCHIATRY: A POSSIBLE MODELFOR PSYCHIATRIC INTERVENTION IN PRISON?J.L. Sénon 1 , P.F. Peloso 21 Service of Psychiatry and Medical Psychology, Poitiers, France;2 Department of Mental Health, Local Health Unit 3, Genoa, ItalyPsychiatry in prison needs a new clinical, ethical and organisationalmodel. Consultation psychiatry can offer such a model, but the applicationof a model developed in general hospital to prison requires adiscussion on the similarities and differences between the two situations.The psychiatric team is in both cases in “other people's house”and is asked to intervene by other physicians; there is always a contextualtaking care of both patient and institution; the body (sick orclosed) has a major importance; there is a secondary issue to breakthe isolation, that of psychiatry in the hospital and that of prison inthe community; psychiatrists risk to be used as “white dressed”165

policemen called to face disorder, violence, protest and legal risk andmust constantly confirm their dignity and negotiate their own space,role and autonomy in evaluation. But prison is not a health care settingand its mission is different: a direct access to the users is not possiblefor health professionals, because other professionals have thedoor’s key; the patient is, as in the hospital, “without family”, but hehas many more impediments to meet his family; the population ofprison has a lower mean age, a strong male predominance and agreater presence of foreigners and drugs abusers. Finally, the time ofpermanence is usually longer.WO50.2.COMPULSORY PSYCHIATRIC TREATMENTSIN PRISONM. Navarro, S. Raharinivo, B. GravierService of Penitentiary Medicine and Psychiatry, Lausanne,SwitzerlandPsychiatrists working in prison are regularly asked to implementcompulsory treatments in agitated, violent prisoners presentingpsychological disturbances. This issue arises at various levels: atthe level of the prison institution, where it leads to numerous discussionsbetween medical teams and the prison administration; atthe level of the elaboration of the health care policy (in what placescan such a treatment be ordered and made?); at the legislative level(is a special legislation necessary?); at the ethical level, consideringthe many questions related to this intervention. Some legislationsban such a treatment within the prison (France), others tolerate it.In any case, the debate is lively between the various concernedpartners. The Canton of Vaud changed recently its legislation concerningcompulsory treatment by detailing scenarios and modalitiesof control and appeal. The application of this legislation inprison settings remains vague. Only a rigorous procedure validatedby the health authorities can avoid drifts and abuses, but we mustavoid that patients remain without care because there is no placefor them.WO50.3.CAN A EUROPEAN FORENSIC PSYCHIATRYEVER EXIST?M. Xavier 1 , A. Fioritti 21 Faculty of Medical Sciences, Lisbon, Portugal;2 Department of Mental Health, Rimini, ItalyThe issue of treatment and placement of the mentally disorderedoffenders (MDOs) certainly arises at the European level, involvingsuch crucial issues as the position of the citizen with respect to thepenal law; acknowledgement of a special status of the MDOs withinthe criminal law; the acknowledgement of a public safety interest inthe use of coercive measures; the balance between punishment andcare; the protection of rights of MDOs and their right to health care.European countries share some common features: all of them havespecial legislations and systems concerning MDOs, show a slowerpace of changes in this area when compared with ordinary services,put the issue at the national level, express concern about the protectionof human rights while ensuring public safety, and had similartrends in the development and use of the psychiatric forensic sectorduring the 1990s. European forensic systems appear much more differentthan their respective psychiatric ordinary services. Each ofthem reflects a complex mix of elements coming from the legal backgroundsystem, health care system, broader welfare system, and theirdegree of integration. The authors discuss these differences with aview to harmonising objectives, ethical values and clinical practice.Cross-cultural comparisons, joint empirical research and involvementof European political bodies may help in building and consolidatinga common European forensic psychiatric knowledge.WO50.4.THE ITALIAN DEBATE ON THE TREATMENTOF THE MENTALLY ILL OFFENDER: AN UPDATER. Catanesi 1 , E. Pirfo 2 , F. Scapati 11 Section of Criminology and Forensic Psychiatry, Universityof Bari; 2 Department of Mental Health, Local Health Unit 3,Turin, ItalyThe complex issue of treatment of mentally ill offenders is analysedreferring to the scientific debate still in progress in Italy, with particularreference to the different reform projects of the penal code, and aspecial focus on the tendency to replace the concept of social dangerousnessby that of the necessity of treatment of the mentally ill recognisedas not responsible. The most remarkable consideration is that itis necessary to consider both the clinical and forensic aspects, thecustody and the treatment, overcoming anachronistic and old fences.There is a particular complexity in conjugating therapy and control,also considering the intrinsic complexity of the violent and criminalbehaviour. The authors emphasize the need for a project in whichcrime prevention can be linked to an individualised rehabilitationand therapeutic intervention by the community services. The need fornew protected residential facilities managed in concert with the penalsystem but integrated in the national health system is also stressed.WO51.PHARMACOLOGICAL AND NON-PHARMACOLOGICAL TREATMENT ISSUESCONCERNING SCHIZOPHRENIA IN KOREAWO51.1.KOREAN MEDICATION ALGORITHM FORSCHIZOPHRENIAC.-H. KimDepartment of Psychiatry and Institute of Behavioral Science inMedicine, Yonsei University College of Medicine, Seoul, KoreaThe rapid development of psychopharmacology during the recentyears has changed the strategy of pharmacotherapy for major psychiatricdisorders. At the same time, an active development of variousclinical practice guidelines or algorithms has taken place. However,there may be problems with applying the foreign guidelines directly toour clinical situation, due to the differences in racial characteristics,socioeconomic conditions, government policy, and clinical practice.In addition, the changes of circumstances outside of clinical situationin Korea may distort clinical practice and may go even against thetrend of recent psychopharmacology. As a solution to such problems,the Korean Medication Algorithm Project for Major Psychiatric Disorders(KMAP) was started with the support from the Korean Collegeof Neuropsychopharmacology (KCNP) and the Korean Academy ofSchizophrenia. In 2001, a medication algorithm for schizophreniawas developed and distributed. We present the objectives, processes,methods as well as the outline of this algorithm for schizophrenia.166 World Psychiatry 3:S1 - October 2004

WO51.2.TRENDS IN PHARMACOLOGICAL TREATMENTFOR SCHIZOPHRENIA IN KOREAY.S. Kim, Y.M. Ahn, K.Y. LeeDepartment of Psychiatry, Seoul National University College ofMedicine, Seoul, KoreaClozapine and risperidone were introduced in Korea around 1996.After then, olazapine, zotepine, nemonapride, quetiapine, amisulpride,aripiprazole, and ziprasidone became available. A survey donein 1999 showed that the new antipsychotics took up 18.1% of thetotal number of antipsychotic prescriptions. A survey done amongsome in-patient units in 2001 showed that the proportion was 27.1%.In 65.9% of cases the new antipsychotic was risperidone. The meandose calculated by chlorpromazine equivalents was 763.4±546.0 mg.As of now, the proportion of new antipsychotics among the totalantipsychotic prescriptions is expected to be even higher. However,the price of new antipsychotics hinders more popular usage. A multicenterstudy reported that the effective dose for risperidone was4.9±1.7 mg and that of olanzapine was 15.1±5.4 mg. These findingssuggest that effective dosage is not different from those of Westerncountries. The combination among antipsychotics, either newantipsychotics with typical ones or two or more new antipsychotics,occurred in 31.1% of cases. The rate of extrapyramidal side effectswas 31.9% and anticholinergics were prescribed in 68.2% of newantipsychotic users. In the guideline developed for schizophrenia in2001 by the Korean College of Neuropsychopharmacology and KoreanAcademy of Schizophrenia, new antipsychotics were recommendedas the first line drug. This guideline will affect the trend of antipsychoticprescription.WO51.3.THE ROLE OF DRUG COMPLIANCE ANDNON-PHARMACOLOGICAL FACTORS IN THELONG-TERM COURSE OF SCHIZOPHRENIA INKOREAS.Y. Kim, J.P. Hong, S.H. Kang, C.Y. KimDepartment of Psychiatry, Asan Medical Center, Universityof Ulsan, Medical College, Seoul, KoreaSince the introduction of new antipsychotics in the treatment ofschizophrenia, improvement in the short-term efficacy or side effectprofile has been repeatedly reported. However, the efficacy of newantipsychotics still remains to be explored in two important aspects:first, whether these drugs are helpful in the prevention of relapse, andsecondly, whether they are effective in providing a better quality of lifein the long run. In this study, the authors looked into the relationshipof antipsychotic compliance and the rate of recurrence and re-admissionof schizophrenic patients. The issue of efficacy has been alsoexplored not only in the aspect of improvement of psychotic symptoms,but also in the improvement or the maintenance of psychosocialprofile. We found that a significant portion of the schizophrenicpatients with good compliance also experienced relapse of schizophrenia,raising questions regarding several issues: the optimal maintenanceregimen for schizophrenic patients, the use of appropriateevaluation methods in antipsychotic use, the long-term naturalcourse of schizophrenia, and the importance of the evaluation ofnon-pharmacological factors in the treatment of patients with schizophrenia.WO51.4.MENTAL HEALTH SITUATION AND PSYCHOSOCIALTREATMENT FOR SCHIZOPHRENIA IN KOREAJ.I. ParkDepartment of Psychiatry, College of Medicine, KangwonNational University, Chunchon, KoreaPsychosocial interventions can improve the course of schizophreniawhen integrated with psychopharmacologic treatments. However, theapplication of psychosocial approaches depends not only on the particularneeds of a patient in the various phases of the person’s life andillness, but also on the context of mental health situation over thecountries. Since the enactment of the mental health act in 1995, community-basedmental health services have been introduced in Korea,with an increasing range of psychosocial interventions. However,there is still an upward trend in the number of psychiatric beds, especiallyin mental institutions. Failure of deinstitutionalization made itdifficult to focus on psychosocial interventions in inpatient settings.A stepwise and evidence-based process towards integrating pharmacologicaland psychosocial treatment is required.WO52.INPATIENT TREATMENT OF PERSONALITYDISORDERSWO52.1. PERSONALITY DISORDERS:INDICATIONS FOR HOSPITAL ADMISSIONA. GonzálezUnidad de Hospitalización Psiquiátrica, Hospital Príncipe deAsturias, Alcalá de Henares, Madrid, SpainThis paper reviews the current indications for hospital admission ofpatients with personality disorders (PD) and compares them with ourdaily practice. We study non-psychopathological factors involved inthe hospitalisation (family pressure, legal risk, lack of other resources,etc.) and analyse the short-term hospitalisation results and their consequencesin our practice. We studied the hospitalisation of patientsdiagnosed with PD in the Hospital Principe de Asturias of Alcala deHenares (Madrid) in a year. We explored the reasons for hospitaladmission, the characteristics and difficulties of hospitalisations andthe rate of re-hospitalisation: all of this was compared with the literatureon the topic. The main reasons for hospital admission were selfharmand violent behaviour. We found an important number ofadmissions due to non-psychopathological factors. The rate of rehospitalisationwas high and the changes observed after the hospitaldischarge were practically non-existent. According to these results,we question the clinical benefit of short-term hospitalisations ofpatients diagnosed with PD in psychiatric units. Alternative resourcesthat fit better to the profile of these patients must be sought.WO52.2.INPATIENT TREATMENT OF PERSONALITYDISORDERS: MILIEU MANAGEMENTA. MorenoHospital De Día, Instituto Psiquiátrico José Germain, Leganés,Madrid, SpainThe current literature emphasizes the difficulties of the inpatienttreatment of personality disorders (PD). In this presentation we shallbriefly review the milieu management of personality disordered inpa-167

tients. We shall also present our experiences on team work, collaborativeapproaches, rules/limits/flexibility, and time scheduling forinpatient therapies in PD. We found that the implementation of aclear, explicit set of rules is of major importance in PD inpatient treatment.Also, some kind of flexibility is sometimes helpful. Long hospitalisationscan be iatrogenic in many occasions. Using day hospital asa middle step to outpatient treatment can be useful in many cases. Abrief, well structured approach to treatment will be helpful in themanagement of PD. Day hospital treatment can be more helpful, inmany cases, than a prolonged inpatient therapy.WO52.3.INPATIENT TREATMENT OF PERSONALITYDISORDERS: CURRENT PSYCHOTHERAPEUTICGUIDELINESM. DelgadoUnidad de Hospitalización Breve, Instituto Psiquiátrico JoséGermain, Leganés, Madrid, SpainWe aim to review the main clinical and practical issues regarding thecurrent psychotherapeutic approaches for the inpatient managementof personality disorders (PD). We will briefly review individual, family,and group short-course therapy approaches. We will also presentour experience with a brief, directive, psychoeducational groupapproach for borderline inpatients. Psychotherapeutic approaches tothe treatment of personality disorders are tough to implement, andhave a limited success rate. We have found some promising resultswith psychoeducational group therapy for borderline patients. Due tothe limited success obtained with any kind of psychotherapy, weshould try only brief approaches, with limited expectations, mainlyaimed for crisis resolution and facilitation of a subsequent, long-term,outpatient treatment.WO52.4.TREATMENT OF PERSONALITY DISORDERS:ARE THE ATYPICAL ANTIPSYCHOTIC DRUGS AREAL INNOVATION?S. GarattiniIstituto di Ricerche Farmacologiche "Mario Negri", Milan, ItalyThe use of atypical antipsychotic drugs is increasing enormously insome countries like Italy, indicating that these drugs are not prescribedonly for schizophrenic patients but are used for personality disorderstoo. Atypical antipsychotic drugs are ill-defined as a class and havebeen tested in schizophrenic patients sensitive and resistant to classicantipsychotic agents. Claims by pharmaceutical manufacturers aboutthe superiority of atypical antipsychotics are not backed by adequatetrials. They certainly offer an advantage in terms of less extrapyramidaladverse reactions, but this does not mean that fewer patients decide tostop treatment. Particularly worrisome is the weight gain caused byatypical drugs because this may increase the risk of cardiovascular diseasesand diabetes. Finally, the atypical antipsychotics cost severaltimes more than the classical antipsychotics and this results in a financialburden for national health services and a switch of funds thatcould be put to better use for mentally ill patients.WO53.AN INTEGRATED RESEARCH-BASED APPROACHTO TREATING FIRST EPISODE PSYCHOSIS(Special Workshop organized by the InternationalSociety for the Psychological Treatment ofSchizophrenia and other Psychoses, ISPS)WO53.1.THE PARACHUTE PROJECT FOR FIRSTEPISODE PSYCHOSIS: A FIVE YEAR FOLLOW-UPINCLUDING COST ANALYSIS OF CAREJ. Cullberg, S. Levander, M. MattssonDepartment of Mental Health, Stockholm County Council,Stockholm, SwedenThe Parachute project is a Swedish multicenter study for "needadaptedcare" of first episode psychosis. Every first episode psychosispatient in 17 areas (n=253) has been evaluated for the study duringthe years 1996 and 1997 and those accepting to take part in the study(n=175) have been followed up for five years. One historical (n=74)and one prospective comparison group (n=64) (treatment as usual)are also followed up. In addition to clinical and outcome data, a costcomparison has been performed.WO53.2.THE DANISH NATIONAL SCHIZOPHRENIAPROJECT. COMPARISON OF THREE MODELS OFINTERVENTION AT TWO-YEAR FOLLOW-UPB. RosenbaumUnit for Psychotherapy Education and Research, University ofCopenhagen, Glostrup, DenmarkThe Danish National Schizophrenia project is a prospective, longitudinal,multi-centre study, including 562 patients with a first episode psychosisof ICD-10 F-2 type, consecutively referred during two years.Patients were treated with three different interventions: “assertive, integrativepsychosocial and educational treatment programme”, “supportivepsychodynamic treatment as a supplement to treatment as usual”,and “treatment as usual”. The presentation will contain a comparison ofthe three modes of intervention after 2 years of treatment.WO53.3.TREATING STIGMA: THE DIFFERENTIALEFFECTIVENESS OF PSYCHOSOCIAL ANDBIOGENETIC CAUSAL EXPLANATIONS INREDUCING NEGATIVE ATTITUDES TOWARDMENTAL ILLNESSJ. ReadDepartment of Psychology, University of Auckland, New ZealandTreatment of mental health problems is often rendered harder by thestigma faced by clients as a result of being diagnosed as, and treatedfor, mental illness. Destigmatisation programmes frequently assumethat the public should be taught to think of mental health problems inillness terms. The international research shows, however, that thepublic continues to reject the “medical model”, believing that mentalhealth problems are predominantly caused by adverse life events,especially in childhood. Furthermore, research also shows that biogeneticcausal beliefs are associated with greater fear and prejudicethan psychosocial causal beliefs. In a recent New Zealand study, amedical model explanation of hallucinations significantly increasedperceptions of dangerousness and unpredictability, whereas a psy-168 World Psychiatry 3:S1 - October 2004

chosocial explanation for the same symptoms reduced such perceptions.WO53.4.ANTISTIGMA AS PREREQUISITE FOR EARLYINTERVENTION IN FIRST EPISODE PSYCHOSIS.LESSONS FROM THE TIPS PROJECTJ.O. JohannessenDivision of Psychiatry, General Hospital of Stavanger, NorwayThe presentation will describe the Early Treatment and Intervention inPsychosis Study (TIPS), a prospective longitudinal study of first-onsetpsychosis from four Scandinavian health sectors with equivalent firstepisodetreatment. Two sectors carried out an extensive early detection(ED) program, and the other two did not (not-ED). We have included281 consecutive patients with a DSM-IV diagnosis of non-organic,non-affective psychosis between 1997 and 2000. The duration ofuntreated psychosis (DUP) was significantly shorter for the ED groupcompared with not-ED (median 5 weeks vs. 16 weeks). Clinical statuswas significantly better for patients from the ED sectors, both at presentationand at three months. First results from one year follow-up willbe presented. Antistigma strategies will be highlighted.NEW RESEARCH SESSIONSNRS1.PSYCHOTIC DISORDERS (I)NRS1.1.TREATMENT OF SCHIZOPHRENIA PRIOR TO THEDIAGNOSIS OF SCHIZOPHRENIAP. Handest, J. ParnasCognitive Research Unit, Department of Psychiatry, HvidovreHospital, University of Copenhagen, DenmarkDrawing on the results of the Copenhagen Prodromal Study, psychiatrictreatment prior to the diagnosis of schizophrenia is described ina group of patients with psychotic schizophrenia spectrum disorders.The Copenhagen Prodromal Study is an ongoing combined pro- andretrospective survey of psychopathology in the schizophrenic prodromeand schizophrenic spectrum disorders. Fifty-one subjectsreceived a diagnosis of psychotic schizophrenia spectrum disorders,but had not received such a diagnosis prior to the inclusion in thestudy. Two-thirds of these subjects had received some form of psychiatrictreatment before inclusion in the study, psychotherapy as well aspharmacological medication. The previously treated versus theuntreated group were compared regarding to age, gender, suicideattempts, Global Assessment of Functioning (GAF) and Positive andNegative Syndrome Scale (PANSS) scores, prodromal symptoms,expressive psychopathological phenomena (formal thought disorder,contact disturbances) and subjective psychopathological phenomena(depressive symptoms, anxiety, cenestesias, disturbances of cognition,perception and Self) at the time of inclusion. The various kindsof previous treatments were not predicted by psychotic symptoms,but by other symptoms (e.g. depressive symptoms and anxiety).Despite long-lasting psychotic symptoms, several patients did notreceive antipsychotic medication, largely because these symptomsremained unnoticed by doctors or psychologists. It is concluded thatpsychotic symptoms are missed in patients seeking treatment forother symptoms like depression and anxiety, leading to an underdiagnosisof psychotic disorders. This points to a large potential forearly recognition of psychotic disorders, provided that the level ofknowledge of the early and manifold symptoms of schizophrenia israised among practitioners, psychologists and psychiatrists. At presentthe main ethical concern seems not to be an over-diagnosing ofschizophrenia, even though this concern about “false positive schizophrenic”is often mentioned in the discussion of early detection andtreatment of schizophrenia.NRS1.2.OUTCOME AND ITS PREDICTORS INSCHIZOPHRENIA BEFORE 35 YEARS OF AGEWITHIN THE NORTHERN FINLAND 1966 BIRTHCOHORTM. Isohanni, E. Lauronen, I. Isohanni, J. Veijola, J. Miettunen,J. MoringDepartment of Psychiatry, University of Oulu, FinlandFollow-up studies of schizophrenia have reported divergent rates ofoutcome. Because these findings are based on samples from particularhospitals or clinics, their generalizability is limited. Only follow-up ofan epidemiologically based cohort can establish the prognosis ofschizophrenia in the population. We report outcomes of schizophreniabefore age 35 years in a longitudinal, population based birthcohort, and test the prognostic significance of selected demographic,developmental and illness-related variables. All 144 living members ofthe Northern Finland 1966 Birth Cohort who had a psychotic episodewere asked to participate in a field study during 1999-2001. Fifty-nineof participants were diagnosed with DSM-III-R schizophrenia. Interviewsand medical records were used to rate measures of outcome,including clinical global impression, social and occupational functioning,positive and negative symptoms, occupational status, psychiatrichospitalizations and medication. Based on available data, outcomewas categorized as good/moderate or poor; complete recovery wasstudied as well. While 25 (42%) cases had good/moderate and 34(58%) had poor outcome, only one schizophrenia case was consideredas fully recovered. Mortality was high before age 35 years: tencases (10-fold risk) had died (most by suicide). When compared togood outcome cases, cases having poor outcome had earlier age of illnessonset and more often genetic risk. To conclude, too few patientshave favorable outcome of schizophrenia in this relatively early onsetgroup. Some predictors for good and poor outcome can be found.NRS1.3.REACTIVE PSYCHOSIS AND ICD-10 F23 ACUTEAND TRANSIENT PSYCHOTIC DISORDERS:EVIDENCE FROM A REGISTER-BASED STUDYA.C. Castagnini 1 , A. Bertelsen 2 , P. Munk-Jørgensen 21 Department of Psychiatry, Addenbrooke’s Hospital,Cambridge, UK; 2 Department of Psychiatric Demography,Psychiatric Hospital in Aarhus, Risskov, DenmarkICD-10 F23 “acute and transient psychotic disorders” (ATPD) categoryintegrates several clinical concepts such as bouffée délirante,cycloid psychosis, psychogenic (reactive) psychosis, schizophreniformpsychosis, into the diagnostic paradigm of acute transient psychoses.ATPD nomenclature remains as uncertain as their clinical validity. Thepurpose of this study was to evaluate the relationship between theconcept of reactive psychosis (RP), equivalent to a main ICD-8 diagnosisof ‘other psychoses’ (298), and ATPD. Subjects with an ICD-8298 diagnosis on their last admission in 1992-93 and re-admitted in169

1994-95 according to ICD-10 classification were identified from theDanish Psychiatric Register. ICD-8 diagnosis of RP was coded in19.2% of patients with functional psychoses in 1992-93. Nearly 40%of these patients were re-admitted in 1994-95. F2 schizophrenia,schizotypal and delusional disorders and F3 affective disorders groupsaccounted for two thirds of ICD-10 diagnoses assigned. Diagnosis ofATPD was found in 262 (20%) cases, with a higher proportion ofF23.3, F23.0, and F23.9 sub-categories. A significant majority werefemale and life events preceding acute psychosis occurred in a fewcases. ATPD overall prevalence decreased to 8.7% of non-organic psychoticand affective disorders in 1994-95. A retrospective survey ofsuch patients revealed that nearly a quarter of them had a previousadmission and more than half (53%) were given the RP diagnosis,mainly ICD-8 298.3 acute paranoid reaction. ICD-8 diagnosis of RPshowed little empirical continuity to ATPD and conformed more toF23.3 acute delusional disorders among ATPD subtypes.NRS1.4.EARLY SIGNS IN SCHIZOPHRENIA SPECTRUMDISORDERSR.M.G. Norman 1 , D. Scholten 1 , A.K. Malla 2 , T. Ballageer 31 University of Western Ontario, London; 2 Department ofPsychiatry, McGill University, Montreal; 3 Department ofPsychiatry, University of Manitoba, CanadaNon-specific early indicators of illness and psychological distressoften occur prior to the onset of psychotic symptoms in schizophreniaspectrum disorders. In this presentation we examine whether thenature of such early signs have implications for the course of the psychoticdisorder. The frequencies of various early signs were examinedin 96 first episode patients suffering from schizophrenia, schizoaffectiveor schizophreniform disorder. A factor analysis of these earlysigns identified five dimensions of early signs, including emotionaldysphoria and odd perceptual and cognitive content; impaired functioning;changes related to psychobiological or vegetative functioning;suspiciousness accompanied by difficulties in concentration; andirritability. Impaired functioning in the pre-psychosis period wasassociated with higher levels of negative symptoms at presentation fortreatment, and higher levels of psychobiological disturbance wasassociated with lower positive symptoms of psychosis after a year oftreatment. The latter findings may indicate that patients with moreprofound indications of affective disturbance or stress have a betterprognosis.NRS1.5.PERSISTENT NEGATIVE SYMPTOMS IN FIRSTEPISODE PSYCHOSIS: EARLY IDENTIFICATIONOF A POOR OUTCOME SUBGROUP OFSCHIZOPHRENIA SPECTRUM PSYCHOSESA. Malla 1 , R. Norman 2 , J. Takhar 2 , R. Manchanda 21 Department of Psychiatry, McGill University, Montreal;2 University of Western Ontario, London, CanadaPatients with schizophrenia who show persistent negative symptomsare an important subgroup with generally a poor functionaloutcome but difficult to identify early in the course of illness. Theobjective of this study was to examine characteristics which discriminatebetween first episode psychosis (FEP) patients in whomprimary negative symptoms do or do not persist after one year oftreatment. In a large sample of patients (n=156) with a DSM-IVdiagnosis of FEP, those whose primary negative symptoms did(n=36) or did not (n=35) persist at one year were contrasted on theirbaseline and one year characteristics. Results showed that patientswith persistent primary negative symptoms (n=36) had a significantlylonger duration of untreated psychosis (DUP) (p

toms (n=7) were included. We found correlations between parents’and raters’ estimates of DUP, and a limited range of predictive valueof DUP for symptoms and general measures for overall outcome afterone year. Gender differences in DUP were observed. These data suggestthat the concept of DUP is very general but of relevance for outcomein psychosis.NRS2.PRIMARY CARE AND LIAISON PSYCHIATRYNRS2.1.CLIMATE/GP: BUILDING CAPACITY TO TREATANXIETY AND DEPRESSIVE DISORDERS INPRIMARY CAREG. AndrewsClinical Research Unit for Anxiety and Depression, University ofNew South Wales at St. Vincent’s Hospital, Sydney, AustraliaLess than half the people with anxiety or depressive disorders getmedical help with their disorder, even though most attend a generalpractitioner for other reasons. Australia has striven to improve recognitionand treatment of these disorders by general practitioners and,while recognition and prescribing has improved, there remains ashortfall in necessary psychotherapy skills. We have developed acomputerised patient education system that teaches the cognitivebehaviour therapy steps that are an essential component of treatmentfor people with these disorders. Some patients do these programs inthe doctor’s office and others, acting on prescription from the doctor,can do the programs at home while connected to the Internet. Thereare five depression modules that target people of different ages andgender, and three modules for anxiety (for panic/agoraphobia, socialphobia and generalised anxiety disorder). Each module takes four orfive sessions to complete. The sessions are interactive, and begin bymeasuring symptoms, checking homework from a previous sessionand then educating about the disorder by using an illustrated storyline akin to an Asterix or Tintin book. Finally, homework is printed.The story lines can be viewed on www.climate.tv.NRS2.2.FREQUENCY OF CONSULTATIONS ANDGENERAL PRACTITIONER RECOGNITIONOF PSYCHOLOGICAL SYMPTOMSJ. BushnellUniversity of Otago at Wellington School of Medicine andHealth Sciences, Wellington, New ZealandGeneral practitioners (GPs) are widely reported to “miss” half thepsychological problems in their patients. This study aimed to describethe relationship between consultation frequency and general practitionerrecognition of psychological symptoms. A survey of 70 randomlyselected GPs and 3414 of their patients was conducted in thelower North Island of New Zealand. Of GPs selected, 90% participated.The Composite International Diagnostic Interview (CIDI) wascompleted for 70% of selected patients. In patients with a CIDI-diagnoseddisorder, 63.7% (95% confidence interval (CI): 53.3-74.1) wereconsidered by the general practitioner to have had psychologicalsymptoms in the last year; 40.1% (CI: 31.0-49.2) to have had clinicallysignificant psychological problems, and 33.8% (CI: 24.9-42.6) weregiven an explicit diagnosis. However, in those CIDI-diagnosedpatients who had been seen five or more times during the last year,these recognition figures increased to 80.2% (CI: 68.9-91.4), 59.4%(CI: 45.9-72.9) and 53.6% (CI: 40.1-67.1) respectively, and droppedto 28.8% (CI: 13.0-44.7, 13.6% (CI: 3.4-23.7), and 10.7% (CI: 1.4-19.9) among patients not consulting during the last year. GPs oftendiffered from the CIDI in their assessment of clinical significance anddiagnosis. GP non-recognition of psychological problems was at aproblematic level only among patients with little recent contact withthe GP. Efforts to improve patient outcomes by addressing GP recognitionof mental disorder may be more effective if they foster continuityof care, focus on the disorders most likely to be missed, take intoaccount high levels of comorbidity of common mental disorders,encourage patient disclosure of psychological issues, and target newor infrequent attenders.NRS2.3.THE EFFICACY OF ENHANCED COUNSELLINGIN THE PRIMARY PREVENTION OFHEPATITIS C AMONGST INJECTING DRUGUSERS: A RANDOMISED CONTROLLED TRIALM. Abou-SalehDivision of Addictive Behaviour, Department of Mental Health,St. George’s Hospital Medical School, London, UKThis study aimed to assess the efficacy of enhanced counselling in theprevention of hepatitis C amongst injecting drug users, as comparedwith a brief, informational intervention. It was a randomised controlledtrial, with participants stratified into two groups by self-reportedrecent sharing behaviour. The enhanced counselling group receivedup to four one-hour sessions of manual-guided therapy, based uponharm-reduction strategies and techniques of motivational interviewing,delivered by trained therapists. The simple educational counsellinggroup received one ten-minute session of purely informational,didactic intervention on the risks of hepatitis C and ways in whichthese could be minimised. The setting consisted of nine local drugtreatment agencies in London and the South-West, plus one inpatienttreatment centre. The subjects were 95 drug users who had injected atleast once in the past six months, and who had a test within the lastthree months to confirm that they were currently hepatitis C seronegative.Primary outcome measurement was seroconversion rate attwelve months. In addition, measures of change in self-efficacy andrisk-taking behaviour, along with the overall cost-effectiveness of eachintervention, were measured using a battery of standardised researchtools. Follow-ups are still ongoing, with data on the first 33 recruitedclients analysed so far. Preliminary findings indicate little differencebetween the two groups, although both groups exhibited improvementsin most areas over time, and seroconversion rates were significantlylower than expected. Compliance with enhanced counsellingwas a significant problem. The cohort analysed so far is too small todraw any firm conclusions about the efficacy of enhanced counselling,although early indications are that it may not perform significantly betterthan a simple educational intervention, and background effectssuch as ongoing treatment and the process of testing for hepatitis Cmay be enough to initiate positive change.NRS2.4.SUBSTANCE ABUSE AMONG ADOLESCENTSAND CRITICAL ROLE OF COUNSELLINGA. Mallik, K.R. BanerjeeNational Institute of Behavioural Science, Kolkata, IndiaDuring the last few years, there has been a remarkable increase in theuse of psychoactive drugs and alcohol in our society, particularlyamong youths. The management of substance related disorders and171

disorders associated with alcohol is a multidisciplinary approach.The role of psychotherapy and counseling is important. Counseling isan act of assistance and is a particular form of brief psychotherapybased on humanistic-existential theory. By counseling an individual isassisted to become self-sufficient, self-dependent, self-directed and toadjust efficiently to the demands of a better and meaningful life. In themanagement of substance abusing persons, early detection and evaluationis essential, which has to be followed by predetoxificationcounseling, detoxification, after care, follow-up and rehabilitationalong with psychologist counseling. Substance and alcohol abuse frequentlycoexist with other psychiatric conditions, which are often difficultto detect and evaluate. During management, including counseling,dependence and tolerance already developed with differentchemicals and alcohol are important to consider. The chances ofpolydrug abuse, denial, relapse and coexisting mental disorders orbehavioural problems are to be kept in mind. Counseling with familymembers and group counseling will help in family and social rehabilitation.Psychoanalytically oriented psychotherapy, behaviour therapy,cognitive therapy, interpersonal therapy are also useful for substanceabusers and alcohol dependent patients. Adequate and properrelapse prevention strategies are to be considered during counselingof substance abusers and alcohol dependent persons. Psychosocialintervention through counseling is to be done for prolonged maintenanceof total sobriety. Individual psychotherapy and counseling isneeded, but group therapy may be more effective and acceptable tomany patient who perceive substance abuse or alcohol dependenceas a social problem rather than a personal psychiatric problem. Tomake counseling meaningful and effective, an empathetic attitude offamily and community members is essential.NRS2.5.DISTURBANCE OF EMOTIONAL EXPERIENCEAS PRIMARY DISORDER IN OPIATE ADDICTST.I. BoukanovskayaNorth-Ossetian State Medical Academy, Vladikavkaz, RussiaMany studies report a frequent association between affective or personalitydisorders and opiate dependency. However, the question ofdirection of causality is still unsettled. The present study was aimed atthe investigation of emotional experience, for the description ofwhich we used a modified version of the Bartlett and Izard’s Scale ofDifferential Emotions (SDE). The study sample consisted of 56 opiateaddicts, 41 depressive patients and 69 healthy subjects of the sameage. The average scores for 10 emotional states in addicts was significantlylower than in healthy subjects (3.7±0.16 versus 4.2±0.34;p

NRS2.8.HEALTH CARE COST IN SOMATOFORMDISORDERSE. Di Rosa 1 , R. Ficili 2 , G. Martino 1 , R. Zoccali 1 , A.E. Di Rosa 1 ,M. Meduri 11 Department of Neurosciences, Psychiatry andAnaesthesiology and 2 Social Service School, University ofMessina, ItalyWe evaluated the health care costs in patients with somatoform disordersin comparison with patients affected by physical illnesses,screened in primary care. Forty-two patients with somatoform disordersand 65 patients with physical illnesses, aged over 60, were consecutivelyrecruited. Several assessment instruments were used toevaluate the psychic state of all the subjects. The costs supported bythe national sanitary service for laboratory assays and therapy over asix months follow-up were evaluated. A significant difference wasobserved only regarding laboratory assays (higher costs in physical illnessesgroup; p

ased psychosocial intervention. Resistance handling, skills training,psychoeducation, mid-way homes, sheltered workshops, communityawareness and resource mobilization are gaining more importance.With the introduction of the new mental health act, much stress hasbeen focused on mental health and welfare law.NRS3.4.HOME BASED MENTAL HEALTH CARE:CAN WE DISTINGUISH EFFECTIVE INGREDIENTS?T. Burns 1 , J. Catty 21 Department of Psychiatry, Warneford Hospital, Oxford;2 St. George’s Hospital Medical School, London, UKOver 90 high quality studies of home based care for mental illnesshave been published world-wide. Their results have been mixed andthere has been a vigorous debate to try and understand these differences.Much of the controversy has centred on the greater reductionsin bed usage reported in North American studies (often of assertivecommunity treatment) compared to European studies. We undertookto try and identify the factors driving these reported differences. Wealso approached study investigators to get a more detailed clarificationof the components of the services they reported and to individuallytest these components to see which were common in experimentalservices and, using regression analysis, to see if any were morehighly associated with reduction in bed usage than others. Nineteencharacteristics of home based care services were identified by a consensusexercise among local experts. Over 60 researchers replied withcharacteristics of their study services. Of these, 6 factors were foundto occur most frequently in studies. Two loose ‘clusters’ can be identifiedwithin these 6 factors. Regression analysis indicates that two ofthem –‘home visiting’ and ‘responsibility for health and social care’ –are most responsible for reducing bed occupancy, irrespective ofhealth care culture. These findings, along with the findings about therole of control services, sharpen our focus on what may make a differenceand also explain some anomalous results and help direct furtherresearch.NRS3.5.COMMUNITY INTENSIVE THERAPY TEAM VERSUSINPATIENT SERVICESA.K. DarwishChild and Adult Mental Health Service, Pontypridd, Wales, UKOur community intensive therapy team (CITT) has been formallyoperational since April, 1998. CITT takes referrals from generic teamsof the child and adolescent mental health services covering an area of420,000 population. CITT is made of medical and nursing staff. CITTtakes cases with acute psychoses, eating disorders, cases with thepotential to develop personality disorder and complex cases of autisticspectrum disorder, attention deficit hyperactivity disorder orlooked after children with complex mental health concerns. The teamworked with 23 eating disorder patients and 15 psychotic cases. Weassess, investigate, medicate, monitor and support the patient andfamily at home. We take the case back promptly in the case of arelapse. We ‘titrate’ our therapeutic in-put to the ability of the patientand family to make use of therapy. We invest heavily in liaising withother agencies. The management is based on forging a therapeuticrelationship between the CITT and the patient, family and professionals.In this relationship CITT attempts to be: consistent, available,responsive, clear in communication, and appropriately reciprocating.The paper describes the history of how CITT came to being, how itfunctions, the outcome to date and the future.NRS3.6.RESIDENTIAL FACILITIES FOR THE ELDERLYIN ITALY: A SURVEY IN FIVE REGIONSG. de Girolamo 1 , A. Tempestini 2 , G. Cavrini 31 Department of Mental Health, Local Health Unit; 2 Institute ofClinical Neurology, and 3 Faculty of Statistics, University ofBologna, ItalyThe ‘PROGRES-Anziani’ (PROGetto RESidenze – Residential Projectfor the Elderly) is aimed to survey the main characteristics of all residentialfacilities for the elderly in five Italian regions (Phase 1), and toassess in detail a representative sample of facilities and residents (Phase2). In Phase 1 structured interviews were conducted with the managersof all residential facilities located in five regions (Calabria, Sardinia,Sicily, Umbria and Veneto). In Phase 2 a random sample of facilities isbeing assessed in detail and residents (n=1,800) are being administeredthe Resident Assessment Instrument (RAI), an international multidimensionalinstrument to assess elderly residents, and a set of specificinstruments to evaluate cognitive and behavioural problems. In 2003,in the five regions involved in the survey (out of 21), there were 747 residentialfacilities; preliminary data are available for 620 facilities(82.9%), with a total of 30,265 beds and a median number of 34 bedsfor each facility. The mean age of residents was 78.4 years (+6.7). In 512facilities (83.1%) there was at least one resident with dementia; themedian number of residents with dementia-related disorders was 11. In376 facilities (61.0%) there was at least one resident with other severepsychiatric disorders; the median number of residents with other psychiatricdisorders was 5. In conclusion, residential facilities for the elderlyhost a substantial number of aged subjects; in most facilities thereare subjects with dementia and other severe psychiatric disorders. Acloser look at this vulnerable population is needed in order to meettheir specific needs and improve their quality of life.NRS4.BIOLOGICAL RESEARCHNRS4.1.DRD4 RECEPTOR GENE EXON III POLYMORPHISMIN INPATIENT SUICIDAL ADOLESCENTSG. Zalsman, A. Frisch, R. Lewis, E. Michaelovsky, H. Hermesh,L. Sher, E. Nahshoni, L. Wolovik, S. Tyano, A. Apter, R. Weizman,A. WeizmanGeha Mental Health Center, University of Tel Aviv, Israel;Columbia University, New York, NY, USASome studies have suggested the possible association of the dopaminereceptor subtype 4 (DRD4) gene exon III 48bp repeat polymorphismwith novelty seeking behavior. As suicidal behavior in adolescents islinked to risk taking behavior, we evaluated the association of suicidalitywith DRD4 polymorphism in Israeli inpatient suicidal adolescents.Sixty-nine inpatient adolescents who recently attempted suicidewere assessed by structured interview and rating scales for detailedclinical history, diagnoses, suicide intent and risk, impulsivity, violence,and depression. The frequency of DRD4 alleles was comparedbetween the suicidal inpatients and 167 healthy control subjects. Nosignificant association between the DRD4 polymorphism and suicidalbehavior was found. Analysis of the suicide-related measures demonstrateda significant difference in depression severity between suicidalinpatients homozygote and heterozygote for the DRD4 alleles(p=0.003). The relevance of this finding to increased depression severityin suicidal adolescents, if replicated, is as yet unclear.174 World Psychiatry 3:S1 - October 2004

NRS4.2.GLUCOCORTICOID RECEPTOR TRANSGENIC MICEARE MODELS FOR DEPRESSIONP. Gass 1 , S. Chourbaji 1 , S. Ridder 1,2 , A. Urani 1 , C. Zacher 1 ,H. Flor 1 , G. Schütz 2 , F.A. Henn 11 Central Institute of Mental Health Mannheim (CIMA),University of Heidelberg; 2 German Cancer Research Center(DKFZ), Heidelberg, GermanyImpaired glucocorticoid receptor (GR) signaling is a postulatedmechanism for the pathogenesis of major depression. Since in vivoexpression and functional studies of GR are not feasible in humans,we have generated different mouse strains that over- or underexpressGR. This presentation will summarize neuroendocrinological andbehavioral findings that have been obtained in two mouse strains thatturned out to be highly interesting for depression research: a) micethat lack GR selectively in the central nervous system show a disinhibitionof the hypothalamic-pituitary-adrenal (HPA) system similar todepressed patients, but reduced anxiety and despair behaviour; due tothe lack of GR in the brain, they represent a behavioural model for adepression-resistent mouse strain; b) heterozygous mice that underexpressGR exhibit normal baseline behaviors, but after stress exposurethey demonstrate helplessness and despair; similar to depressedpatients they show a disinhibition of the HPA system and a pathologicaldesamethaxone/corticotropin releasing hormone test. Thus theyrepresent a murine depression model with good face and constructvalidity. These mice can be used to study long-term plasticity changesunderlying the pathogenesis of depressive episodes. Using moderngenomic or proteomic techniques they may turn out to be valuabletools to detect new molecular targets for antidepressive therapy, andthus open new therapeutic avenues for faster and better treatmentwith less side effects.NRS4.3.EFFECT OF WORRY ON CEREBRAL BLOODFLOW IN NORMALS AND IN PATIENTS WITHGENERALIZED ANXIETY DISORDERR. Hoehn-Saric, M.W. Schlund, D.F. WongJohns Hopkins School of Medicine and Kennedy-Krieger Institute,Baltimore, MD, USAWorry is an uncontrollable, verbally mediated, analytic-cognitiveactivity concerning potentially hazardous future events. In anxietydisorders, and particularly in generalized anxiety disorder (GAD),worries become excessive and often unrealistic and may generalize tosituations that, ordinarily, are not regarded to be dangerous. We arepresenting results of several studies that examined the effect of worrisome,in contrast to neutral, thoughts on regional cerebral blood flow,using functional magnetic resonance imaging (fMRI) and positronemission tomography (PET). When normal subjects were permittedto worry undisturbed for several minutes over a personal topic,regional cerebral blood flow (rCBF), measured with PET, was activatedin medial-orbital prefrontal regions but inhibited in limbic regions,regions generally activated by anxiety. These findings confirm clinicalevidence that worry is an avoidance mechanism that helps to attenuatemore severe manifestations of anxiety through the inhibiting effectof the prefrontal cortex on the limbic system. However, this inhibitorymechanism may fail in anxious patients. Repeated listening toworry, as well as neutral, sentences led to stronger fMRI blood oxygenationlevel-dependent (BOLD) responses in GAD patients than innormals in prefrontal, limbic/paralimbic and pontine regions, indicatingin patients a more intense activation of areas that process cognitive/emotionalinformation and affective responses. Anxiety reductionafter treatment with citalopram led to BOLD reduction while listeningto worry and to neutral sentences. Thus, heightened anxietycaused poor discrimination between inputs describing adverse andharmless conditions, which improved after reduction of anxiety. Theresults of the studies confirm the clinical impression of “generalization”of anxiety responses in GAD patients, which is sensitive topharmacotherapy.NRS4.4.ANTI-PANIC TREATMENTS: DO THEY EXERT THEIREFFECTS VIA THE RESPIRATORY SYSTEM?G. Perna, L. Liperi, S. Cammino, A. Bersani, L. BellodiAnxiety Disorders Clinical and Research Unit, Vita-SaluteSan Raffaele University Medical School, Milan, ItalyBreathing is one of the main systems involved in the phenomenologicaland biological features of panic disorder. Klein’s theory hypothesizesthat panic attacks result from an abnormally lowered thresholdof a specific suffocation monitor. We hypothesize that the anti-panicproperties of the anti-panic drugs could result from an action of thesecompounds on the respiratory system. Neurotransmitters can modulatethis complex system and several studies reported a relationshipbetween the neurotransmitters’ modulation and CO 2sensitivity. Carbondioxide sensitivity and respiratory function are influenced by severalneurotransmitters, including serotonin, GABA, norepinephrineand acetylcholine, the most important neurotransmitters modulatedby anti-panic drugs. Several studies investigated the effects of psychotropicdrugs on the response stimulation with hypercapnic gasmixtures. Two lines of research have been developed: the first investigatedchanges of some physiological responses to the inhalation ofCO 2before and after anti-panic treatment, while the second investigatedthe modulation of the panic/anxiety response to CO 2inhalationby psychotropic drugs. Both showed a “normalization” of therespiratory function after treatment with anti-panic drugs. Recently,some studies have shown a higher level of irregularity and complexityin respiratory functions of patients with panic disorder comparedto healthy controls, supporting the idea of an abnormal regulation ofthe respiratory system as a key mechanism in panic disorder. Preliminaryresults from our centre showed that paroxetine treatment causesa significant decrease of the irregularity of tidal volume and minuteventilation patterns, compared with pre-treatment condition, inpatients with panic disorder. This decrease in the breathing patternirregularity suggests that a modulation of the respiratory functioncaused by the serotonergic activity of paroxetine could be an importantmechanism of the anti-panic effect of this drug. The regulation ofbreathing irregularity might be considered as an expression of a “normalization”of the deranged pathogenetic mechanisms underlyingpanic disorder. Although the serotonergic system influences the functionof many brain areas involved in the regulation of body functions,serotonin receptors have been found in many body organs other thanthe brain: serotonin transporters are expressed on human pulmonarymembranes, are important in the maintenance of patent upper airwaysin obstructive sleep apnea and influence phrenic nerve activity.Sertraline was able to decrease dyspnea in seven patients with chronicobstructive pulmonary disease, and paroxetine relieved respiratorysymptomatology of patients with obstructive sleep apnea. Thus, serotonergiccompounds could also exert their anti-panic properties viamodulation of peripheral organs.175

NRS4.5.THIRD TRIMESTER EXPOSURE TO SEROTONINREUPTAKE INHIBITORS INCREASES THE RISK FORPERINATAL COMPLICATIONS AND IS ASSOCIATEDWITH CHANGES IN MOTOR QUALITY IN INFANCYR. Casper, B. Fleisher, J. Ancajas, E. Gaylor, A. DeBattista,A. Gilles, E. HoymeDepartments of Psychiatry and Pediatrics, Stanford University,Stanford, CA, USAThe primary objective of the study was to compare the birth anddevelopmental outcomes of children exposed to selective serotoninreuptake inhibitors (SSRIs) during the first trimester (n=12) withthose of children exposed to SSRIs during the third trimester of pregnancy(n=37). Information regarding delivery and neonatal coursewas collected from obstetric and neonatal medical records. Children,mean ages 14-15 months, underwent neurologic and dysmorphologyexaminations and were tested using the Bayley Scales of Infant Development(BSID-II). Children with late exposure had a shorter gestation(38.8 vs. 39.8 weeks; p

including continuation of pharmacotherapy, or to TAU along withbrief CT. Relapse/recurrence to major depression was assessed overtwo years. Adding CT to TAU resulted in a significant protective effect,which was amplified when patients had experienced more depressiveepisodes previously. For patients with five or more previous episodes(41% of the sample), CT reduced relapse/recurrence from 72% to46%. Our findings extend the accumulating evidence that cognitiveinterventions following remission can be useful in preventingrelapse/recurrence in patients with recurrent depression.NRS5.2.THE EFFECTIVENESS OF THE TREATMENT OFDEPRESSION WITH ANTIDEPRESSANTS,PSYCHOTHERAPY OR COMBINED THERAPYS. Kool, J. DekkerMentrum Mental Health Institute, Amsterdam, The NetherlandsThe issue whether combining antidepressants and psychotherapy ismore effective than either of these treatment modalities alone in mildto moderate depression has not been resolved. Data are presentedfrom two consecutive randomized controlled trials investigating thisquestion. Pharmacotherapy comprised fluoxetine or venlafaxine asthe first antidepressant. Psychotherapy consisted of 16 sessions ofshort psychodynamic support therapy. 263 patients were included inthe two trials. Analyses were performed using the last observationcarried forward procedure. Rates of recovery, defined as a HamiltonDepression Rating Scale score of less than 7, were 24% for pharmacotherapy,31% for psychotherapy and 40% for combined therapy.Defining response rate as an improvement of at least 1 standard deviationon the Short Check List-90 (SCL-90) subscale of depression,the results were 44%, 61% and 73% respectively. Results were notrelated to depression severity and duration. It is concluded that combinedtreatment is the first choice in patients with major depression ofmild to moderate severity.NRS5.3.ELDERLY DEPRESSION: CLINICAL SYMPTOMS,BRAIN ABNORMALITIES AND DRUG RESPONSEA.C. Altamura 1 , R. Bassetti 1 , A. Santini 1 , G.B. Frisoni 2 , E.Mundo 11 Chair of Psychiatry, Department of Clinical Sciences “LuigiSacco”, University of Milan; 2 Laboratory of Epidemiology andNeuroimaging, San Giovanni di Dio Fatebenefratelli Institute,Brescia, ItalyFifty-three patients with late onset (>60 years) DSM-IV major depressiveepisodes were treated with flexible doses of standard antidepressantsfor six months. The Brief Psychiatric Rating Scale (BPRS), theHamilton Rating Scale for Depression (HAM-D) and the HamiltonRating Scale for Anxiety (HAM-A) were administered at baseline, after1, 3, and 6 months. The presence of vascular/degenerative brainprocesses, assessed by computed tomography (CT) scans andfrontal/vascular indexes, and of mild/moderate cognitive impairment(24-28 total score at the Mini Mental State Examination, MMSE) wereassessed at baseline and evaluated with respect to the antidepressantresponse. Baseline clinical characteristics were compared between subjectswith and without mild cognitive impairment and between subjectswith and without CT abnormalities (t-tests for independent samples).Baseline depressive symptoms were correlated with CT scan indexes.Treatment response was evaluated by ANOVA with repeated measureson HAM-D, HAM-A, BPRS scores across the different groups definedby presence/absence of mild cognitive impairment, normal/abnormalCT or presence/absence of BPRS “emotional withdrawal”. Patientswith CT abnormalities showed higher baseline scores on the BPRSitem “emotional withdrawal” (p=0.002). The HAM-D “depressedmood” item was negatively correlated to the right frontal index(p=0.006). Patients with CT abnormalities showed a lower reduction ofHAM-D total scores than patients with normal CT (F=5.154, p

Asberg Rating Scale (MADRS), and for Axis II disorders with theStructured Interview for the Diagnosis of Personality Disorders forDSM-IV. Levels of depression were high in the study (26%). Correlationsbetween EPDS and MADRS were very high, showing greatcoherence to PND diagnosis (p

schizophrenics, to free themselves from the care system by promotingtheir initiative and supporting their efforts towards autonomy andself-determination; employing the principles of self-help in meetingbasic needs like housing, work, social life and entertainment. Severalstudies have been performed on this initiative. They have shown thatthis approach may help contain in-patient stays and costs of care,enhance the insight in, and possibly protect against the increase of,unmet needs and improve satisfaction in relevant areas even in thecase of severely-ill mental patients.NRS6.3.THE JOINT CRISIS PLAN ON THE USE OFCOMPULSION IN PSYCHIATRIC TREATMENT: ARANDOMIZED CONTROLLED TRIALC. Henderson, C. Flood, M. Leese, G. Thornicroft, K. Sutherby,G. SzmuklerHealth Services Research Department, Institute of Psychiatry,King’s College, London, UKThis study aimed to investigate whether a form of advance agreementfor people with severe mental illness can reduce inpatient service useand the use of compulsory admission or treatment. It was a singleblind randomized controlled trial conducted in eight communitymental health teams in Southern England. 160 people with an operationaldiagnosis of psychotic illness or non-psychotic bipolar disorder,who had experienced a hospital admission within the previous 2years, were recruited. The Joint Crisis Plan (JCP) was formulated bythe patient, the care co-ordinator, the psychiatrist, and the projectworker, containing contact information, details of mental and physicalillnesses, treatments, relapse indicators, and advance statementsof preferences for care in the event of future relapse. Admission tohospital, bed days, and use of the Mental Health Act over 15-monthfollow-up were the main outcome measures. Use of the MentalHealth Act was significantly reduced for the intervention group,10/80 (12.5%) of whom experienced compulsion versus 21/80(26.5%) of the control group (p=0.028). Consequently, those in theintervention group spent significantly less time under compulsorytreatment, i.e. a mean of 14 compared to 31 days (p=0.04). 30 people(24%) in the intervention group had any admission to hospital versus44 (35%) in the control group; this was of borderline significance(p=0.07). The difference between the two groups in bed days was notsignificant (p=0.15). In conclusion, the intervention showed little evidencefor decrease in admissions but coercive treatment was approximatelyhalved. This is the first structured clinical intervention thatappears to reduce compulsion in mental health services.NRS6.4.IS PRIVACY THE NEW BARRIER TO QUALITY CARE?N. TerryCenter for Health Law Studies, St. Louis University, St. Louis,MO, USAAs an abstract concept, health privacy is not binary; patients, physiciansand regulators alike enthusiastically endorse the protection ofpersonal health information. Its operational characteristics, what weprotect and how we protect it, however, have profound implicationsfor the practice of millennium medicine, particularly psychiatry. Thispaper explores: a) the extent to which regional (European Union) andnational (USA and Australia) organizations are moving from “confidentiality”(or disclosure-centric) to “privacy” (or collection-centric)models for protecting health information; b) how competing interestsin the health information domain, such as attempts to reduce medicalor medication errors, improve access through the use of technologically-mediatedcare and increase health care efficiency, are shapingregulatory choices; c) the extent to which the specific properties ofthe client-psychiatrist relationship may require discrete treatmentfrom privacy and confidentiality regimes and how some systemsattempt to achieve that by providing additional legal protection for“process” notes; and d) how “privacy” litigation may be poised tobecome part of the medical malpractice landscape.NRS6.5.THE ROLE OF THE GATEWAY PROVIDER INACCESSING PSYCHIATRIC SERVICESA.R. StiffmanGeorge Warren Brown School of Social Work, WashingtonUniversity, St. Louis, MO, USAThis paper examines the central influence of a gateway provider onaccess to treatment for mental health problems in two populations ofyouth: American Indians and inner city African American and whiteyouth. The gateway provider may be a professional, an informalprovider, or, for American Indian youth, a traditional healer who firstidentifies a problem and sends a youth to psychiatric treatment. Thefirst study was based on interviews with 800 inner city youth (85%African American and 15% white) and 222 of their providers; the secondstudy was conducted in 400 American Indian youth and 190 oftheir providers. In both studies youth and provider data were merged.Structural equation modeling (SEM) was used to analyze both models.In the study of inner city youth, 55% of the variance in psychiatricservice provision was explained by gateway provider perception ofneed (.54), knowledge of resources (.26), and burden (-.14). In thestudy of American Indian youth the SEM revealed that 42% of thevariance in psychiatric services was determined by gateway providerassessment of youths’ addictions or mental health problems (.36),perception of youth environment (.28), and resource knowledge(.27). In both studies, youth report of their own mental health problemscontributed no variance in services. The values of all SEMindices were high, with the adjusted goodness of fit indices (AGFI)equaling .99. The results demonstrate the pivotal role of gatewayproviders in accessing psychiatric services.NRS6.6.THE PRESCRIPTION OF PSYCHOTROPIC DRUGSIN RESIDENTIAL FACILITIES. A NATIONAL SURVEYIN ITALYG. de Girolamo 1 , R. Tomasi 2 , G. Santone 3 , A. Picardi 4 ,R. Micciolo 5 for the PROGRES group1 Department of Mental Health, Local Health Unit of Bologna;2 Department of Mental Health, Local Health Unit of Bozen;3 Psychiatric Clinic, United Ancona Hospitals and MarcheUniversity, Ancona; 4 National Institute of Health, Rome; 5 Chairof Statistics, University of Trento, ItalyThe PROGRES project is a two-wave project aimed to survey Italianresidential facilities (RFs). In this presentation we report on the prescriptionsof psychotropic drugs to 2,962 patients living in 265 RFs.Structured interviews about patients’ sociodemographic and clinicalcharacteristics were conducted with RF managers and staff; additionalinformation was obtained from clinical records. Conventionalantipsychotics and second-generation antipsychotics were prescribedto 65% and 43% of the sample respectively. Benzodiazepines wereprescribed to two-third of the sample, while antidepressants were theclass of psychotropics least used. Haloperidol was the most frequent-179

ly prescribed compound. Polypharmacy was common: on averageeach treated patient was assuming 2.7 drugs (±1.1). Antipsychoticpolypharmacy was also common. The most common prescriptionprofile was represented by the association between one second-generationantipsychotic and one benzodiazepine (7.0%). Many prescriptionswere loosely related to specific diagnoses: for instance,mood stabilizers were prescribed to many patients who did not havea diagnosis of bipolar disorder, whereas 1/3 of patients with bipolardisorder did not receive mood stabilizers. Antiparkinsonian drugswere prescribed to approximately 1/4 of the sample (n=762). Mildand severe adverse events in the last month were reported for 9.9%and 1.4% of the sample respectively. Almost 15% of patients in drugtreatment were suffering from mild to severe tardive dyskinesia. Inconclusion, patterns of psychotropic drug prescriptions to severepatients living in RFs are only in part satisfactory and offer muchroom for improvement. Studies are also needed to identify the mosteffective strategies to improve prescribing practice.NRS6.7.OVERPRESCRIPTION OF PSYCHOTROPIC DRUGS:AN EPIDEMICT. ScheffDepartment of Sociology, University of California, Santa Barbara,CA, USAI would like to discuss the implications of a single case, in the contextof the statistics on psychotropic drug prescription. On her third birthday,a child was found to have suffered liver failure and brain damageas a result of the simultaneous prescription of 14 medications, including8 psychotropic drugs. The prescribing doctors, pharmacists, andcaretakers were found to be negligent in an 8 million dollars civil suit.In my own experience of cases, it is incredibly easy for a physician toadd one or more presciptions, but almost impossible to remove one,much less all of them. Another case is described in which 7 psychotropicdrug prescriptions were removed, one by one, over a fouryear period, against resistence by the prescribing physicians, butmuch to the benefit of the patient.NRS6.8.TRAINING PSYCHIATRISTS TO TALK MOREEFFECTIVELY TO CLIENTSP. Timms, T. CraigGuy’s, King’s and St. Thomas’ School of Medicine, London, UKCompliance therapy is a mode of discourse combining facets of cognitivetherapy, Rogerian counselling, information–providing andnegotiating. It was developed at the Maudsley Hospital by David,Kemp and Hayward. It has been shown to both increase adherence tomedication regimes and to reduce relapse in people with psychosisafter discharge from hospital. However, the original studies were performedusing just two therapists, who were not part of the usual treatmentstructure and functioned independently of it. The questionremained as to whether these skills were easily transferable to psychiatrists.A 2-day package of compliance therapy training was developed.It combined group work, information about concordance andwork with role players, giving participants an experience of usingcompliance therapy skills “live” in front of other colleagues. It wasdelivered to 48 psychiatrists in training. A questionnaire was performedbefore and after training. This demonstrated that traineesboth felt more confident and had moved towards a more egalitariannotion of the client/doctor relationship. These findings were replicatedwhen the training was delivered to a group of senior psychiatrists.Although this package was developed to enhance adherence to medication,its components seem to encourage a greater emphasis onboth eliciting the patients’ experience and encouraging informedchoice. The training is relatively brief and likely to be cost effective.NRS7.PERSONALITY DISORDERS AND AGGRESSIVEBEHAVIOURNRS7.1.DEMOCRATIC THERAPEUTIC COMMUNITIESFOR TREATING PERSONALITY DISORDER:CAN THEY BE SUCCESSFULLY REPLICATED?T. Burns 1 , M. Fiander 21 Department of Psychiatry, Warneford Hospital, Oxford;2 St. George’s Hospital Medical School, London, UKThe Henderson Hospital in London was established in 1950 as thefirst democratic therapeutic community (DTC) for the treatment ofindividuals with personality disorder (initially ‘psychopathic personalitydisorder’). The unit has been extensively quoted and replicatedinternationally and has been remarkably stable in its practice for 50years. Recent research indicates some success in reducing offendingbehaviour. A decision was made to replicate the unit – to open twoother units in parts of the country and try to offer the same treatmentregime. Doubts had been expressed about the faithfulness of previousunits following the same principles and the perceived ‘uniqueness’and status of the Henderson was thought to present a barrier to faithfulreplication. An evaluation was undertaken of the practice of theoriginal and both replications. This evaluation included a qualitativeorganisational study of the processes in the three units, a clinicalassessment of referred clients and their passage through the units andan economic analysis of their practice. This presentation focuses onthe clinical descriptions of those individuals referred for treatmentand those accepted and their survival within the three regimes (takenas the primary outcome measure). Differences in survival outcomebetween the three units will be presented along with indications ofbaseline characteristics associated with improved survival. Practicedifferences identified in the organisational descriptions will be consideredto understand the differences.NRS7.2.QUETIAPINE IN PSYCHOTIC PATIENTS WITHBORDERLINE PERSONALITY DISORDER:A CASE SERIEST. Gruettert 1 , L. Friege 21 Department of Psychiatry and Psychotherapy, FlorenceNightingale-Hospital, Düsseldorf; 2 Department of Psychiatry andPsychotherapy, Christian-Albrechts-Universitaet, Kiel, GermanyClassical antipsychotics are often used in psychotic, depressed and/orimpulsive patients with borderline personality disorder (BPD), buttheir use is associated with significant side effects and problems withcompliance. New antipsychotics are more likely to be well toleratedand to show a wider spectrum of efficiency. Encouraged by the positiveside effect profile of quetiapine (no extrapyramidal side effects, noweight gain, no galactorrhoea) we initiated a case series with this drugin psychotic BPD. Currently (at least 14 days) psychotic outpatientswith BPD were examined both before and 4 and 12 weeks after treatmentwith quetiapine (mean dose prescribed was 537.5±118.9mg/day). 12 ambulatory female patients with BPD were examined. All180 World Psychiatry 3:S1 - October 2004

patients showed self injurious or recurrent suicidal behavior also triggeredby psychotic experiences. For all variables (Clinical GlobalImpression, CGI; Global Assessment Scale, GAS; Barratt ImpulsivenessScale, BIS; Hamilton Scale for Depression, HAMD; Short CheckList-90-P, SCL-90-P) Page’s trend test was significant (p

ent quality standards for the care of vulnerable women prisoners athigh risk of suicide; b) establish a clinical programme at HM PrisonService, Durham to survey the needs of women who primarily pose arisk of serious harm to the public emanating from severe clinical disordersof the personality, and deliver clinical interventions to thispatient population.NRS8.PSYCHOTIC DISORDERS (II)NRS8.1.THE LONGITUDINAL ANALYSIS OF THE IMPACT OFANTIPSYCHOTIC MEDICATION ON THE INCIDENCEAND THE COSTS OF INPATIENT TREATMENT INPEOPLE WITH SCHIZOPHRENIAR. Kilian 1 , M.C. Angermeyer 2 , T. Becker 11 Department of Psychiatry II, Ulm University, Guenzburg;2 Department of Psychiatry, University of Leipzig, GermanyThe study examines the impact of antipsychotic medication on theincidence and the costs of inpatient treatment in patients with schizophrenia.In a prospective longitudinal study, the incidence and thecosts of inpatient treatment, the type of antpsychotic medication, aswell as the clinical and social characteristics of 307 outpatients withschizophrenia were assessed five times during 2.5 years. A randomeffectlogit model and a random effect tobit model were used toanalyse the impact of antipsychotic medication type on the incidenceand the costs of inpatient treatment. Selection effects were controlledby means of propensity-scores. Patients who received antypsychotictreatment with conventional, new atypical or depot neuroleptics had alower incidence of inpatient treatment and in the case of inpatienttreatment caused lower costs in comparison to patients withoutantipsychotic treatment. No significant differences between the effectsof conventional, new atypical or depot antipsychotics were found.These data suggest that antipsychotic treatment reduces generally theincidence and the costs of inpatient treatment. An extension of the useof clozapine or new atypical antipsychotics to all patients with schizophreniawill not generally improve the treatment effectiveness regardingto the incidence and the costs of inpatient treatment.NRS8.2.PLASMA LEVELS AND DURATION OF ANADEQUATE TRIAL WITH CLOZAPINE INTREATMENT-REFRACTORY SCHIZOPHRENIAP. SchulteMental Health Services, Department De Dijk, Heiloo,The NetherlandsClozapine is a medicine of last resort in refractory schizophrenia andschizoaffective disorder. Therefore it is important to know how toclassify a trial with clozapine as adequate. A systematic review onplasma levels and adequate duration of a trial with clozapine revealed19 trials investigating clozapine levels. These were classified accordingto predefined methodological quality criteria. All five trials withonly minor methodological problems revealed a clozapine plasmathreshold of 350 to 400 µg/l. In addition, three of four methodologicalwell designed trials showed significantly more responders abovethis threshold in comparison to lower levels. A meta-analysis of thesefour trials shows 35 responders out of 115 patients (30%) with plasmalevels below the threshold and 47 responders out of 64 patients(73%) above the threshold. Research into optimal duration of a trialwith clozapine is more difficult to interpret because of methodologicalheterogeneity. The trials should follow up the patients for at leastsix months. Two trials investigated time to response after dose escalation.The third trial linked time to response to clozapine plasma levels.We conclude that after reaching a stable clozapine level the clinicaleffect will be observable within eight weeks.NRS8.3.NEW COGNITIVE OUTCOMES OF DRUGTREATMENT: CLOZAPINE IMPROVEMENT OFSOURCE MONITORING BIAS IN RESISTANTSCHIZOPHRENIAS. Anselmetti, R. Cavallaro, E. Ermoli, L. Bianchi, B. Papini,E. SmeraldiDepartment of Neuropsychiatric Sciences, Vita Salute SanRaffaele University, Milan, ItalySome studies in the last decades investigated and confirmed the roleof the source monitoring deficits in schizophrenic patients, in particularthose affected by positive symptoms of Schneiderian quality, butlimited data are available about their change in response to effectivedrug treatment. Our study aimed to determine whether antipsychoticswere effective in reducing source monitoring deficit and whetherchanges in this aspect of cognition were related to reduction of delusions.The sample consisted of 26 schizophrenic patients (DSM-IVcriteria) who were poor responders to classical antipsychotics and torisperidone, switched to risperidone and clozapine, respectively.Patients were assessed by the Positive and Negative Syndrome Scale(PANSS), a source monitoring task (Keefe et al., 2002), and a batteryincluding the evaluation of cognitive functions known to be defectivein schizophrenia, the Brief Assessment of Cognition in Schizophrenia(BACS), before and after 8 weeks of drug switching. A statistically significantreduction of PANSS delusion score and of misattribution ofself-generated items to external sources (seen or heard) was foundafter 8 weeks of treatment, with the only statistical contribution ofpatients with active delusions at baseline for the source monitoringvariable change. Source monitoring change in patients treated withantipsychotics might be used as a biological marker of antipsychoticactivity.NRS8.4.ATYPICAL ANTIPSYCHOTIC AGENTS IN THETREATMENT OF SCHIZOPHRENIA WITHOBSESSIVE-COMPULSIVE SYMPTOMSI. Reznik 1,2 , R.D. Strous 1,2 , M. Kotler 1,2 , A. Weizman 21 Mental Health Center, Beer-Yakov; 2 Sackler Faculty of Medicine,Tel Aviv University, Ramat-Aviv, IsraelObsessive-compulsive (OC) symptoms have been observed in a substantialproportion of schizophrenic patients. There are some reportsdescribing the appearance de-novo or re-emergence of preexistingOC symptoms under atypical antipsychotic agents (AA). However,there are also reports describing a positive effect of AA in OC-schizophrenicpatients. The complex nature of the treatment response inthis group of schizophrenic patients is as yet unclear. The effects ofAA on OC symptoms may vary, with evidence of improvement insome, and worsening among others. Based on our experience withclozapine and olanzapine as sole agents and in combination withserotonin reuptake inhibitors, we suggest some factors that may predictresponse to AA in schizophrenic patients with significant OCsymptoms. Schizophrenic patients who began to exhibit OC symptomswithin the course of the psychotic process might be successfully182 World Psychiatry 3:S1 - October 2004

treated with AA alone. When OC symptomatology precedes thedevelopment of schizophrenic process, AA alone may be inefficientand may even worsen OC symptoms, so they should be used concomitantlywith specific antiobsessive agents. There is a definite doserelatedpro-obsessive influence of clozapine, but not of olanzapine,that may be explained with their different receptorial affinity. Furthercontrolled investigations of various AA in larger cohorts of OC-schizophrenicsare needed to substantiate our observations and to elaboratethe most effective and safe therapeutic approaches to these difficult-to-treatpatients.NRS8.5.ATYPICAL ANTIPSYCHOTICS RECONSIDERED:HAS HALOPERIDOL WITHOUT PROPHYLACTICANTICHOLINERGIC MEDICATION BEEN AMISLEADING COMPARATOR IN CLINICAL TRIALS?R. RosenheckVA Connecticut Health Care System, West Haven, CT, USAOver two-thirds of all clinical trials evaluating atypical antipsychoticshave used haloperidol without prophylactic anticholinergic medicationas the comparator. This review has three parts. First, we comparesix-week results of two major olanzapine trials: one which usedhaloperidol with prophylactic benztropine (n=309) as the comparatorand the other which used haloperidol with anticholinergics as needed(n=1,966). Next, studies are reviewed that assessed the risk of akinesiain treatment with conventional antipsychotics without prophylacticanticholinergic medication, and evaluated the potential forconfusing this side effect with treatment resistant negative symptoms.Finally recent meta-analyses are reviewed with a focus on studies thatused haloperidol as comparator with and without prophylactic anticholinergics.While olanzapine adherence was similar in the two largetrials, haloperidol adherence was far worse in the trial that did notuse prophylactic anticholinergics, but was no different from that ofolanzapine in the trial that did. When haloperidol was given with prophylacticbenztropine, olanzapine had virtually no advantages. Previousresearch suggests that in the absence of prophylactic anticholinergics20% of patients may develop akinesia with inactivity and withdrawalthat can mimic secondary symptoms of schizophrenia, butshow no pseudo-parkinsoniam symptoms. Examination of the resultsof two recent meta-analyses show that, although limited in number,studies that used prophylactic anticholinergics with haloperidol wereunfavorable to atypicals, unlike those the used haloperidol alone. Inconclusion, failure to use prophylactic anticholinergic medicationwith haloperidol may have biased randomized clinical trials in favorof the atypical antipsychotics.NRS8.6.PREVALENCE OF METABOLIC ABNORMALITIESIN SCHIZOPHRENIC PATIENTS TREATED WITHANTIPSYCHOTICSM. De Hert, D. Van Eyck, H. Peuskens, A. de Patoul,L. Hanssens, A. Scheen, J. PeuskensUC St. Jozef, Kortenberg, BelgiumEpidemiological studies have demonstrated an increased risk for diabetesin schizophrenic patients treated with certain atypical antipsychotics,particularly clozapine, olanzapine and quetiapine. In the currentanalysis we describe the prevalence of baseline metabolic abnormalitiesin a cohort of schizophrenic patients. The cross-sectionalstudy population is derived from a naturalistic cohort of treatedschizophrenic patients, being followed prospectively for 1 year.Extensive metabolic data are being collected. Preliminary data on 100non-diabetic schizophrenic patients, stable on medication (90% onatypical antipsychotics) for at least 6 months, have been analyzed sofar. The metabolic syndrome (Adult Treatment Panel III criteria) ispresent in 23% of patients. 25% of patients are overweight, 39% areobese. The prevalence of individual metabolic risk factors is: 45%hypertriglyceridemia, 44% increased waist circumference, 29%reduced high density lipoprotein, 20% hypertension, 10% impairedfasting glucose. In 4% of patients, results of an oral glucose tolerancetest (OGTT) met the criteria for diabetes and 16% of the cohortexhibited impaired glucose tolerance. 35% of patients had post-glucosehyperinsulinism and delayed insulin release, sometimes with atendency to reactive hypoglycemia. In this epidemiological study onthe prevalence of metabolic disturbances in schizophrenic patients,the high prevalence of the metabolic syndrome and the observedabnormalities in OGTT may be related to early stages of metaboliccomplications of antipsychotic treatment. The prospective nature ofthe study will identify the predictive value of the observed abnormalitiesas well as the association of these events with atypical antipsychoticuse and anthropomorphic measures.NRS9. MOOD DISORDERS (II)NRS9.1.LITHIUM AND ATYPICAL ANTIPSYCHOTICS IN THEMAINTENANCE TREATMENT OF BIPOLARDISORDER: A 2-YEAR OPEN-LABEL STUDYA.C. Altamura, D. Salvadori, M. Russo, E. MundoChair of Psychiatry, Department of Clinical Sciences “LuigiSacco”, University of Milan, ItalyLithium has been showing a good efficacy in preventing recurrences inbipolar disorder (BD) (although it is not so effective in rapid cyclingforms or in dysphoric mania), but is associated with a low therapeuticindex and a long onset of response. There is increasing evidence thatnovel antipsychotics (e.g. olanzapine) are efficacious both in the acuteand in the maintenance treatment of BD. The aim of this study was tocompare the efficacy of lithium and novel antipsychotics (inmonotherapy or in combination) in the maintenance treatment of BD.The sample consisted of 30 subjects (14 males, 16 females) with aDSM-IV diagnosis of BD (15 type I and 15 type II) randomly assignedto 3 groups matched for clinical and demographic characteristics (age,onset, duration of illness and recurrence indexes). Group 1 wasassigned to lithium, group 2 to lithium and novel antipsychotics (olanzapineor quetiapine) and group 3 to novel antipsychotic monotherapy.Patients were euthymic at the start of the study and were assessedby the Brief Psychiatric Rating Scale (BPRS) and the Clinical GlobalImpression (CGI) from the baseline every 2 months for a 2 year followupperiod. BPRS scores remained stable over time in the 3 treatmentgroups (F=2.09, p=0.08) with no differences among groups (F=0.88,p=0.42). However, considering CGI scores, group 2 showed a betterimprovement (F=3.91, p=0.03). In summary, novel antipsychotics asmonotherapy showed a similar efficacy to mood stabilizers on psychopathologyscores. However, atypical antipsychotics appeared to bebetter on global functioning scores over time. Confirmation of thesepreliminary data in larger samples and with longer follow-up is warranted.183

NRS9.2.MENSTRUAL FUNCTION IN WOMEN TAKINGMOOD STABILIZERSN. RasgonDepartment of Psychiatry and Behavioral Sciences,Stanford School of Medicine, Palo Alto, CA, USAWe examined reproductive function in women aged 18-45 with bipolardisorder taking mood stabilizing medications to determinewhether receiving valproate impacted menstrual function or reproductive/metabolichormone levels. Women completed menstrualcycle questionnaires and provided blood samples for measurement ofa range of reproductive endocrine and metabolic hormone levels.Eighty women participated in completing the questionnaires and 72of them provided blood samples. Fifty-two women (65%) reportedcurrent menstrual abnormalities; 40 (50%) reported menstrual abnormalitiesthat preceded diagnosis of bipolar disorder. Fifteen women(38%) reported developing menstrual abnormalities since treatmentfor bipolar disorder. Fourteen of these 15 developed abnormalitiessince treatment with valproate (p=0.04). Of these 15 patients reportingmenstrual abnormalities since starting medication, 12 (80%)reported changes in menstrual flow (heavy or prolonged bleeding),and five (33%) reported changes in cycle frequency. Reproductiveand metabolic values outside the normal range across groups includedelevated 17-alpha-OH progesterone levels, luteinizing hormone:follicle stimulating hormone ratios and homeostasis model assessment(HOMA) values and low estrogen levels. Three of the 50 women(6%) taking valproate met criteria for polycystic ovarian syndrome(p=0.20). Rates of menstrual disturbances are high in women withbipolar disorder and, in many cases, precede the diagnosis and treatmentfor the disorder. Treatment with valproate additionally contributessignificantly to the development of menstrual abnormalities.Women with pre-existing menstrual abnormalities may represent agroup at risk for reproductive dysfunction while treated for bipolardisorder.NRS9.3.ANTIDEPRESSANT-INDUCED MANIA IN BIPOLARDISORDER: PREDICTIVE CLINICAL VARIABLES IN ACASE-CONTROL STUDYE. Mundo, C. Montresor, M. Russo, E. Cattaneo, A.C. AltamuraChair of Psychiatry, Department of Clinical Sciences“Luigi Sacco”, University of Milan, ItalyAntidepressant-induced mania (AIM) occurs quite frequently inpatients with bipolar disorder (BP). In this study we evaluated whichclinical variables could be predictive of AIM. One hundred patientswith a DSM-IV-TR diagnosis of BP I or II, who had had at least onedepressive episode treated with antidepressants, were selected. Patientswere subdivided into two subgroups according to the presence (n=13)or absence (n=87) of manic/hypomanic episodes occurring duringantidepressant treatment. As possible predictive clinical variables weconsidered: gender, diagnostic subtype, age at onset, duration ofuntreated illness, number of spontaneous hypomanic and manicepisodes, number of depressive episodes, previous suicidal attempts,the presence of mood stabilizers, the presence of psychotic symptomsduring spontaneous episodes, the presence of positive family history forpsychiatric disorders in first-degree relatives. Data were comparedbetween the two groups using Student’s t test on the continuous variablesand chi-square test on categorial variables. The absence of moodstabilizer treatment during antidepressant therapy was the only variablesignificantly associated with the development of AIM (p

NRS9.6.GENDER DIFFERENCES IN AGE OF ONSET OFBIPOLAR I DISORDER AND FAMILIAL LOADINGM. Grigoroiu-Serbanescu 1 , M.M. Nöthen 2 , S. Ohlraun 3 ,M. Rietschel 3,5 , W. Maier 5 , P. Propping 4 , P. Wickramaratne 6 ,M.-J. Georgescu 1 , D. Prelipceanu 1 , M. Grimberg 1 , D. Sima 11 A. Obregia Psychiatric Hospital, Bucharest, Romania;2 Department of Medical Genetics, University of Antwerp, Belgium;3 Division of Genetic Epidemiology in Psychiatry, Central Instituteof Mental Health, Mannheim, Germany; 4 Institute of HumanGenetics, University of Bonn, Germany; 5 Department ofPsychiatry, University of Bonn, Germany; 6 Department ofPsychiatry, Columbia University, New York, NY, USAThere is growing evidence that individual treatment response of bipolarpatients depends on genetic factors, like family history (FH), andgender differences in clinical traits, including age of onset (AO). Ingenetic studies, AO was proposed as a definition criterion for morehomogeneous phenotypic subgroups which might enhance thechance of identifying the genes of bipolar disorder and developingmore effective treatments. But it seems that AO in itself is a heterogeneousvariable. The objective of this study was to investigate the effectof gender, FH and psychotic symptoms on AO in bipolar I illness. AOwas analyzed in two independent samples – a Romanian (n=242) anda German one (n=220) – which were pooled together (462 patients:218 males, 244 females). The probands were recruited from consecutivehospital admissions without regard to FH and diagnosed accordingto DSM-IV. FH-type showed a strong effect on AO in the totalsample (p

clinical cases confirming the important role of a multimodal approachwhere psychodynamic psychotherapy, medication and a rehabilitationprogram are important not only to recover lost capacities, but also tomodify the patient’s feeling towards external and internal objects.NRS10.4.THE ITALIAN STUDY WOMEN ANDSCHIZOPHRENIA (SIDeS): FIRST RESULTSG. Boidi 1 , P. Ciancaglini 1 , A. Carolei 2 , F. Gigli-Berzolari 2 ,A. Marinoni 21 Department of Mental Health, Local Health Unit 3, Genoa;2 Applied Medical Science and Psychobehavioral Institute,niversity of Pavia, ItalyThe goals of the study Women and Schizophrenia (SIDeS) are, onone hand, to check if the gender-oriented approach to pathologies, inparticular to schizophrenia, is used by Italian departments of mentalhealth and, on the other hand, to create a database for follow-up longitudinalstudies on particular patients, in order to study specific genderproblems in pharmacological, psychological, and rehabilitatingtreatments. The study is a cross-sectional and multicentred examinationbased on a naturalistic approach, with the following inclusioncriteria: patients over 18 years old of both sexes with a diagnosis ofschizophrenia according to ICD-10 or patients who take antipsychotics.The sample has been chosen using the temporal clustermethod. During a period of three months in 2003, about 800 patientswere gathered from 14 departments located in 10 different Italianregions. For each department a service card with general informationand items on frequent gender-oriented practices has been filled out.The patient card shows personal and behavioral information (smoking,alcohol, drugs, sexuality), information on the disease and onpharmacological and other kinds of treatments, for a total amount of149 variables. An analysis conducted on the initial results shows thatin Italian psychiatric centers a correct gender-oriented approach,based on evidence from the literature, still needs to be achieved.Regarding treatments, some differences relating to the sex variablewere observed. Work at different levels is recommended to improvethe appropriateness of psychiatric treatments as regards gender.NRS10.5.1000 DISCHARGES IN 3 1/2 YEARS:A CRISIS ORIENTED TREATMENT FOR ACUTEINPATIENT WOMENP.A. BerrettoniHospital Neuropsiquiatrico Braulio A. Moyano, Buenos Aires,ArgentinaAlmost four years ago, a new tendency in treating critical acute inpatientwomen has been implemented at the Neuropsychiatric Hospitalfor Women “Braulio A. Moyano” of Buenos Aires, Argentina. Sincethen, the number of chronic patients has been reduced to half the originalcount. This was obtained by challenging the until then staticarchaic principles of psychiatric hospitalization that prevailed inArgentina for near a century. A quick, comprehensive and updatedtreatment modality has allowed the Acute Inpatient Service to dischargeover 1000 patients in this period of time. The strategy consists ofintegrating pharmacological and psychotherapeutic treatments, aimingat resolving the patient’s main crisis, with the maximum effective contact,and fast acting symptom relief. A crisis model has been developedalong with this treatment modality to provide quick detection of the crisisand ensure short stays.NRS10.6.FAMILIES AND MENTAL HEALTH PROVIDERS:STEPS TO PARTNERSHIP. EDUCATIONALSTRATEGIES WITHIN THE BRAZILIAN PROGRAM TOFIGHT STIGMA BECAUSE OF SCHIZOPHRENIAC.C. VillaresSão Paulo Federal University, São Paulo, BrazilThe Brazilian site of the WPA Global Program against Stigma andDiscrimination because of Schizophrenia was launched in early 2001in São Paulo, the country’s largest city. The Project, under the responsibilityof the Brazilian Psychiatric Association, shares the WPAGlobal Program mission and general strategies. Initial surveys conductedin 2001 with patients and caregivers revealed that stigma experienceswere strongly related to lack of information, orientation andsupport groups. Also, the experience of other participant sites and theliterature on partnership in mental health supported the significanceof collaboration between families/users and the mental health serviceproviders for the development of sustainable anti-stigma programs.Within this framework, a set of strategies was designed to foster theempowerment of families, caregivers and users, aiming to supporttheir active involvement in actions and to develop capacity and leadershipto enable mutual support and advocacy. Thus, establishing apartnership with users and caregivers has been a primary goal of theBrazilian Project. This presentation will address the issue of partnershipfrom the perspective of the educational strategies developedwithin our Project. Since 2002, a team consisting of mental healthprofessionals, family members and users has been in charge of organizingand evaluating the educational meetings, named “Talking AboutSchizophrenia”, offered twice a year in the first year, and scheduled tobe delivered every three months in 2003. Six meetings organized untilthe present time reached around 600 persons in the community -mainly consumers, family members, mental health professionals andmembers of the clergy. The meetings were evaluated with the Portugueseversion of the Canadian Presentation Evaluation Form,developed by the Calgary site of the WPA Global Program. With thispresentation, we will attempt to: a) present a profile of the participantsand offer a brief evaluation of this action in the context of theBrazilian efforts related to the Global Program; b) summarize thelearnings from this activity: what did we learn about expectations andviews of families and users? What do the caregivers want from themental health system? c) discuss the issue of partnership betweenusers, families and mental health providers from the perspective ofeducation and support groups.NRS11.CHILD AND ADOLESCENT PSYCHIATRY (I)NRS11.1.THE INTERFACE BETWEEN PAEDIATRICPRACTICE AND THE LAWC. Kaplan, H. Lambert, J. Hale, J. Owens, M. CoulthardUniversity of Newcastle upon Tyne, UKChildren are presenting increasingly frequently with complex physicaland mental diseases where the treatment and management strategieshave given rise to concerns about the legality and ethical constraintswithin which professionals operate. The expression of differingwishes by parents, children and doctors raises important andcomplex issues, which require resolution in the interest of the child.We have established a series of colloquium discussions in Newcastle186 World Psychiatry 3:S1 - October 2004

upon Tyne, which bring together senior clinicians and senior lawyersto discuss cases of this nature. Examples include girls treated for cancerwho wish to store germinal tissue where parents object; caseswhere patients object to genetic screening of their children when thiswill reveal information about their own genetic status; cases where achild’s right to information is contested and many others. Legal andhealth professionals are united in their view that the child’s interestsare paramount. However there are many differences in the decisionmaking process followed by the two professions. The meetings haveprovided rich discussions of differing approaches and how best tobring these together productively. Many dimensions of these issueswere discussed, including the need to support health service professionsin following courses of action that are often fraught with difficulty.Suggestions about the development of guiding principles aremade and will be presented for discussion.NRS11.2.THE HEALTH-RELATED QUALITY OF LIFEOF CHILDREN SUFFERING FROMATTENTION-DEFICIT/HYPERACTIVITYDISORDER AND THE COSTS TO SOCIETYL. Hakkaart-Van Roijen 1 , B.W.C. Zwirs 2 , J.K. Buitelaar 3 ,T.W.J. Schulpen 2 , C.P.W.M. Veraart 4 , F.F.H. Rutten 11 Institute for Medical Technology Assessment, Erasmus MedicalCenter, Rotterdam; 2 University Medical Center, Utrecht;3 University Medical Center, St. Radboud, Nijmegen; 4 Eli Lilly, TheNetherlandsThe objective of this study is to estimate the health related quality oflife (HRQoL) of attention-deficit/hyperactivity disorder (ADHD)children and the societal costs for the Netherlands. An initial populationof 10,000 children aged 6-8 years were rated by their schoolteachers on a scale to determine the probability of ADHD. A total of150 children with low scores and 150 with high scores for externalisingitems were invited for detailed assessment of the burden of illnessof ADHD for the patient and their relatives. We applied a prospectivefollow-up study design. We planned to collect data on health care utilizationand HRQoL of three categories of children: 50 ADHD childrenin the community (group 1), 100 clinical ADHD children (group2) and 50 controls with no ADHD (group 3), at four moments in time(baseline, 6 months, 12 months and 18 months). The Child HealthQuestionnaire (CHQ-50) was used for measuring the HRQoL. Additionally,health care utilization and productivity loss of the mother ofthe respondents were assessed. At baseline a total of 165 questionnaireswere distributed for the three groups. The response rates were:group 1, 94% (n=33); group 2, 90% (n=64) and group 3, 78% (n=47).In group 1, 33% of the respondents were identified as ADHD by apaediatrician. Results on HRQoL and costs will be presented. This isthe first study on HRQoL and costs from a societal perspective in theNetherlands including an ADHD population in the community.NRS11.3.ATTENTION-DEFICIT/HYPERACTIVITYDISORDER IN OMANI YOUTHM.M. Al-Sharbati 1 , M. Simsek 21 Department of Behavioural Medicine and 2 Department ofBiochemistry, College of Medicine and Health Sciences, SultanQaboos University, OmanThis study aimed to explore the characteristics of attentiondeficit/hyperactivitydisorder (ADHD) among the Omani youth. Atthe child and adolescent psychiatry clinic of the Sultan Qaboos UniversityHospital, a questionnaire consisting of the diagnostic criteriafor ADHD (DSM-IV), in addition to other variables, was filled by theparents of the referred patients. The study extended from February2000 to September 2003. Two hundred and twenty-one cases ofADHD were investigated, diagnosed and treated. Boys constituted70% of the patients. The mean age was 8.1 years (SD 2.8). Parentalconsanguinity was high (48%). One hundred and fifty (67.9%) casesexhibited both inattention and hyperactive-impulsive behavior, while45 (20.4%) had inattention only. The remaining 26 (11.8%) werehyperactive and impulsive. Seventy-two (32%) of the patients sufferedfrom head injuries; among them 77.8% were caused by fallingfrom heights. The intelligence level of the patients was normal in27.6% of cases, while 66.5% suffered from mental retardation. Themajority (79.6%) of the cases had comorbidity, of whom 141 had asingle comorbidity – mainly mental retardation (103 cases). One hundredand thirty nine patients were enrolled in normal schools, 41were preschoolers, 35 were not enrolled in any school, and 6 wereattending special schools for mentally handicapped. About half of thepatients (49.3%) were not given medication, as they required furtherinvestigations, while 29.8% were treated with a psychostimulant(methylphenidate), and 14.5% were given tricyclics. These data suggestthat a significant number of Omani youth is affected by ADHD,which emphasizes the importance of public awareness, in addition toprovision of facilities for diagnosis, treatment and follow-up.NRS11.4.NON-PHARMACOLOGICAL APPROACHES TOHELPING CHILDREN DIAGNOSED WITH ADHDAND THEIR FAMILIESS. TimimiLincolnshire Partnership NHS Trust, Lincolnshire, UKThis presentation will review the literature on non-pharmacologicalapproaches to helping children diagnosed with ADHD and their families.Firstly, I will present evidence regarding the physical and psychologicaldangers associated with the use of stimulants in children. Alltoo often balanced information about risks as well as benefits are notprovided to parents who are making the difficult decision of whetherto put their children on a stimulant or not. When parents are given thefull picture, many (in my experience the majority) decide that they donot wish their child to take a stimulant, in which case we need to beaware of effective non-pharmacologically centred approaches that canbe used as an alternative. Many psychiatrists (in my experience themajority!) are not aware that a whole raft of effective non-pharmacologicalinterventions are available and backed by scientific evidence.These include systemic interventions, lifestyle changes, specific behaviouralmanagement strategies and examining value systems. I will alsopresent my own work in this area and the impact local initiativesincorporating these multiple perspectives has had on local levels ofstimulant prescribing.NRS11.5.TRAVELLERS: A SCHOOL-BASED TARGETEDMENTAL HEALTH PROMOTION PROGRAMMEFOR EARLY ADOLESCENTSP. Dickinson, D. Thomas, M. AgeeUniversity of Auckland, New ZealandThis presentation outlines the conceptual background, theoreticalframework (e.g., mental health promotion, metaphor, meaning making,emotional literacy, cognitive strategies, coping and social support)and findings from phase two of the Travellers project – a target-187

ed, selective mental health promotion programme designed toenhance protective factors for young people who are at increased riskfor the development of mental health problems. The Travellers programmewill be described in terms of adolescent mental health concerns;emerging mental health promotion theory and practice; andprevention and early intervention models. The key elements of Travellerswill be described. The programme was trialled in ten secondaryschools over two years as an experimental design with 302 participants(females, n=164, males, n=138) and a matched usual care comparisongroup (n=202; females, n=114, males, n=90). The Travellersprogramme provides a means of early identification and selection ofyoung people who may benefit from participating in an early interventionprogramme. The programme has achieved a statistically significantreduction in participants’ distress (p

tion is a core deficit and a phenotypic marker in schizophrenia. Cognitivedysfunction is: a) present before or at the onset of illness; b)present in virtually all patients; c) relatively stable and present whensymptoms are in remission; and d) present in non-psychotic biologicalrelatives of patients or individuals at risk of the illness. Schizophrenicpatients show deficits in a variety of cognitive domains, includingexecutive function, attention, memory and language. Cognitiveimpairment tends to be independent of the symptoms of the illness.Different dimensions of symptom clusters, such as negative symptoms,psychotic symptoms, and disorganized behaviour, have been found tohave dissimilar relationships with cognitive performance. In general,cognitive deficits are more strongly related to negative symptomsand/or disorganized behaviour, whereas the psychotic dimension hascomparatively weaker relationships with neuropsychological performance,although specific findings vary among studies. Neurocognitiveabilities, rather than symptoms, are consistently linked to functionaloutcome. This raises the possibility that treatments producingimprovements in cognitive function might prove to have synergisticeffects with psychosocial interventions. The atypical antipsychoticsmay be effective in this area and the various medications may have differentneurocognitive profiles. Positive symptoms may be linked toimpaired verbal memory. Delusions and hallucinations can be regardedas resulting from a failure of reality discrimination, or reality distortion,whereby internal events or thoughts are misattributed to externalsources. Studies aimed at evaluating the relationship between cognitivedeficits and positive symptoms and testing selective treatments arehighly warranted, and preliminary data on cognitive substrates ofdelusions and their treatment will be presented.NRS12.4.IS ALEXITHYMIA RELATED TO NEGATIVESYMPTOMS OF SCHIZOPHRENIA? PRELIMINARYLONGITUDINAL FINDINGSO. Todarello 1 , P. Porcelli 2 , G. Dello Russo 11 Department of Neurology and Psychiatry, University of Bari;2 Psychosomatic Unit, De Bellis Hospital, Castellana Grotte,Bari, ItalySome features of alexithymia resemble affective flattening, emotionalblunting, and alogia, that are negative symptoms of schizophrenia.Previous studies showed an association between negative symptomsand alexithymia, but were limited by the use of cross-sectional designs.This study aimed to evaluate whether alexithymia is associated withnegative and depressive symptoms and is related to the change ofschizophrenic symptoms over time. A consecutive sample of 29 schizophrenicoutpatients was evaluated at baseline and at 3, 6, and 12months during appropriate treatment. They were assessed by the Positiveand Negative Syndrome Scale (PANSS), the Montgomery-AsbergDepression Rating Scale (MADRS), the Global Assessment of Functioning(GAF), and the 20-item Toronto Alexithymia Scale (TAS-20) ateach time point. The psychiatric scale scores showed a significantsymptom improvement over time, while the TAS-20 scores remainedstable over the study time. On regression analysis, the TAS-20 at baselinewas the only predictor of alexithymia at the 12-month follow-up,after controlling for psychopathology. However, a high prevalence ofalexithymia (65.5%) was found among schizophrenic patients. In conclusion,alexithymia seems to be unrelated to negative, positive, anddepressive symptoms, which suggests that it is an independent constructfrom schizophrenia. The high prevalence of alexithymia amongschizophrenic patients indicates, however, that alexithymia may play arole in schizophrenia that has not been yet elucidated.NRS12.5.USE OF ATYPICAL ANTIPSYCHOTICS IN ACUTEPSYCHOTIC INPATIENTS IN HOSPITALPSYCHIATRIC WARDS IN CENTRAL ITALYG. Bersani 1 , F. Pacitti 2 and the Italian Collaborative Study Groupon New Antipsychotics in Acute Inpatient Units1 Department of Psychiatric Sciences and Psychological Medicine,La Sapienza University, Rome; 2 Department of Medicine,University of L’Aquila, ItalyThe aim of this study was to examine the criteria and the outcome ofthe use of atypical antipsychotics (AAPs) in 730 acute psychotic inpatients(schizophrenia, bipolar and schizoaffective disorder) in 25 hospitalpsychiatric wards from Central Italy. Clinical interviews andPositive and Negative Syndrome Scale (PANSS) assessments wereconducted at the beginning of treatment and at patients’ discharge. Afactor analysis of scores on the PANSS was performed to extract fourfactors (negative symptoms, positive symptoms, disorganized thoughtand anxiety/depression) and the mean changes in PANSS factorscores were analyzed. 53% of patients were treated with risperidone,25.7% with haloperidol, 9.3% with clozapine, 9.1% with olanzapineand 2.9% with quetiapine. The presence of positive symptoms wasthe first criterion for the use of all AAPs, the second was the presenceof disorganization for clozapine, and of negative symptoms for olanzapine,risperidone and quetiapine. In the analysis of mean changesin PANSS factor scores, the positive and negative symptoms factorsshowed a greater improvement in patients after treatment with allAAPs compared to patients treated with haloperidol. These resultsconfirm even in acute patients with different psychotic disorders awide range effect of new antipsychotics, in accordance with clinicalexpectations.NRS12.6.INVOLUNTARY TREATMENT WITH CLOZAPINE INTREATMENT RESISTANT SCHIZOPHRENIAP. SchulteMental Health Services, Department De Dijk, Heiloo, TheNetherlandsLack of insight and opposition against treatment is a frequent phenomenonamongst psychotic patients, especially the most seriouslyaffected. We wanted to assess the results of involuntary treatmentwith clozapine, by a retrospective chart review. 17 psychotic patientswith long-standing illnesses were eligible for involuntary treatmentwith clozapine because of treatment resistance (n=16), severe sufferingof the patient (n=15) or his environment (n=4), assaultiveness(n=10), self-harm/suicidality (n=4), self-neglect (n=3) or stopping toeat (n=2). Eligible patients got the choice between oral or intramuscularinjection treatment with clozapine. Seven patients compliedafter all with oral treatment. Treatment tolerability was good in mostpatients with clozapine injections and there were no unexpected sideeffects. Mean Clinical Global Impression-Severity (CGI-S) scoredecreased significantly from 6.4 before initiation of clozapine to 4.6 atthe end of the acute treatment phase and 4.4 at last observation(whether on or off clozapine). No patient showed deterioration whileon clozapine. Seven of 17 patients were considered as responders(Clinical Global Impression-Improvement, CGI-I of 1 or 2) at the endof the acute treatment phase. At last observation 10 of the 11 patientsstill on clozapine were classified as (very) much improved, althoughthe patients on clozapine were followed up for a mean of 16.7months. Custodial restriction at last observation was reduced in 11patients and not changed in 6. No patient needed more custodial189

estriction at last observation in comparison to baseline. In conclusion,involuntary treatment with clozapine may be feasible and effectivein seriously ill, treatment resistant psychotic patients.NRS13.CHILD AND ADOLESCENT PSYCHIATRY (II)NRS13.1.INPATIENT MANAGEMENT OF MULTI-IMPULSIVEANOREXIA AND BULIMIAJ.H. LaceySt. George’s Hospital Medical School, London, UKFor clinical researchers of bulimia, the last two decades have been atherapeutic success; however, when bulimia or the bulimic form ofanorexia nervosa becomes associated with addictive or self-damagingbehaviour, treatment response is poor. Treatment remains empiricaland response perplexing to the rational clinician. This paper willdescribe the development of a new inpatient and partial hospitalisationprogramme. The paper will briefly describe the individual therapeuticapproaches used by a multidisciplinary team, and the way thatthey are harnessed for therapeutic effect. The management, includingself-audit, will be emphasised, and the ethos and working practices ofthe team briefly stated. The body of the programme will describe themanagerial techniques used. Outcome results at the end of treatment,at one year, and at five years will be presented (in terms of binge-eating,self-induced vomiting, alcohol and drug abuse, and self-damagingbehaviour). Clinical indicators of poor outcome will be given.NRS13.2.ENVIRONMENTAL PSYCHOLOGYAND HOME VISITS IN EATING DISORDERS –A NEGLECTED FIELD OF FAMILY THERAPYF. TúryInstitute of Behavioural Sciences, Semmelweis University,Budapest, HungaryEnvironmental psychology is a new discipline in applied psychology,and its role is underestimated in the family therapeutical practice. Thepresentation will summarize the basic concepts of environmental psychology,which is the theoretical background in the interpretation ofhome visits. Home visits can serve as a good strategy in the process offamily therapy. In our practice the visits at home of eating disorderedpatients have become a routine part of the therapeutical process. Theexperiences of visits at home of 15 patients with eating disorders willbe presented. There are two ways in which home visits may be usefulfor family therapy. On one hand there is a good opportunity to introducein vivo structural tasks. Information about the personal boundariesare useful in the planning of therapeutical interventions. On theother hand the visit can serve as a tool for strengthening the psychotherapeuticrelationship: changing the traditional doctor role,warming family atmosphere, entering into the personal spaces. Therapistsbecome participating observers as in cultural anthropology.The observation of personal boundaries on the basis of environmentalpsychology, structural family therapy, and the cognitive-behaviouralpoint of view provide important information relating to thefamily context of the pathological behaviour.NRS13.3.CZECH ADOLESCENTS AND EATING DISORDERSF.D. Krch 1 , L. Csémy 1 , H. Drábková 21 Psychiatric Clinic, Prague;2 PVSS Prague, Czech RepublicIn a questionnaire study, 60% out of 725 schoolgirls (average age of14.5 years) from Prague and Ceske Budejovice (a small town) werenot satisfied with their bodies, and 60% stated that they would liketo lose weight. 2% of girls vomited regularly every week and 1.8% atleast once a month. In risk attitudes and behaviour there was no differencebetween girls from Prague and Ceske Budejovice andbetween students of 8th and 9th grades. There was a negative correlationbetween the scores on Eating Attitude Test-26 (EAT-26) and ascale of perfectionism, and a positive correlation between EATscores and a measure of self-confidence. The group of girls with riskyeating attitudes turned out to be at higher risk also concerning use ofaddictive substances. They smoked cigarettes and marijuana anddrank alcohol more often. They also went to shopping centres moreoften. Girls with high EAT score assessed the atmosphere in theirfamily as less harmonic and helpful, and their relationship to thefather as unsatisfactory. Their mothers were treated in psychiatrymore often, their mothers and sisters dieted more often and in thefamilies of these girls an exceptional performance was appreciatedmore often.The study was supported by the GA CR grant 406/01/0393.NRS13.4.AN INTEGRATIVE APPROACH TO ANOREXIAAND BULIMIA: PRELIMINARY DATA OF ARESEARCH PROJECTL. Onnis and the Eating Disorders Research GroupDepartment of Psychiatric Sciences, La Sapienza University,Rome, ItalyThis research project aims to test a therapeutic strategy that couldimprove the prognosis of anorexic and bulimic syndromes, reducingtheir tendency to chronicity. Twenty-four patients suffering fromanorexia nervosa (n=12) or bulimia nervosa (n=12) diagnosedaccording to DSM-IV were divided into two homogeneous groups: anexperimental group, which received a medical-nutritional treatmentand a family psychotherapy, and a control group, which received amedical-nutritional treatment only. We have measured three sets ofparameters: a) clinical parameters, strictly connected with theanorexic and bulimic symptoms (as indicated by the DSM-IV diagnosticcriteria); b) individual parameters, concerning eating behaviourand psychological characteristics of the patients (Eating AttitudeTest, EAT; Body Uneasiness Test, BUT; Machover Human FigureDrawing Test; Corman Family Drawing Test); c) relational parameters,concerning family interactional dynamics (using a modified versionof the Wyltwick Family Tasks). All these parameters have beentested and evaluated before and after the therapeutic process both inthe experimental group and in the control one. Up to now we haveevaluated 2/3 of the total research samples and we can present preliminarydata only. The results already obtained show a clearimprovement of the anorexic and bulimic symptoms in the patients ofthe experimental group, correlated with a parallel improvement of thedysfunctional family interactive models and the patient’s psychopathologicalcharacteristics. This improvement was not found inthe control group.190 World Psychiatry 3:S1 - October 2004

NRS13.5.VIOLENCE, GENDER AND NARRATIVECOMPETENCE IN ADOLESCENCEG.F. RonningFoshay Tower, Minneapolis, MN, USAThe adolescents’ ability to tell a coherent and meaningful narrativeabout the world and their view of self is both a means and a measureof development and outcome. The adolescent who is able to representexperiences and internal states in words may have a better outcomethan those who, unable to represent their inner world in anymeaningful way, will act out in violent and self destructive ways. Thisis a study of the relationships between adolescent violence, gender,and narrative competence. The research design has involved theanalysis of over 200 subjects admitted to an adolescent treatment program.I found a clear inverse correlation between symptom intensityas measured by the Short Check List-90 (SCL-90) and violent behavior.When all forms of violence to the self and/or others were combined,the incidence for males and females was nearly identical. Thenarrative ability of the adolescent is being investigated, using a structuredand scored autobiography collected during, and one year following,hospital admission. Correlations will be made with violentbehavior and gender as well as with other clinical, demographic anddiagnostic variables. As the research progresses, it shows a consistentrelationship between violence, symptoms, and narrative capacity.NRS13.6.YOU CAN’T TREAT TRAUMA IF YOU DON’TKNOW ABOUT IT: A NEW ZEALAND TRAININGPROGRAMMEJ. ReadDepartment of Psychology, University of Auckland, New ZealandThis paper first summarises the international research literatureshowing that the majority of trauma histories, including sexual andphysical abuse in childhood and adulthood, are not known by mentalhealth staff. The research about how clinicians currently respondto disclosures of childhood abuse will be presented. Research investigatingthe reasons for the apparently poor standards of clinical practicein these two areas will be presented, including New Zealandresearch. These include fear of vicarious traumatization, fear of distressingthe client and lack of training in how to ask sensitively andhow to respond to disclosures appropriately. Policy guidelines (thatall mental health clients must be asked about trauma, and all staffmust be appropriately trained), and a training programme – currentlyoperating in Auckland, New Zealand - will be presented, along witha plan of evaluation of the training programme.NRS13.7.RISK-TAKING BEHAVIOR AND SUICIDEAMONG YOUNG ADULTS. TOWARD A DEFINITIONOF SUICIDE SPECTRUMM. Pompili, M. Innamorati, I. Mancinelli, P. Girardi, A. Ruberto,R. TatarelliDepartment of Psychiatry, S. Andrea Hospital, La SapienzaUniversity, Rome, ItalyRisk taking behavior is defined as a group of behaviors that is distinguishablefrom overt self-destructive behavior by the criteria of timeand awareness. The effect of the behaviors is long-term, and the personis usually unaware of or does not care about the effect of thebehavior. Our study aims at assessing the correlation between risktaking behavior and suicidality among young adults. We surveyed 183University students (81 males and 102 females). The following scaleswere administered to each participant: Physical Risk AssessmentInventory (PRAI), for assessing a variety of health and sport riskbehaviours; Beck Hopelessness Scale and Reasons for Living Inventory(RFL), both assessing suicide risk. We also administered a selfreportedquestionnaire to investigate whether or not the individualthought of or attempted suicide in the last 12 months or in his lifetime.Principal components analysis was performed. 3% (n=5; 4 menand 1 woman) of participants attempted suicide in the last 12 months(1.1% more than once); only one subject out of five had attemptedsuicide sometime in the past. Men engaged in risk-taking behaviorsmore often than women. Those who thought of or attempted suicidein the last 12 months were at higher risk of suicide and engaged inhealth risk behavior more often than others, but engaged in high-risksports less frequently.NRS13.8.DANCE/MOVEMENT THERAPY IN CHILDRENAND YOUNG ADOLESCENTS WITH EMOTIONALAND BEHAVIOURAL DISORDER AND/ORNOCTURNAL ENURESISR.S. Abdel AzimCairo University Hospital, Kasr el Nil, Cairo, EgyptA randomised controlled trial, preceded by a pilot study and followedsix months later by a follow-up assessment, has been conducted withchildren suffering from emotional and behavioural disorder and/ornocturnal enuresis (primary or secondary), according to ICD-10research criteria. They were assigned at random to two groups. GroupA (n=11) received dance/movement therapy; group B (n=10) did notreceive any therapy or medication. The intervention took place over 7weeks time (2 sessions/week). Each session lasted 90 minutes: 60 minutesof dance movement and 30 minutes of verbal feedback. There wasno statistically significant change between the pre- and post-interventionassessment in the control group, versus a statistically detectableamelioration on some of the parameters in post-intervention assessmentin the dance/movement group, as well as a long-term effect ofamelioration in the dance/movement group on the six month followupassessment.NRS14.CULTURAL AND PREVENTIVE PSYCHIATRYNRS14.1.MANAGEMENT OF OVERSEAS AND LOCALPATIENTS IN INNER LONDONF. CarranzaGordon Hospital, London, UKGlobalisation has had an impact on the world economy. The effectshave extended to areas such as health, with events and changes inone country having an impact in other parts of the world. The geographicalmobility among patients with mental illness is high, and thisis also reflected in the number of these individuals who travel whilstunwell, or become ill whilst in a foreign country. This study comparesdata from the admission of overseas patients and local residentpatients to a psychiatric unit in London. It was conducted in 31 localresidents and 31 overseas visitors admitted to a psychiatric hospitalbetween 1 January and 31 December 1999 under the care of the mentalhealth team based in the area of Westminster in central London.191

Statistical methods were used to analyse the data. Differences werefound in multiple parameters related to the admission, assessment,treatment, and discharge. These data have financial, ethical, legal,medical, and social implications relevant to patients, care serviceproviders, and other organisations, which will be discussed in thepresentation.NRS14.2.MIGRATION AND MENTAL HEALTH: A REVIEWD. BusséCentres Assistencials Emili Mira i López, Diputació deBarcelona, SpainWe reviewed the literature on migration and mental health. 120papers were selected. Overall, the interest in this field has recentlydeclined in the USA, whereas it increased in Northern Europe andCanada. North American studies traditionally looked at the existingdifferences between groups of Native-American, Afro-American, Hispanic,Caribbean and European origin compared with the populationof Anglo-Saxon origin. The studies focused on general psychiatricmorbidity and more specifically on psychosis, post-traumatic stressdisorder, suicide, somatoform and affective disorders. In Europe (speciallyin the UK, the Netherlands and Scandinavian countries)research focused on Afro-Caribbean, Middle East and Mediterraneancommunities. We had little access to Mediterranean and third worldpublications. New world conflicts, new refugees and different trendsin migration are affecting the topics and theories in this research area.NRS14.3.PREVENTIVE PSYCHIATRY IN INDUSTRYB. Altenberg, R. HenkelS.C. Johnson, Inc., Racine, WI, USAFor the past twenty years, world-wide manufacturer S.C. Johnson,Inc. has participated in a program designed to give unlimited highqualitymental health treatment to its employees. The emphasis of thisprogram is preventive medicine through early identification and treatmentof psychiatric disorders for all workers. Care includes no-costpsychotherapy and minimal-cost continuing medical psychiatric carefor employees, dependents and retirees. Over three thousand patientshave been treated with no appreciative loss of work time. Only threedisabilities have been issued and the average number of hospitalizations(including dependents) has remained two per year. The majorityof treated employees (95%) have remained with the company. Theefficacy of early intervention thus saving millions of corporate dollarsin lost time, retraining, and repatriating is clearly demonstrated anddocumented. As a result of this unique approach, all parties benefit:the corporation through significant cost savings, the employees byimproved mental health, and the health care provider who is able toprovide complete services without the restrictions imposed by complicatedinsurance criteria and conditions.NRS14.4.PREVENTION OF SCHIZOPHRENIC DISORDERSA. GrispiniDepartment of Mental Health Rome E, Rome, Italyfunctions of the infant and early social maladaptive environment.This interactive level is responsible for a pathological Self-organisation,a cognitive deficit and environmental dysfunctions which initiatea second level of interaction toward the onset of full psychosis ora schizophrenic spectrum disorder. A key concept of early vulnerabilityis that there is a continuous interchange between brain and mind.Early brain abnormalities could promote a maladaptative neuro-psychologicaldevelopment, but they could be the consequence of severeearly parenting/environmental failures. A comprehensive epigeneticand neuro-developmental model is proposed to set up pragmaticinterventions to reduce incidence (primary prevention), prevalence(early secondary prevention) and severity of schizophrenic disorders(early tertiary prevention). This includes promotion of a positive mentalhealth attitude and reduction of causal risk factors, destigmatisation,genetic counseling, prevention of pregnancy and obstetric complications,neurodevelopmental assessment in infants and children atrisk, familial premorbid prevention, prevention of mental illnesses inchildren with a schizophrenic parent, cooperation with school andteachers, identification of schizotaxia in adolescents and youngadults, and early identification of mental states at risk, prodromalstates, transition psychosis, and early psychotic onset.NRS14.5PRIMUM NON NOCEREE.F.C. StampDelmont Private Hospital, Melbourne, Victoria, AustraliaSocietal and political expectations, legal imperatives and financialconsiderations significantly influence psychiatry in subtle and directways. Psychiatry has advanced in its scientific approach but the currentphilosophies of service provision obscure the primacy of basictenets, among others the imperative of Primum Non Nocere, by failingto keeping the patient central and phenomenology accurate. When aperson’s thinking, feeling, memory and behaviour is disrupted, themanifestation is signaled in society. A psychiatrist reads the signalsand formulates the symptoms. Clusters of symptoms are recognizedclinically, socially, economically and politically as syndromes, whichare “managed” in establishment ways. Encapsulated within a “diagnosis”,additional attributes can be ascribed which may debase validmental functioning. Primum Non Nocere demands that the doctorcorrectly determine the diagnosis by considering each element beforehe makes any individual attribution and subsequent collection ofattributes. Incorrect attribution at any step may result in error. Anerror diverts the way forward and the view backward. Collectivismmay multiply the error. Social, legal, political and economic paradigms,individually and collectively, intrude between the patient andthe doctor curtailing the exercise of Primum Non Nocere, increasingthe risk of harm to the patient, as well as the doctor who carries thesubstantive liability for diagnosis and prescription. To what degree has“first do no harm” unwittingly become “legally liable harm”, “friendlyharm” or “calculated harm”? Meaningful adherence to discipline specificethical and phenomenological expertise will protect against theperversion of the profession by opportunistic institutions.Preventing schizophrenic disorders is a social, economic, human andmedical priority for public health. This requires a reconsideration ofthe meaning of early vulnerability as a stable trait of mental functioning,which includes a first level of interaction between genetic andorganic factors, constitutional strength of basic psychophysiology192 World Psychiatry 3:S1 - October 2004

NRS14.6.CHARACTERISTICS AND TRAUMATA OF SEXUALOFFENDERSM. Dudeck 1 , S. Barnow 1 , C. Spitzer 1 , M. Stopsack 2 , M. Gillner 3 ,H.-J. Freyberger 11 Clinic and Polyclinic for Psychiatry and Psychotherapy, Ernst-Moritz-Arndt University, Greifswald; 2 Institut for Psychology,Ernst-Moritz-Arndt University, Greifswald; 3 Clinic for ForensicPsychiatry, Hanseklinikum Stralsund, GermanyForensic psychiatric studies indicate that persons in prison and psychologicallydisturbed sexual offenders have a high degree of traumaticexperiences. In addition, the diagnosis of a personality disorder,particularly cluster B according to DSM-IV, has been discussedin recent publications as predicting sexual offences. The aim of thisstudy was to investigate the extent to which the diagnoses and traumataof sexual offenders differ from those of non-sexual offenders.Against this background, 51 male, forensic psychiatric patients attwo forensic clinics in Mecklenburg/West Pomerania, Germany,were examined using a structured interview to record their traumata.Various self-evaluation questionnaires served to ascertain dissociativeand general psychopathology and interpersonal problems and tospecify their temperament. These data enabled us to compare thevariables recorded for sexual and non-sexual offenders. No linkswere found between sexual offences and forensic or socio-demographicvariables. Nor was it possible to identify any differences indissociative and psychopathological factors between sexual offendersand non-sexual offenders. However, the comparison betweenthese groups showed that the former more frequently reported sexualabuse in their biographies and the diagnosis more frequently indicateda narcissistic personality disorder. But the logistic regressionanalysis controlled for age pointed to only sexual abuse in childhoodas a significant factor. To summarise, our data show that sexual abusein a person’s own earlier history was the only pointer to committinga sexual offence. This supports the idea that one’s own traumaticexperiences are reproduced later and indicates the significance ofdealing with traumatic experiences in childhood for this group ofoffenders.NRS14.7.PERSONALITIES OF PEOPLE WITHMENTAL RETARDATIOND. JanotováPsychiatric Clinic, Ke Karlovu 11, Prague, Czech RepublicWe were observing 250 persons with moderate and severe mental disabilityliving in institutions in Prague. Their were usually admitted forpsychiatric care because of emotional and behavioral disorders. Theaverage age was 35.6 years; in the group there were 150 men and 100women. We found the diagnosis of personality disorder according toICD–10 extremely difficult. We also did not find the generally usedrating scales useful. On the other hand, it is necessary to recognizepersonality disorders in mentally retarded persons in order to establishthe proper diagnosis and treatment. We created a new questionnairebased on clinical descriptions of mood disorders and behavioralabnormalities which are characteristic of personality disorders. Thequestions were answered by tutors and medical staff who were ineveryday and long lasting contact with the patients. Weekly observationsof the psychologists and psychiatrists were also included. Weclassified 55% of the clients as having personality abnormalities and10% as having a personality disorder. In the next phase of ourresearch we will evaluate our findings by using the StandardizedAssessment of Personality devised by Mann et al.NRS15.NEW AND TRADITIONAL APPROACHES IN MENTALHEALTH CARE IN DEVELOPING COUNTRIESNRS15.1.BAREFOOT COUNSELING: A POST-PSYCHIATRICINTERVENTIONB.S. AliDepartment of Family Medicine, Aga Khan University,Karachi, PakistanPost-psychiatry deals with linking service development to the context,values and partnerships with users. In Pakistan psychiatric diagnosisand treatment are stigmatized, inaccessible, unaffordable, andunacceptable to the majority. There is also skepticism regarding pharmacotherapy.In this study, literate women from a semi-urban lowmiddle class community were minimally trained in counseling skillsin 11 sessions of 3 hours each. A baseline survey was conducted toidentify anxious and depressed women in the same community, whowere randomized into an intervention and a control arm. The communitycounselors then provided weekly one hour sessions for 8weeks to the subjects in the intervention arm. Two independent testsused to compare the improvement from baseline to after 8 weeks ofcounseling between the intervention (n=70) and the control arms(n=91) gave a p value of

NRS15.3.AT PEACE WITH THE INNER SELF –FOLLOWING THE CHINESE WAYT. Ng-Tse 1 , A.V. Jablensky 21 Curtin University of Technology and University of Hong Kong,Pokfulam, Hong Kong; 2 Centre for Clinical Research inNeuropsychiatry, University of Western Australia, Perth, AustraliaThe doctrine of Tao (harmony with the nature, inaction and contentment)and the concept of fatalistic voluntarism (fatalism and relationalfatalism) have guided the Chinese to cope with life events, especiallyunpleasant ones. A study aiming to explore the ways Chinesewomen with schizophrenia (n=135) cope with their mental illnesswas conducted in Hong Kong and its neighbouring city Shenzhen.Most of the subjects believed that the illness was part of the predetermineddestiny of their life and the outcome of their illness was not intheir control. They understood that they could not escape the influenceof fate and were inclined to accept life as it is and accommodateboth pleasant and unpleasant events. The strong belief in externalcontrol of events stimulated the women to find ways to adapt andcope with their illness. By following the flow of nature, these womenwere able to endure life in the face of disappointment, discrimination,privation and uncertainty. The fatalistic and activistic attitudes alsoenable these women to do everything in their power to counteract thepresent difficulties, maintain hope for the future and be at peace withthe inner self. They faithfully followed the treatment regime hopingthat their illness could be cured. Consequently the women were moreadaptive to the illness without losing their ego strength. The studyhighlights the role of culture in moderating illness experience. Thefindings also provide clinicians with directions in modifying clinicalpractice and approach in assisting Chinese women to make adjustmentsto their illness, to rehabilitate and to restore health.NRS15.4.EFFECT OF RAJAYOGA MEDITATION ONPSYCHOACTIVE SUBSTANCE ABUSE/DEPENDENCEN. Patel, J. WatumullGlobal Hospital and Research Centre, Mount Abu,Rajasthan, IndiaA retrospective study was carried out on overseas meditation practitionerswho visited the international headquarters of the BrahmaKumaris spiritual institution in 1994-95, to assess the efficacy ofRajayoga meditation (RM) to overcome psychoactive substanceabuse/dependence. Three hundred eighty foreigner males andfemales, including 216 Europeans, having a maximum of eight kindsof substance abuse/dependence for a duration ranging from twomonths to forty years, were interviewed. Data was collected personallyby giving structured questionnaire. The majority of meditationpractitioners (93%) abstained completely from all the substanceswithin one month period of practice of RM and without taking concurrentpsychiatric treatment. This suggest that RM is a successfulmethod to overcome substance abuse/dependence.NRS15.5.OCCULTISM AND PSYCHIATRY:IMPLICATIONS IN CLINICAL PRACTICES. BasuMiravision, Calcutta, IndiaThe Mind’s direct power to effectuate changes in oneself or others orin the physical world had obvious limitations. This led to the seekingof occult knowledge by which dormant psychological powers couldbe harnessed to produce effects (like “healing”) that appeared magical.However, most spiritual teachers in India did not favour suchpractices, as they distracted seekers from real spiritual progress. Actually,there is a hierarchy of these hidden powers and forces. Ordinarily,“occultists” work with powers at the lower end of the hierarchy. InIndia, many psychiatric patients consult such occultists believing thattheir illness has been caused by “hostile” forces. Such “hostile” forcesmay be subjective psychological formations that arise in the individualor in the cultural matrix or stimulated by “perceived” ill-will ofpersons significant to the subject. In their attempt to “correct”,occultists unleash disruptive forces that can further endanger a disbalancedstate. Working with these lower powers often make theoccultists perverse and vindictive. Moreover, many cheats practice inthe disguise of occultists exploiting the belief-structure of people.There are higher powers and forces at the other end of the occult hierarchy.This “higher” occultism necessitates an experiential growth inconsciousness and can provide transpersonal insights to enrich ourintervention strategies. This paper cites examples of how thosepatients who are the “beau-ideal” of occultists can be understood andmanaged in a clinical setting without dismantling their belief-structureand without compromising scientific treatment. This necessitatesa metapsychological understanding of the structure and nature of thehuman being from a consciousness perspective.NRS15.6.THE HUMAN DATA BASE PROJECTR.S. MenezesInstituto Psiquiatrico Forense “Mauricio Cardoso” andCentro Interdisciplinar de Saúde Mental, Porto Alegre,Rio Grande do Sul, BrazilThe Human Data Base Project has been conceived as a tool for theimprovement of health and quality of life of the population. The fundamentalprinciple of this project is the protection of human rights,such as the right to freedom, to privacy, to peace, to education, to justice,to feeding, to distribution of income, to work, to leisure and to ahealthy environment, against militarism and oppression. This projecthas two main objectives. Initially, to propose the guidelines for theconstruction of the Human Data Base, as well as accessory databases,and to delineate work stations for inclusion of data. The more importantobjective, however, is to study the benefits to health and quality oflife of the people of the construction of a database like this, beginningwith a pilot study in the city of Porto Alegre.POSTER SESSIONSPO1.PSYCHOTIC DISORDERSPO1.1.THE SCHIZOPHRENIA DIAGNOSIS AS A BASIS FORTREATMENT IN A POLYDIAGNOSTIC PERSPECTIVEL. Jansson, J. ParnasDepartment of Psychiatry, Hvidovre Hospital, Universityof Copenhagen, DenmarkIn a review of more than 70 polydiagnostic studies on schizophrenia,the rate of schizophrenia by each definition, the interrater reliability,194 World Psychiatry 3:S1 - October 2004

the concordance between the definitions, and the validation findingswere compared. The number of patients by each definition varies considerably,largely dependent on the inclusion/exclusion of affectivesyndromes and the duration of illness required. Disappointingly fewvalidation studies were found. Schizophrenia by modern criteria(DSM-IV and ICD-10) appears to be poorly validated and arbitrarilydemarcated. The choice of schizophrenia definitions for treatmentstudies is a neglected issue considering its psychopathological andprognostic implications. ‘Core schizophrenia’, a subgroup shared bythe majority of current definitions, is not representative of schizophreniaat large because of a bias towards e.g. male sex and pooroutcome. For lack of a single valid definition, the polydiagnosticmethod is preferable.PO1.2.PREDICTORS OF OUTCOME: PRELIMINARY DATAON COURSE, PSYCHOPATHOLOGY ANDTREATMENT FROM THE COPENHAGENPRODROMAL STUDYA. Vollmer-Larsen, P. Handest, A. Urfer, J. ParnasCognitive Research Unit, Department of Psychiatry,Hvidovre Hospital, University of Copenhagen, DenmarkPreliminary data of the 4-year follow-up of 155 first admissionpatients included in the Copenhagen Prodromal Study from 1998 to2000 is presented. The study aims at finding psychopathological andtreatment variables that can serve as predictors of outcome and offuture schizophrenic psychosis. At inclusion the patients were diagnosedaccording to ICD-10 and fell into three equally sized groups:schizophrenia spectrum psychosis, schizotypical disorder and agroup of patients with predominantly personality or affective disorders.Patients were investigated with several psychopathologicalscales with special emphasis on abnormal subjective experiences(basic symptoms; Bonn Scale for Assessment of Basic Symptoms,BSABS) and anomalous self-experience, e.g. changes in self-awareness,sense of corporeality, stream of consciousness and self-demarcation.The follow-up investigation includes reinvestigation on allpreviously used psychopathological scales (among others the Schedulesfor Clinical Assessment in Neuropsychiatry, SCAN; the Positiveand Negative Syndrome Scale, PANSS; the BSABS and the GlobalAssessment of Functioning, GAF) and an assessment of cognitivefunctions including measurements of reaction time, memory function,cross-modal integration, executive functions and estimates ofIQ. A throughout history of treatment, social functioning and psychopathologyis established from the interview and all available hospitalcharts. Data on potential predictors of outcome and risk of psychosis,and on diagnostic stability are presented.PO1.3.DIMENSIONAL STRUCTURE OF MAJORPSYCHOSESA. Serretti, P. OlgiatiDepartment of Psychiatry, Vita-Salute University, San RaffaeleInstitute, Milan, ItalyThe symptoms of major psychoses aggregate in factors, each supposedto have a specific pathophysiological substrate and thus providinga more reliable target for genetic research and drug therapies.Up to now models of one to eight dimensions have been reported. Inthe present study we tested some of the most replicated models in alarge sample of patients diagnosed with schizophrenia, bipolar anddelusional disorders. 1294 inpatients who fulfilled DSM-IV criteriafor the diagnosis of schizophrenia (n=460), bipolar (n=726) and delusionaldisorders (n =108) were assessed using the operational criteriafor psychotic illness checklist with a lifetime perspective. Confirmatoryfactor analysis was used to test the following models: 1) uniquepsychotic dimension, 2) positive-manic items, negative-depressiveitems, 3) the previous model with the addition of a disorganized factor,4A) positive, negative, depressive and manic dimensions, 4B)same as previous model, with loss of pleasure (anhedonia) and loss ofenergy (apathy) included among depressive instead of negative symptoms,5) same as previous model, except for the addition of a disorganizeddomain. The four and five factor models fitted the data muchbetter than simpler ones. Between the two four factor models, 4Bemerged as more appropriate than 4A. The five factor solution displayedthe best fit. In conclusion, our confirmatory factor analysis ina large sample of psychotic subjects showed that major psychosessymptomatology is composed by five factors: mania, positive, disorganization,depression and negative symptoms.PO1.4.VISUAL ILLUSIONS, CONNECTIVITY ANDPSYCHOTIC TRAITSU. Volpe 1 , A. Federspiel 2 , T. Dierks 2 , S. Galderisi 1 , A. Mucci 1 ,L.O. Wahlund 3 , A. Franck 4 , M. Maj 11 Department of Psychiatry, University of Naples SUN, Naples,Italy; 2 University Hospital of Clinical Psychiatry, Bern,Switzerland; 3 Department of Clinical Neuroscience,Occupational Therapy and Elderly Care Research, KarolinskaInstitutet, Huddinge University Hospital, Stockholm, Sweden;4 Department of Hospital Physics, Karolinska Institutet,Huddinge University Hospital, Stockholm, SwedenIllusions are misperceptive phenomena which have been recentlyclaimed to be a prodromal manifestation of psychosis. The aim of thisstudy was to investigate the neural networks implicated in the genesisof apparent motion illusions in humans and the relationships betweentheir local connectivity and psychotic traits. Thirteen healthy controlswere selected and underwent a functional magnetic resonance imaging(fMRI) protocol, while watching apparent motion stimuli, set at twodifferent frequencies (4 and 30 Hz) and randomly intermixed with fourcontrol conditions (two static stimuli, fixation cross and blank screen);stimulus onset asynchronicity was of 6 seconds and each stimulus waspresented 40 times. In the same imaging session, a diffusion tensorimaging (DTI) sequence was run on each subject, in order to evaluatethe fractional anisotropy (FA), an index of local connectivity; furthermore,all subjects were administered the Minnesota Multiphasic PersonalityInventory (MMPI-2). The median split method was used onMMPI-2 Schizophrenia, Paranoia and Psychopathic Deviate scales toidentify sub-groups of volunteers with high or low scores for psychotictraits. In the right V5 area, FA showed a significant increase in subjectswith higher scores for psychotic traits, with respect to those with lowscores. A possible model of misperceptive phenomena is discussed.PO1.5.SOCIAL COGNITION AS A MEDIATING FACTORBETWEEN NEUROCOGNITIVE DOMAINS ANDFUNCTIONAL OUTCOMED.R. Müller, V. RoderUniversity Hospital of Social and Community Psychiatry,University of Bern, SwitzerlandIn recent years cognitive remediation has become an importantapproach in the treatment of schizophrenia. Integrative models try to195

explain the association of deficits in neurocognitive domains andfunctional outcome. Social cognition may be a possible mediatingfactor between them. The integrated psychological therapy (IPT) forgroups was one of the first comprehensive therapy programs to targetdeficits in these areas. The IPT subprogram “cognitive differentiation”(CD) focuses directly on neurocognition (concept formation/executivefunctioning, etc.) and the IPT subprogram “social perception”(SP) represents one segment of social cognition. The other subprogramsof IPT improve social competence. The aim of this meta-analyticstudy was to examine whether schizophrenia patients receiveadditional benefits from CD when combined with SP in comparisonto CD alone. For this purpose 22 independent IPT studies includingCD and SP were selected and quantitatively reviewed. The mostsalient results indicate favourable mean effects of neurocognitivevariables and functional outcome when CD and SP are combined.Nevertheless, both treatment conditions (CD/SP and CD alone)obtain superior effects compared to control groups. Moreover,improvements in some specific neurocognitive domains of schizophrenia(attention, memory, and executive functioning) and in socialcognition variables (social perception) can be identified. In summary,the results indicate some evidence of the probable mediating functionof social cognition between neurocognition and functional outcome.Further experimental studies are necessary to investigate additionaldifferential treatment effects of basic neurocognition and social cognition(insight, social schema, coping skills, etc.).PO1.6.THE QUATRO PROJECT: A RANDOMIZEDCONTROLLED STUDY TO EVALUATE THEEFFECTIVENESS OF ADHERENCE THERAPY ONTHE QUALITY OF LIFE OF PEOPLE DISABLED BYSCHIZOPHRENIA AND THEIR CARERSG. Thornicroft 1 , T. Becker 1 , J. Bindman 1 , A. Schene 1 ,J.L. Vázquez-Barquero 1 , M. Tansella 2 , L. Burti 2 , C. Barbui 2 ,D. Cristofalo 2 , C. Goss 2 , L. Lazzaretto 3 , M. Leese 5 , G. Marrella 2 ,M. Mazzi 2 , M. Nosé 2 , O. Paterno 4 , M. Solfa 21 Project and Centre Principal Investigators (Lipsia, Londra,Amsterdam, Santander); 2 Department of Medicine and PublicHealth, Section of Psychiatry, University of Verona, Italy; 3 Secondand 4 First Psychiatric Service, Main General Hospital, Verona,Italy; 5 Institute of Psychiatry, London, UKIn this controlled study, 400 participants aged 18-70 and with anICD-10 diagnosis of schizophrenia are randomly assigned to twotypes of intervention: adherence therapy, a cognitive-behavioural psychologicalintervention, and health education, used as control treatment.Both treatments will be administered in eight individual sessionsgiven within 4-8 weeks. Participants are recruited in four Europeancommunity psychiatric services (London, Amsterdam, Veronaand Leipzig) and are followed up for 12 months. At baseline and follow-upassessments, standardised instruments to measure clinicaland social outcome, quality of life of participants and their carers, useof services and costs are used. The primary outcome measure for dataanalysis is the quality of life of participants and their carers. Secondaryoutcome measures include psychopathology, disability, socialadjustment, the use of services and costs of care, adherence to treatmentand attitudes towards medication. At mid-term, the progress ofthe study is on schedule: the targeted number of participants has beenpractically achieved in the four centres, treatments are under completionwhile follow-up interviews are underway. The recruitment of theproposed number of participants with a diagnosis of schizophrenia infour different European countries has proven feasible; experimentaland control treatments have been well accepted as well as the batteryof standardised instruments used for baseline and follow-up evaluations.The study is producing high-quality data and a set of standardisedinstruments to be used in the evaluation of relevant dimensionsof outcome in five European countries.PO1.7.AN EARLY INTERVENTION APPROACH TOTREATMENT OF FIRST EPISODE PSYCHOSIS:TWO YEAR OUTCOMEA.K. Malla 1 , R. Norman 2 , R. Manchanda 2 , T. McLean 2 ,J. Takhar 2 , R. Haricharan 21 Departments of Psychiatry, McGill University and DouglasHospital, Montreal; 2 University of Western Ontario, London,CanadaThe Canadian Health Care system lends itself to development of amodel that can address two principal issues in early intervention:improved treatment and reduced delay in treatment. A model of earlyintervention in psychosis was developed in 1997 in one urban locationand recently (2002) transposed to a large urban setting (Montreal).The key components of the model are quick access, prompt comprehensiveassessment in a setting of client’s choice, emphasis onengagement, protocol of medication (novel antipsychotics as firstline) and psychosocial interventions, continuity of care and assertivecase management with emphasis on reintegration through utilisationof non-mental health community resources for a period of two yearsand a lower level intensity treatment and follow-up for an additionalthree years. In addition, the program includes active case identificationand continuous evaluation of symptoms, medication side effects,suicidal behaviour, cognition, quality of life and employment/education.47% of patients entering the programme received their initialcare as out-patients with no negative impact on subsequent utilizationof in-patient resources; 74% and 82% were in remission by years1 and 2; relapse rates were relatively low (17% at 1 year and 27% at 2years); time to remission was associated only modestly with durationof untreated psychosis (r=.23) but more significantly with pre-morbidsocial adjustment in early and late adolescence; time to relapse wasassociated significantly and inversely with time to remission andsocial pre-morbid adjustment in early and late adolescence. Durationof untreated psychosis showed a decline two years following openand improved access to the program. A more active community caseidentification program resulted in recruitment of more severely illpatients with no significant change in duration of untreated psychosis.PO1.8.AN INDIVIDUALIZED PROGRAMME OFCOGNITIVE AND PSYCHOSOCIAL INTERVENTIONIN PSYCHOTIC PATIENTSG. Piegari, D. Sorrentino, F. Mancuso, S. Garramone, A. Mucci,S. Galderisi, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalyIn patients with schizophrenia, the acquisition of social skills may behindered by the presence of cognitive dysfunctions. Moving from thisobservation, it has been proposed that cognitive training increasescompliance to psychosocial interventions and improves functionaloutcome. The present study was aimed to evaluate functional outcomein patients with schizophrenia participating in a rehabilitation196 World Psychiatry 3:S1 - October 2004

programme, combining individualized cognitive and psychosocialinterventions (social skills training, SST). To develop and test the feasibilityof the cognitive and psychosocial interventions, a pilot studywas carried out in a small group of severely ill schizophrenic patients.The developed programme was then applied in a group of 15 chronicstabilized patients with schizophrenia, who were randomized toeither the SST programme or the combined SST and cognitive training.In the first four months, treatment compliance has been excellentin both groups. Only two patients, one for each group, dropped outfrom the study: one experienced a clinical relapse (from the combinedSST and cognitive training group) and the other one was able toresume previously interrupted university courses (from the SSTgroup). Preliminary results of the comparison between the two groupson cognitive functioning, psychopathology and functional outcomewill be presented and discussed.PO1.9.EFFICACY OF REHABILITATION PROGRAMSFOR SEVERE PSYCHIATRIC PATIENTSR. Pioli 1 , M. Vittorielli 1 , G. Rossi 1 , P. Morosini 21 Fatebenefratelli Institute, Brescia;2 National Institute of Health, Rome, ItalyThe aim of the study is to evaluate whether the rehabilitationapproach proposed by the manual VADO (Evaluation of Abilities andDefinition of Objectives) can be considered more effective than routineintervention in reducing the disabilities of schizophrenicpatients. The study is taking place in residential units and day-careunits afferent to eight psychiatric services randomly selected throughoutItaly. Two professionals for each unit were trained in the VADOapproach. Each unit recruited consecutively 10 patients who met thefollowing criteria: a) age not over 49 years; b) diagnosis of schizophrenia,schizotypal disorder or delusional disorder; c) a score for theglobal functioning < 70 on the Personal and Social Functioning Scale(FPS); d) absence of severe disabling somatic illness, psycho-organicsyndromes and mental retardation. Patients were randomly assignedto the study or control group. Each patient will be evaluated at baselineand at six months for: a) global functioning level through theFPS; b) psychopathology through the Brief Psychiatric Rating Scale;c) quality of life through the WHOQoL (brief version); d) satisfactionfor the intervention received. A special schedule will also point out allthe rehabilitation activities the patient went through. 75 patients wererecruited. 37 of them will receive the VADO approach and 37 willreceive the routine intervention. The results and their implicationswill be discussed.PO1.10.TRENDS IN PHARMACOLOGICAL TREATMENT INPATIENTS WITH SCHIZOPHRENIA 1989-1995-1998-2001M. Edlinger 1 , A. Hausmann 2 , G. Kemmler 2 , M. Kurz 1 ,I. Kurzthaler 1 , T. Walch 2 , M. Walpoth 2 , W.W. Fleischhacker 11 Department of Biological Psychiatry; 2 Department of GeneralPsychiatry, University Hospital, Innsbruck, AustriaDespite numerous international efforts towards evidence-basedguidelines for the psychopharmacological treatment of patients withschizophrenia, the transfer of such guidelines into clinical practicehas remained unsatisfactory. We evaluated whether our efforts to promotesuch recommandations have led to measurable changes in thetreatment practice in our hospital by investigating three primaryhypotheses: a) polypharmacy has become less common in recentyears; b) conventional neuroleptics have been replaced by secondgeneration antipsychotics and c) dosing regimes have changedtowards lower doses. We have therefore collected data from the clinicalrecords of all inpatients with ICD-9/ICD-10 diagnosis of schizophreniahospitalized at the Department of Psychiatry at Innsbruck’sUniversity Hospital in the years 1989, 1995, 1998 and 2001. Datafrom 1989 to 1998 showed a significant decrease in the use of two ormore antipsychotics given simultaneosly. The increasing availabilityof second generation antipsychotics led to a rapid change from conventionalto novel antipsychotics. There has also been a significantdecrease in the use of concomitant anticholinergic medication. In2001 treatment strategies were comparable to 1998. Monotherapy,lower doses and a predominant use of second-generation antipsychoticsare standard in schizophrenia treatment in our hospital.PO1.11.COMPLIANCE IN SCHIZOPHRENIA:PSYCHOPATHOLOGY, SIDE EFFECTS ANDPATIENTS’ ATTITUDES TOWARDS THE ILLNESS ANDMEDICATIONA. Hofer, M.A. Rettenbacher, M. Hummer, G. Kemmler,W.W. FleischhackerDepartment of Biological Psychiatry, Medical University,Innsbruck, AustriaIn a cross-sectional study we have investigated the influence of severalfactors on compliance in schizophrenia outpatients: patients’ attitudestowards the illness and antipsychotic medication, adverse effects, carers’and relatives’ attitudes towards illness and medication. Patients sufferingfrom schizophrenia (ICD-10) with a duration of illness of at leastone year, and whose discharge from an inpatient ward has been at least6 weeks prior to inclusion in the study, were investigated. We used asemistructured compliance interview, the Positive and Negative SyndromeScale, the UKU Side Effect Rating Scale, the St. Hans RatingScale and the Hillside Akathisia Scale. 52.5% of the investigatedpatients were fully compliant, 39.3% partially compliant and only 8.2%were non-compliant. We found positive correlations between complianceand the patients’ feeling of a positive effect of the drug on the illness,between compliance and negative symptoms as well as betweencompliance and antipsychotic-induced psychological side effects. Mostpatients considered other illnesses such as diabetes, rheumatoid arthritis,epilepsy or cancer to be worse than schizophrenia.PO1.12.THE FUTURE OF PHARMACOTHERAPY OFSCHIZOPHRENIA AND THE NICE GUIDELINESB. Ravindranath, M. Sandman, S. GriffithsSouth Community Mental Health Team, Chester, UKIn June 2002 the National Institute for Clinical Excellence (NICE),UK, has issued guidelines stating that, based on current evidence,atypical antipsychotics should be considered as first-line medicationsto treat patients with schizophrenia. Further, typical and atypicalantipsychotics should not be prescribed concurrently, and depotpreparations should be prescribed for reasons of compliance and individualpreference. This study looks at current practice to be quantitativelyassessed against published guidelines. Patients with schizophreniaserved by the Chester City Mental Health Team were identified. Aretrospective analysis of case notes including clinic letters over a twoyear period was carried out in order to obtain details of prescribedmedications and other significant information. Out of 86 patients whoentered the study, 17 (19.8%) were excluded as they were not current-197

ly being treated by the team and 8 (9.3%) were found not to be sufferingfrom schizophrenia. This produced a final sample of 61 patients.46 patients (75.4%) were receiving monotherapy and 13 (21.3%) wereon combination treatment. The majority of patients receiving depotantipsychotics were doing so because either compliance has beenidentified as an issue (7 patients, 38.9%) or because the patients hadexpressed a preference for depot medication (4 patients, 22.2%). Ofpatients with a previously established diagnosis of schizophrenia, 38(64.4%) are currently receiving atypical antipsychotic drugs. The atypicalantipsychotics were the most commonly prescribed drug class.This was followed by depot medications. The majority of patients inthe sample were receiving monotherapy. However, some were receivinga combination of antipsychotics. The study also highlights reasonsfor prescribing depot preparations. The future of pharmacotherapy ofschizophrenia in the wake of NICE guidelines will be discussed.PO1.13.COST-EFFECTIVENESS OF ANTIPSYCHOTICTREATMENTS: A NEW METHODOLOGICALAPPROACH. DATA FROM THE EUROPEANSCHIZOPHRENIA OUTPATIENT HEALTHOUTCOMES (SOHO) STUDYM. Knapp 1 , J.M. Haro 2 , S. Kontodimas 3 , D. Novick 3 ,M. Ratcliffe 3 , on behalf of the SOHO Study Group1 London School of Economics and Centre for the Economicsof Mental Health, Institute of Psychiatry, London, UK;2 Sant Joan De Deu-SSM, Barcelona, Spain; 3 Eli Lilly,Windlesham, UKThe study aimed to examine the cost-effectiveness of different antipsychotictreatments in a naturalistic, multi-country setting. The EuropeanSchizophrenia Outpatient Health Outcomes (SOHO) is a 3-year,prospective, outpatient, observational study of health outcomes associatedwith antipsychotic treatment. The study is being conducted in10 European countries. 10,206 patients were eligible for enrolmentafter they initiated or changed antipsychotic treatment for clinical reasonsat baseline. Patients were assessed at baseline, 3, 6 and 12 monthsthereafter. Treatment patterns were at the discretion of the treatingpsychiatrist. Resource use, effectiveness and quality of life data werecollected at each time point. Patients were grouped by treatmentreceived: olanzapine, risperidone, quetiapine, amisulpride, clozapine,oral typicals, depot typicals. Resource use data include inpatient days,day-hospital, outpatient visits to a psychiatrist and antipsychotic andconcomitant medication. Unit costs were collected across participatingcountries. Clinical effectiveness was measured by the ClinicalGlobal Impression-Severity (CGI-S). Quality of Life (QoL) was measuredusing the EuroQol-5 Dimensions (EQ-5D) questionnaire. UKgeneral population data were used to convert QoL scores to utilities.Econometric modelling was used to estimate incremental changes incosts, effectiveness and QoL between the 7 treatment groups, adjustingfor patients’ exogenous characteristics and the influences of site.Treatment effects were allocated to the medication the patient wasreceiving prior to each assessment period. This innovative methodologicalframework to estimate cost-effectiveness and cost-utilityratios is currently being performed and results will be presented anddiscussed. Methodological issues regarding pooling of data acrosscountries will also be explored and discussed.PO1.14.CONTINUATION DETERMINANTS OFANTIPSYCHOTIC TREATMENT IN THE OUTPATIENTSETTING: 12-MONTH RESULTS FROM THESCHIZOPHRENIA OUTPATIENT HEALTH OUTCOMES(SOHO) STUDYJ.M. Haro 1 , D. Novick 2 , M. Belger 2 , S. Tzivelekis 2 , M. Ratcliffe 2 ,on behalf of the SOHO Study Group1 Sant Joan De Deu-SSM, St. Boi de L., Barcelona, Spain;2 Eli Lilly, Windlesham, UKThe study aimed to report how choice of antipsychotic treatmentdetermines patients with schizophrenia remaining on their initialtreatment during the first twelve months. The Schizophrenia OutpatientHealth Outcomes (SOHO) study is a 3-year, prospective, outpatient,observational study of health outcomes associated with antipsychotictreatment. Treatment continuation, defined as maintenance ofthe antipsychotic prescribed at baseline with no antipsychotic additions,was assessed using a logistic regression adjusting for baselinecovariates. 8,530 patients initiating treatment with a single antipsychoticmedication were followed for twelve months. 5,367 (62.9%)remained on their baseline antipsychotic. Treatment continuationvaries with the baseline antipsychotic: olanzapine (65.8%), risperidone(61.2%), quetiapine (42.3%), amisulpride (49.8%), clozapine(70.5%) and oral typical antipsychotics (67.5%). A logistic regression,adjusting for baseline covariates, show an increased likelihoodof medication success on olanzapine compared with risperidone(odds ratio: 1.18; 95% CI: 1.03-1.35), quetiapine (2.15;1.78-2.60),amisulpride (1.68;1.25-2.26) and oral typicals (1.33;1.09-1.63), and adecreased likelihood compared with clozapine (0.51;0.39-0.68).Baseline covariates influencing patients’ treatment continuationwere: body mass index, pre-baseline antipsychotic medication, reasonfor changing medication, overall/depressive Clinical GlobalImpression (CGI) score and alcohol dependency. In conclusion,treatment discontinuation represents an important clinical endpointthat reflects clinician and patient judgments about enduring efficacyand tolerability. Olanzapine and clozapine appear to be associatedwith a higher probability of antipsychotic treatment maintenance.PO1.15.PREDICTORS OF TREATMENT OUTCOMES INPREVIOUSLY UNTREATED PATIENTS WITHSCHIZOPHRENIA: RESULTS FROM THEEUROPEAN SCHIZOPHRENIA OUTPATIENTHEALTH OUTCOMES (SOHO) STUDYJ.M. Haro 1 , I. Gasquet 2 , D. Novick 3 , M. Lorenzo 3 , S. Tzivelekis 3 ,M. Ratcliffe 3 , on behalf of the SOHO Study Group1 Sant Joan De Deu-SSM, St. Boi de L., Barcelona, Spain;2 Paris-Sud Innovation Group in Mental Health Methodology,Hopital Paul Brousse, Villejuif, France; 3 Eli Lilly, Windlesham,UKThe study aimed to identify predictors of outcome after 12 months ofantipsychotic treatment in 919 patients with schizophrenia who hadnever been previously treated with antipsychotics, and who initiallyreceived olanzapine, risperidone or a typical antipsychotic. Data wereextracted from the Schizophrenia Outpatient Health Outcomes(SOHO) study, a 3-year, large, prospective, observational study ofschizophrenia treatment in 10 European countries. Analyses wereadjusted for baseline differences between treatment cohorts (cohortswere defined based on the drug initiated during the baseline visit) andtook into account clinical and socio-demographic factors that may198 World Psychiatry 3:S1 - October 2004

influence outcome. A stepwise selection criterion based on a chisquaredtest (difference between the –2 log likelihood of the full andreduced model) was applied in order to remove the terms that did notappear to have significant influences in predicting the different endpoints.Baseline predictors of Clinical Global Impression (CGI) status,at 12 months, were: antipsychotic treatment (odds ratio: 1.70; 95% CI:1.11,2.61), negative (0.79;0.70,0.90) and positive (1.13;1.00,1.28) CGIsymptom scores, hostile behaviour (0.51;0.34,0.77), employment status(0.61;0.43,0.88), current substance abuse (0.15;0.05,0.41), gender(0.91;0.66,1.27), EuroQol-5 Dimensions Visual Analogue Scale(EQ-5D VAS) (0.99;0.98,0.99) and extrapyramidal symptoms(3.65;1.53,8.70). Likewise, baseline predictors of EQ-5D VAS status, at12 months, were: antipsychotic treatment (difference: 2.73; 95% CI:0.43,5.03), gender (-1.31;-2.72,0.10), housing status (2.20;0.62,3.79),EQ-5D VAS (0.22;0.17,0.27), negative (-2.28;-3.07,-1.48), cognitive(0.85;0.05,1.66), and overall (-0.67;-1.90,0.56) CGI score. In conclusion,in this study we found that several baseline characteristics, in particularchoice of initial antipsychotic treatment, of patients with firstepisodeschizophrenia can be important predictors of CGI and EQ-5DVAS outcomes after 12 months of antipsychotic treatment.PO1.16.CONFERENCE REPORT: BELGIAN CONSENSUSON METABOLIC PROBLEMS ASSOCIATED WITHATYPICAL ANTPSYCHOTICSM. De Hert 1 , A. De Nayer 2 , A. Scheen 3 , L. Van Gaal 4 ,J. Peuskens 1 , on behalf of the Consensus Group1 U.C. St.-Jozef, Kortenberg; 2 C.H. Ste.-Thérèse, Gilly; 3 Division ofDiabetes, Nutrition and Metabolic Disorders, Department ofMedicine, C.H.U. Sart Tilman, Liège; 4 Department of Diabetology,Metabolism and Nutrition, Antwerp, BelgiumThe recently published consensus for the management of metaboliccomplications associated with second generation antipsychotics(SGA) might not be sufficiently sensitive: in light of our data, it seemsthat screening with fasting glucose misses a number of patients withimpaired glucose metabolism, and taking into account the possibilityof possible reversal of the metabolic complication with early withdrawalof the incriminated medication, metabolic screening should bemore frequent during the first 6 months; also, the importance of thehyperlipidemia demands more frequent monitoring. Therefore, aworkshop was convened by Belgian psychiatrists, diabetologists andpharmacists to formulate appropriate recommendations for practicingpsychiatrists when initiating and maintaining therapy with SGA. Theconsensus statement issued recommendations for the management ofthe basic metabolic risk in every schizophrenic patient (risk factorsand metabolic disorders to screen for and to follow), choosing theSGA, the follow-up of patients on SGA, attitude in case of SGA-associatedglucose metabolism disorder. The need and the way to informpatients about the metabolic effects of SGA were discussed. Close collaborationbetween the psychiatrist and the general practitioner or theendocrinologist was strongly advised. Recommendations for nonschizophrenicpatients treated with SGA were also proposed. Recommendationsand consensus have been reached on the management ofweight gain and dyslipidemia while on SGA therapy.PO1.17.CLINICAL EFFICACY AND TOLERABILITYOF ANTIPSYCHOTIC TREATMENTS IN LATINAMERICAN PATIENTS WITH SCHIZOPHRENIAS. Assunção 1 , A. Hodge 2 , M. McBride 2 , H. Zavalaga 3 ,C. Arango Davila 4 , R. Haydar 5 , P. Gargoloff 6 , I. Ruiz 7 ,C. Adrianzen 8 , on behalf of the IC-SOHO study group1 Eli Lilly, Brazil; 2 Clinical Outcomes and Research Institute, EliLilly, Australia; 3 Hospital de la Policía Nacional del Perú, Lima,Peru; 4 Centro de Estudios Cerebrales, Valle University, Cali,Colombia; 5 Calle Cochera del Gobernador, Cartagena, Colombia;6 Hospital Dr. Alejandro Korn de Melchor, La Plata, Argentina;7 Eli Lilly, Mexico; 8 Eli Lilly, PeruThe Intercontinental Schizophrenia Outpatients Health Outcomes(IC-SOHO) is a 3-year global, prospective, observational study examininghealth outcomes associated with antipsychotic treatment inoutpatients with schizophrenia. The aim of this study is to summariseefficacy and tolerability results in Latin American (LA) patients following12 months of antipsychotic therapy. Treatment efficacy wasdetermined through the improvement in the Clinical Global Impression-Severity(CGI-S) rating scale. Tolerance to treatment was recordedby the clinician via adverse event questionnaires. Data wereadjusted for baseline differences and multivariate comparisons wereperformed between patients prescribed olanzapine, risperidone or atypical antipsychotic as monotherapy at baseline. Patients in theolanzapine group (n=1269) were significantly (p

This increased mortality rate was likely multifactorial (age, sex andhigh temperatures), although high prevalence of phenothiazine usemay also have contributed. We investigated this hypothesis by examiningthe use of two commonly prescribed anxiolytic and sedativeneuroleptics, cyamemazine and alimemazine, in the psychiatric hospitalcenter of Paul Guiraud of Villejuif. Between 1st and 20th August2003, 435 out of 530 hospitalized patients (82%) received a phenothiazine:263 of 435 (60.5%) received alimemazine, and 172 of 435(39.5%) received cyamemazine. Mean annual mortality rate calculatedfrom 1998 to 2002 for hospitalized patients was 5.8 deaths per year(1.83/1000 hospitalized patients). In 2003, with 11 deaths with apeak occurrence during the 3 weeks of the heat wave, the rateincreased to 3.47/1000. This represents a 90% increase in mortalityrate from preceding years. Besides age, gender and increased temperatures,it appears that other variables such as overuse of phenothiazines,which impair thermoregulation, may have contributed to elevatedmortality observed during the heat wave in France.PO1.19.SUDDEN UNEXPECTED DEATHS WITHPSYCHOTROPIC AGENTS, WITH FOCUS ONRELATIONSHIP TO ENVIRONMENTAL HIGHTEMPERATURESG. Chouinard 1,2,3 , N.H. Bhanji 1,2 , P.T. Sean 4 , C. Houssou 4 ,P. Beauverie 4 , B. Lachaux 41 Clinical Psychopharmacology Unit, Allan Memorial Institute,McGill University Health Centre, Montreal, Canada; 2 Departmentof Psychiatry, McGill University, Montreal, Canada; 3 Centre deRecherche Fernand Séguin, Louis H. Lafontaine Hospital,Department of Psychiatry, University of Montreal, Canada; 4 CentreHospitalier Paul Guiraud, Villejuif, FrancePsychiatric patients have elevated risk for sudden unexpected deaths(SUDs), which are defined as unintentional deaths occurring in otherwisehealthy individuals, or occurring in individuals with stablemedical problems not associated with lethality. The associationbetween SUDs and psychopharmacotherapy merits investigationsince these agents may contribute to SUDs. The recent increasedmortality observed in French patients prescribed neuroleptics duringthe heat wave in August 2003 led our focus to thermoregulatorymechanisms contributing to SUDs. PubMed database (1990 throughOctober 2003) revealed three classes of agents associated with SUDs:antipsychotics, antidepressants and sedative-hypnotics. Proposedmechanisms included: hyperthermia/autonomic instability; cardiotoxicity;electrolyte imbalances; and respiratory drive blunting.SUDs occur as consequence of illness (either directly or indirectly) orfollowing treatment (directly or indirectly). Antipsychotics may produceautonomic instability with temperature dysregulation, febrilecatatonia, heatstroke and neuroleptic malignant syndrome. Hyperthermiaand temperature dysregulation may also occur with benzodiazepinesand tricyclic antidepressants (TCAs). TCAs and antipsychotics(including atypicals) may cause cardiac arrhythmias, dyslipidemia,weight gain and diabetes; SUDs may result from concomitantsmoking. Bupropion also causes SUD. Electrolyte disturbances secondaryto syndrome of inappropriate antidiuretic hormone secretioncan cause cardiovascular fatality: agents implicated include antidepressants(TCAs, selective serotonin reuptake inhibitors, monoamineoxidase inhibitors, and newer agents); antipsychotics (typical andatypical); mood stabilizers, and sedative-hypnotics. Blunting of respiratorydrive, especially with alcohol, may cause SUDs with benzodiazepines,loxapine and clozapine. In conclusion, psychotropic medications,including the newer agents, may be associated with SUDsvia several mechanisms. Temperature dysregulation appears to be anunderappreciated cause of SUDs.PO1.20.ATYPICAL ANTIPSYCHOTICS: EXPERIMENTALEFFICACY OR CLINICAL EFFECTIVENESS?J.L.R. Martín 1 , V. Pérez 2 , M. Sacristán 3 , F. Rodríguez-Artalejo 4 ,C. Martínez 5 , E. Álvarez 21 Foundation for Health Research in Castilla-La Mancha(FISCAM), Toledo; 2 Santa Creu and Sant Pau Hospital,Barcelona; 3 Association PAIDEIA for Childhood Integration,Madrid; 4 Universidad Autónoma de Madrid; 5 Alarcos Hospital,Ciudad Real, SpainThe study aimed to assess, through a systematic review, atypical versustypical medication in the treatment of schizophrenia, based on anapproximation of the circumstances that arise in daily clinical practicewith these patients. The outcome measure in this review was allcausediscontinuation of treatment during the course of the trial. Asecond outcome was specific discontinuation for adverse events. Theincluded studies were high-quality randomized controlled trialswhich compared any of the four clinically best-established atypicalantipsychotics (quetiapine, olanzapine, risperidone or clozapine)against either of two typical antipsychotics regarded as the gold standard(haloperidol or chlorpromazine). The electronic search yielded1042 references. One hundred and forty-nine relevant reports werethen selected. The meta-analysis (7754 subjects) indicated a favorableeffect for atypical medication where dosage was flexible, both in theshort, RR 0.70 (0.64 to 0.76), p

diabetic medication in the past as documented in the database.Using conditional logistic regression and adjusting for gender andage, statistically significant elevations in risk were observed forpatients receiving more than one SGA (OR=3.26, 95% CI=1.76-6.05),clozapine (OR=2.14, 95% CI=1.09-4.20) or quetiapine (OR=4.10,95% CI=2.06-8.17), compared to exposure to FGAs alone. Althoughnot statistically significant, odds ratios for olanzapine (OR=1.59, 95%CI=0.87-2.90) and risperidone (OR=1.59, 95% CI=0.85-2.99) werealso elevated. In conclusion, exposure to multiple SGAs, clozapine orquetiapine increased the risk of developing diabetes mellitus, asdefined by receiving a new prescription for an anti-diabetic agent.PO1.22. DOSING OF SECOND GENERATIONANTIPSYCHOTIC MEDICATION IN A STATEHOSPITAL SYSTEML. Citrome, A. Jaffe, J. LevineNathan S. Kline Institute for Psychiatric Research, Orangeburg,NY; New York University School of Medicine, New York, NY, USAThe study aimed to describe the dosing of second generation antipsychotics(clozapine, risperidone, olanzapine, quetiapine, ziprasidone,and aripiprazole) among inpatients in state-operated psychiatric centersin New York State, and to contrast this to dosing recommendationsmade in the manufacturers’ product labeling. Information onpatients and their antipsychotic medication treatment was extractedfrom a database containing drug prescription information from theinpatient facilities operated by the New York State Office of MentalHealth. The principal period covered was April 1, 2003 through June30, 2003. Dosing trends were calculated by examining the secondquarter of calendar years 1997-2003. There were marked difference indosages used compared to the Food and Drug Administration (FDA)-approved dosage ranges recommended in the product labeling. Specifically,the average daily dose of olanzapine was 22.63 mg (n=1463),exceeding the 20 mg maximum recommended by the manufacturer.43.7% of patients prescribed olanzapine received a daily dose greaterthan 20 mg. Among the patients prescribed quetiapine (n=801), 28.5%received a daily dose exceeding 750 mg. In contrast, patients prescribedrisperidone (n=1287) received an average daily dose of 4.53mg, substantially lower than the maximum of 16 mg evaluated duringthe registration studies. Examining dose trends over time, it appearsthat the divergence from product label recommendations occurredgradually and are possibly reflective of additional clinical experiencewith patients not normally included in dose-finding registration studies.In conclusion, recommended dose ranges obtained during drugregistration trials do not necessarily reflect clinical realities. Phase IVclinical trials that specifically target more difficult-to-treat patients areneeded.PO1.23.RETROSPECTIVE ANALYSIS OF RISK FACTORSIN PATIENTS WITH TREATMENT-EMERGENTDIABETES DURING CLINICAL TRIALS OFANTIPSYCHOTIC MEDICATIONSM.O. Sowell 1 , N. Mukhopadhyay 1 , P. Cavazzoni 1 , C. Carlson 1 ,J. Buse 21 Lilly Research Laboratories, Indianapolis, IN; 2 University ofNorth Carolina School of Medicine, Chapel Hill, NC, USARecent reports have described new-onset diabetes during treatmentwith atypical antipsychotics. In this retrospective analysis, we assessedthe short-term (generally less than 1 year exposure with a medianexposure time < 6 months) risk of treatment-emergent diabetes (TED)among patients with schizophrenia during clinical trials of antipsychoticmedications. From a large non-diabetic cohort of patients withschizophrenia (n=5013), the relationship between baseline randomglucose level and baseline risk factors for diabetes, weight gain, andthe impact of therapy assignment on the risk of TED were assessed.At study entry, approximately one third of patients identified with TEDpossessed baseline random glucose levels >140 mg/dl and approximatelytwo thirds possessed multiple risk factors for diabetes. Bothbaseline random glucose and the presence of multiple pre-existing riskfactors for diabetes appeared to have a major impact on the risk ofTED. The impact of treatment-emergent weight gain on the short-termrisk of TED was relatively small and did not achieve statistical significance.Patients treated with olanzapine did not have a significantlygreater risk of short-term TED compared to a pooled cohort ofpatients receiving other interventions (risperidone, haloperidol andplacebo). These data suggest that, overall, the risk factors for diabetesin patients with schizophrenia overlap those in the general population.These results also suggest that many patients identified with TEDmay actually have had pre-existing glycemic abnormalities or a highbaseline burden of risk factors for diabetes.PO1.24.FASTING LIPID PROFILES OF PATIENTS WITHSCHIZOPHRENIA TREATED LONG-TERM WITHOLANZAPINE, RISPERIDONE, OR TYPICALANTIPSYCHOTICST.A. Hardy, M.O. Sowell, E. Marquez, C.C. Taylor,L. Kryzhanovskaya, P. CavazzoniLilly Research Laboratories, Indianapolis, IN, USAThe study aimed to compare fasting lipid profiles of stable, normoglycemicpatients with schizophrenia or schizoaffective disordertreated long-term with olanzapine, risperidone, or typical antipsychotics.This cross-sectional study included 184 stable, matched (sex,body mass index) patients who had been treated continuously for 1year with olanzapine (7.5-25.0 mg/day; n=67), risperidone (2.0-7.5mg/day; n=65), or typical antipsychotics (various agents, doses;n=52). Patients with fasting blood glucose higher than 110 mg/dLwere excluded from the analysis. Blood samples were collected afteran 11-hour observed fast. Fasting lipids (triglycerides, TG; cholesterol,lipoproteins), glucose, insulin, insulin sensitivity, and predicted10-year cardiovascular disease (CVD) risk (Framingham model) werecompared. Overall, the three treatment groups were well matched.The olanzapine group had significantly higher mean (but not median)fasting TG levels than the risperidone group. However, three influentialoutliers were identified in the olanzapine group; no significantdifferences were observed when these values were removed. No significantbetween-group differences were observed in mean cholesterollevels (total; low density lipoprotein, LDL; high density lipoprotein,HDL), LDL particle size, or total cholesterol/HDL ratio. Verylow density lipoprotein (VLDL), apolipoprotein B, and LDL particleconcentration were significantly higher during olanzapine thanrisperidone treatment. No significant differences were seen in fastingglucose, insulin, insulin sensitivity, or predicted 10-year CVD risk. Inconclusion, for these stable patients with schizophrenia on long-termantipsychotic therapy, modest but significant differences in fasting TGlevels and some qualitative differences in lipoproteins were observedbetween olanzapine and risperidone groups. The cross-sectionalstudy design and TG outliers limit the interpretation of these findings.Nonetheless, predicted 10-year CVD risk was comparable betweentreatment groups.201

PO1.25.IS COGNITIVE IMPROVEMENT WITHANTIPSYCHOTIC TREATMENT PSEUDOSPECIFIC?E.M. Marquez 1 , R.S.E. Keefe 2 , S.E. Purdon 3 , S.L. Rock 1 ,K.J. Alaka 1 , S. Ahmed 1 , R.C. Mohs 11 Lilly Research Laboratories, Indianapolis, IN, USA; 2 DukeUniversity Medical Center, Durham, NC, USA; 3 University ofAlberta, Edmonton, CanadaWhile cognitive deficits of schizophrenia appear to improve with olanzapine(OLZ) treatment, the relationship between this improvementand other changes in symptoms and side effects (i.e. positive, negative,and extrapyramidal symptoms (EPS)) has not been determined. Cognitivedeficits and positive symptoms have repeatedly been demonstratedto be independent dimensions of schizophrenia; however, there is substantialevidence that some aspects of cognition are related to negativesymptoms or EPS (measured by the Simpson-Angus Scale). Using posthocpath analyses, we investigated the relationship between cognition,derived from a cognitive battery composite score, and Positive andNegative Syndrome Scale (PANSS) negative and positive scores as wellas EPS. Three double-blind, randomized OLZ versus haloperidol studieswere included, resulting in a heterogeneous overall sample (OLZ,n=311) including first-episode, early-phase, and stabilized chronicschizophrenia patients. In the first-episode study, at 24 weeks there wasa cognitive effect size of 0.48, with the direct therapy effect accountingfor 85.1% (p

the antipsychotics was assumed. Conditional probabilities of developingany of four adverse events was calculated. Treatment was modified(decreased dose, medication switch) according to incidence ofAEs and physician judgment, obtained from a local cross-sectionalstudy and clinical trials previously published. Only direct medicalcosts (during 2002) from a third-party payer perspective were computed.Results are shown as annual cost per month with psychoticsymptoms controlled. Univariate sensitivity analysis was performed.Initiating treatment with ziprasidone showed the most favorable costeffectivenessratio - i.e., the dominant option (showing lower costsand the greater number of months with symptoms controlled) versusthe comparators. The annual cost per patient per month with symptomscontrolled was Euro 1,035 with ziprasidone versus Euro 1,084,Euro 1,087, and Euro 1,090 with haloperidol, risperidone, and olanzapine,respectively. Results are robust to one-way sensitivity analysis.In conclusion, AEs associated with antipsychotic drug use producea considerable economic impact. These results emphasize theneed to consider how ziprasidone’s favorable tolerability profile canproduce a positive impact not only on the clinical aspects of schizophreniabut also on health care budgets.PO1.29.CLOZAPINE, BUT NOT HALOPERIDOL,REVERSES SENSORIMOTOR GATINGIMPAIRMENTS MEDIATED BY KAPPA OPIOIDRECEPTOR ACTIVATION IN RATSM. Bortolato, R. Frau, M. Orrù, G.N. Aru, A. Casti, G. Boi,M. Puddu, M. Fa, P. Salis, G. Mereu, G.L. GessaDepartment of Neuroscience, University of Cagliari, ItalyThe recent discovery of new highly selective ligands for kappa opioidreceptors (KOR) has strengthened the evidence that KOR play a rolein the modulation of cognitive processes and their activation inducesperceptual distortions and hallucinatory effects. Since the deficit ofsensorimotor gating is generally regarded as the psychophysiologicalsubstrate for such anomalies, the present study was directed at assessingthe role of KOR on sensorimotor gating, by testing the effects ofthe activation and the blockade of KOR on the behavioral paradigmof prepulse inhibition (PPI) of the acoustic startle reflex (ASR), ahighly dependable model for the evaluation of informational filtering.To this aim, we examined whether the selective KOR agonist U50488(1.25, 2.5, 5 mg/kg, s.c.) was able to disrupt PPI in rats. Interestingly,both the doses of 2.5 and 5 mg/kg of the KOR agonist significantlyimpaired sensorimotor gating, and this effect was prevented by theselective KOR antagonist nor-binaltorphimine (NBI, 10 mg/kg, s.c),providing compelling evidence that KOR selective activation inducesattentional deficits. Remarkably, the same effect was also reversed bythe atypical antipsychotic clozapine at the doses of 5 and 10 mg/kg(i.p.), but not by the typical antipsychotic haloperidol (0.1 and 0.5mg/kg). Taken together, our results highlight a role for KOR in sensorimotorgating mechanisms and suggest they might represent aputative new target in the treatment of psychotic disorders unresponsiveto typical antipsychotics and with prevalence of negative symptoms.PO1.30.EEG ABNORMALITIES ASSOCIATED WITHANTIPSYCHOTICS: A COMPARISON OFQUETIAPINE, OLANZAPINE AND HALOPERIDOLB. Amann, O. Pogarell, R. Mergl, G. Juckel, H. Grunze, C. Mulert,U. HegerlPsychiatric University Hospital, Munich, GermanyIn this study the effects of the atypical antipsychotics quetiapine andolanzapine, and the typical antipsychotic haloperidol, on EEG patternswere retrospectively investigated in 81 patients under a stablemonotherapy with either drug (quetiapine: n=22, olanzapine: n=37,haloperidol: n=22). These three subgroups were compared with acontrol group of healthy subjects (n=30) which were matched regardingsex and age. Diagnoses of patients (DSM-IV) were schizophrenia(n=61), brief psychotic disorder (n=9), schizoaffective disorder (n=8),and delusional disorder (n=3). There were no statistically significantdifferences regarding demographic characteristics between thegroups. Digital EEG recordings were retrieved from a database andvisually assessed by two independent investigators, one blindedregarding medication. One patient from the quetiapine group (5%),13 olanzapine patients (35%), five of the haloperidol patients (23%)and two subjects of the control group (7%) had an abnormal EEG.Epileptiform activity was observed in four patients (11%) of the olanzapinegroup, and none in the others. EEG abnormalities were statisticallysignificantly increased with dose in the olanzapine group, incontrast to patients treated with haloperidol, quetiapine or healthysubjects. In conclusion, EEG abnormalities seem to occur rarely inpatients treated with quetiapine, comparable to the control group, butsignificantly more often with haloperidol and olanzapine, possiblydue to different receptor profiles of these substances. To our knowledge,this is the first electrophysiological investigation comparing thenew atypical antipsychotics quetiapine, haloperidol and olanzapinewith a control group.PO1.31.RELATIONSHIP BETWEEN ANTIPSYCHOTICTREATMENT AND SUBCORTICAL BRAIN VOLUMES:AN MRI STUDY OF SCHIZOPHRENIAU. Volpe 1 , S. Galderisi 1 , M. Quarantelli 2 , G.B. Cassano 3 ,A. Vita 4 , A. Rossi 5 , A. Mucci 1 , B. Alfano 2 , M. Maj 11 Department of Psychiatry, University of Naples SUN, Naples;2 National Council of Research, Institute of Biostructure andBioimaging, Naples; 3 Department of Psychiatry, Neurobiology,Pharmacology and Biotechnology, University of Pisa;4 Department of Mental Health, S. Maria delle Stelle Hospital,Melzo, Milan; 5 Department of Experimental Medicine, Universityof L’Aquila, ItalyPrevious structural brain imaging studies have reported a volumetricincrease of the subcortical structures in the brain of patients withschizophrenia. A role of chronic antipsychotic treatment in determiningthis abnormality has been hypothesized. In the present study, relationshipsbetween antipsychotic treatment and the volume of subcorticalstructures were investigated in a sample of 65 subjects with aDSM-IV diagnosis of schizophrenia. Fifteen patients were treated withstandard neuroleptics, 38 with novel antipsychotics and 7 with bothtypes of drugs; drug daily doses were expressed as chlorpromazineequivalents. The magnetic resonance images were obtained from animaging protocol consisting of two conventional spin echo sequences,each including 15 oblique axial slices; the volumes of putamen, globuspallidum, caudate nucleus, and thalamus were obtained and normal-203

ized for intracranial volume. When subjects with schizophrenia werecompared to age- and sex-matched healthy controls, all the evaluatedsubcortical structures, with the exception of the left caudate, showedan increased volume in the patient group, which was statistically significantfor the pallidum and thalamus. No relationship was foundbetween the observed volumetric increase in thalamus and pallidumand the medication dose. ANOVA revealed no significant effect of thetype of antipsychotic medication (novel vs. standard antipsychotics)on the basal ganglia volumetry. At least in chronic and stabilizedpatients with schizophrenia, volume increase in subcortical structuresseems to be independent of antipsychotic treatment.PO1.32.MRI FINDINGS IN SCHIZOPHRENIA:RELATIONSHIPS WITH DIAGNOSTIC SUBTYPEAND TREATMENT WITH ANTIPSYCHOTIC DRUGSU. Volpe 1 , S. Galderisi 1 , M. Quarantelli 2 , G.B. Cassano 3 ,A. Vita 4 , A. Rossi 5 , A. Mucci 1 , B. Alfano 2 , M. Maj 11 Department of Psychiatry, University of Naples SUN, Naples;2 National Council of Research, Institute of Biostructure andBioimaging, Naples; 3 Department of Psychiatry, Neurobiology,Pharmacology and Biotechnology, University of Pisa;4 Department of Mental Health, S. Maria delle Stelle Hospital,Melzo, Milan; 5 Department of Experimental Medicine, Universityof L’Aquila, ItalyThe term “deficit syndrome” (DS) refers to a diagnostic subtype ofschizophrenia, characterized by the presence of primary and enduringnegative symptoms. Structural brain imaging studies, comparingpatients with DS with those with nondeficit schizophrenia (NDS)and with healthy controls, have reported discrepant findings. In thepresent study neuromorphological abnormalities in DS and NDS andtheir relationships with antipsychotic treatment were evaluated.Sixty-five patients with a DSM-IV diagnosis of schizophrenia (34 DSand 31 NDS) and 27 healthy controls were enrolled. Each subjectunderwent a conventional spin echo MRI examination. Patients withDS received a lower dose of antipsychotic drugs. Gray matter volumeswere decreased in frontal and temporal lobes in the wholepatient group, when compared to controls. The volume of right thalamuswas larger in NDS than in DS patients, while both cerebellarhemispheres showed a volumetric increase in the latter with respectto the former group. Thalamic and lateral ventricles volumes wereincreased in the NDS group, with respect to healthy controls. Theright cerebellar hemisphere was larger in DS patients than in healthycontrols. ANCOVA revealed that the volumetric abnormalities foundin DS vs. NDS patients were not related to the dose or type of antipsychotictreatment or to the illness duration. Structural neuroimaging ofschizophrenic subjects revealed significant differences between thetwo subgroups, lending support to the hypothesis that the two syndromeshave different etiopathogenetic mechanisms.PO1.33.PREDICTORS OF CLOZAPINE RESPONSE INSCHIZOPHRENIA: A NEURAL NETWORK ANALYSISF. Cocchi, E. Politi, R. Cavallaro, E. SmeraldiDepartment of Neuropsychiatric Sciences, Vita Salute SanRaffaele University, Milan, ItalyClozapine is the first antipsychotic drug shown to be effective in treatingschizophrenia resistant to neuroleptics. However, only a limitednumber of schizophrenic patients have benefits from clozapine, andthey must cope with toxicity risks. Treatment outcome prediction isthen of great importance, also because clozapine treatment wasrecently found to be effective in a number of neurological and psychiatricconditions. Unfortunately, the available studies are not able tosuggest significant predictive variables or groups of variables, probablybecause of the complex relationships between response and differentindividual characteristics. Artificial neural networks (ANN) aresystems of cybernetic analysis able to analyze data series, extractingcomplex relationships among variables that are related in non-linearways to one or more dependent variables. A number of applicationsof ANN systems to the analysis of clinical psychopharmacology datasets are already available in literature. The aim of our study was toevaluate, in a naturalistic study on 124 subjects treated with clozapine,factors significantly contributing to the long-term prediction ofclozapine response, by means of an ANN system of analysis withback-propagation methodology. ANN extracted 45 significant contributorsthat clustered in 4 prototypes of response able to explainquantitative probability of different qualitative patterns of response.This methodology is able to make predictions of individual responseand not only of average, group response.PO1.34.CONTEXT-DEPENDENT INFORMATIONPROCESSING IN PATIENTS WITH SCHIZOPHRENIAAND ITS RELATIONSHIP WITH COMT GENOTYPEM.P. De Candia 1 , A. Bertolino 1 , F. Sambataro 1 , S. Dimalta 1 ,L. Fazio 1 , M. Altamura 1 , N. Antonucci 1 , G. Caforio 1 , G. Nappi 1 ,E. Daneluzzo 2 , A. Rossi 2 , M. Nardini 11 Department of Neurological and Psychiatric Sciences,University of Bari; 2 Department of Psychiatry, University ofL’Aquila, ItalyNeurocognitive deficits are features of schizophrenia. Failure in contextualinformation processing (CIP) has been hypothesized as beingthe single function responsible for cognitive impairments, through aninvolvement of the prefrontal cortex. Dopamine (DA) plays a role incognitive functioning in humans. Catechol-O-methyltransferase(COMT) plays an important role in modulating the activity of prefrontalcortex, through a functional polymorphism (Val108/158 Met)which accounts for a significant variation in DA catabolism. In thisstudy we investigated the processing of “context information” inschizophrenics compared to healthy controls. We examined theeffects of genotype on this cognitive domain. 37 patients (27 withschizophrenia, 10 with schizophreniform disorder according toDSM-IV), drug-free from one week (1 month if treated with depotneuroleptics), treated with olanzapine, and 37 normal controlsmatched on sociodemographic characteristics were tested. The subjectsperformed the AX-Continuous Performance Test (CPT) test. Weevaluated number of target AX, errors (BX, AY) and d’context (amore specific index of sensitivity to context). The number of BX wassignificantly higher in patients (p=0.003), d’context was lower(p

PO1.35.POSSIBLE IMPACT OF POLYMORPHISMSOF METABOLIZING ENZYMES ON THETHERAPEUTIC OUTCOME OF OLANZAPINEIN PATIENTS WITH SCHIZOPHRENIAN. Aydin 1 , A. Sükrü Aynacioglu 2 , B. Anwald 2 , R. Kerb 2 ,I. Ozturk 1 , H. Herken 31 Department of Psychiatry, University of Atatürk, Erzurum,Turkey; 2 Pharmacogenetics Laboratory, Epidauros BiotechnologyAG, Bernried, Germany; 3 Department of Psychiatry, Faculty ofMedicine, University of Gaziantep, Erzurum, TurkeyOlanzapine is a psychotropic agent which demonstrates antipsychoticactivities by antagonizing selectively monoaminergic receptors.Cytochrome P4501A2 (CYP1A2), flavin-containing monooxygenase 3(FMO3), and cytochrome P450 2D6 contribute to the metabolism ofthe drug. More than 20% of patients do not respond very well to olanzapinetreatment and 10% of patients have an increase in disease symptomatology.The possible impact of polymorphisms of these enzymeson olanzapine therapeutic outcome is not known. Therefore we determinedsome known polymorphisms of CYP1A2, FMO3, and CYP2D6in 95 patients with schizophrenia to assess their impact on response toolanzapine therapy or olanzapine-related adverse events. The Scale forthe Assessment of Negative Symptoms, the Scale for the Assessment ofPositive Symptoms and the Brief Psychiatric Rating Scale were used atbaseline and 6 weeks after treatment. We found a borderline significantimpact of FMO3 158K (p=0.030) and CYP1A2*1F (p=0.036) polymorphismson therapeutic response to olanzapine for positive symptoms.There was no significant effect of CYP2D6 genetic polymorphisms ontherapeutic outcome of olanzapine therapy. Our preliminary resultssuggest that genetic polymorphisms of metabolizing enzymes involvedin the metabolism of olanzapine may influence the success of treatment.PO1.36.THE ROLE OF THE CYP2D6 GENOTYPEIN MAINTENANCE THERAPY WITHZUCLOPENTHIXOL DECANOATEI. van Berlo-van de Laar, R. Teijeiro, B. PloegerHospital Pharmacy Deventer Ziekenhuizen, Zwolse Poort,The NetherlandsWe studied the relations between the CYP2D6 genotype, zuclopenthixolserum concentrations, extrapyramidal symptoms, and adjusting to theright dose during maintenance therapy with zuclopenthixol decanoate.Blood samples were taken just before administrating zuclopenthixoldecanoate and 5 days later. On day 0, we assessed zuclopenthixolserum concentration, CYP2D6 genotype, liver enzymes, serum creatinine,Extrapyramidal Symptoms Rating Scale (ESRS) score, and ClinicalGlobal Impression (CGI) score. On day 5, we assessedzuclopenthixol serum concentration, ESRS score and CGI score, numberof dose adjustments of zuclopenthixol decanoate in the past anduse of anticholinergics. Of the 23 patients, 10 were extensive metabolisers(EMs), 11 intermediate metabolisers (IMs) and 2 poor metabolisers(PMs). IMs were adjusted to a lower dose than EMs (234 mg vs. 380mg, p=0.03). The dose frequency and the zuclopenthixol serum concentrationswere comparable. The number of dose adjustments in IMswas higher than in EMs (3.9 vs. 1.5, p=0.009). The zuclopenthixolserum concentration on day 5, corrected for the dose, was higher inIMs than in EMs (factor 1.8, p=0.013). The zuclopenthixol serum concentrationafter 14 days, corrected for the dose, was also higher in IMsthan in EMs but this was not significant. This was also the case for theuse of anticholinergics in the past and the ESRS scores. The variationin the different genotype groups is very large in all measured parameters.In conclusion, knowledge of the CYP2D6 genotype in combinationwith measuring zuclopenthixol serum concentrations can be of usein adjusting patients to the right dose of zuclopenthixol decanoate. Theoptimal dose can be 200 mg/14 days in IMs and 300 mg/14 days inEMs. However, adjusting the dose on the basis of clinical effectsremains important.PO1.37.GENETICS OF CLOZAPINE-INDUCED WEIGHT GAIN:BETA-3 ADRENERGIC RECEPTOR AND G-PROTEINBETA-3 SUBUNIT/PROTEIN KINASE GTRANSDUCTION PATHWAY POLYMORPHISMSV. De Luca 1 , R. Hwang 1 , D.J. Mueller 1 , T. Shinkai 1 , V.S. Basile 1 ,M. Masellis 1 , H.Y. Meltzer 2 , J.A. Lieberman 3 , J.L. Kennedy 11 Neurogenetics Section, Center for Addiction and Mental Health,University of Toronto, Canada; 2 Department of Psychiatry,Vanderbilt University, Memphis, TN, USA; 3 Department ofPsychiatry, University of North Carolina, Chapel Hill, NC, USAClozapine, the prototype of atypical antipsychotics, has high affinityfor many G-protein coupled receptors. In particular, it is an antagonistat the beta-3 adrenergic receptor (beta-3) and the Trp64Arg polymorphismin this receptor has been postulated to be involved in the mechanismof obesity. This receptor is a G-protein coupled one and theC805T polymorphism in the G-protein beta-3 subunit (GNB3) maycontribute to obesity. In addition, the homologous of human proteinkinase G gene (PRKG1) in Drosophila affects food-search behavior.We tested the hypothesis that clozapine-induced weight gain is associatedwith genetic variation in beta-3 and this signal transduction pathway.Eighty patients with a DSM-III-R diagnosis of schizophreniawere prospectively assessed for clozapine-induced weight gain. Theywere subsequently genotyped for the Trp64Arg in beta-3, C805T inGNB3 and C2276T in PRKG1 genes. A modified analysis of covariancemodel was utilized to detect differences in mean weight gainamong various genotypic groups. We observed a trend for beta-3(p=0.10) and no significant results with regard to GNB3 (p=0.33) andPRKG1 (p=0.31). However, further investigations in larger and independentsamples are required.PO1.38.PREDICTION OF CHANGES IN MEMORYPERFORMANCE BY PLASMA HOMOVANILLICACID LEVELS IN CLOZAPINE-TREATED PATIENTSWITH SCHIZOPHRENIAT. Sumiyoshi 1,2 , A. Roy 1 , C.-H. Kim 1 , K. Jayathilake 1 , M.A. Lee 1 ,C. Sumiyoshi 3 , H.Y. Meltzer 11 Department of Psychiatry, Vanderbilt University School ofMedicine, Nashville, TN, USA; 2 Department of Neuropsychiatry,Toyama Medical and Pharmaceutical University School ofMedicine, Toyama, Japan; 3 Department of Developmental andClinical Psychology, Fukushima University, Fukushima, JapanCognitive dysfunction in schizophrenia has been demonstrated to bedependent, in part, on dopaminergic activity. Clozapine has beenfound to improve some domains of cognition, including verbal memory,in patients with schizophrenia. This study tested the hypothesisthat plasma homovanillic acid (pHVA) levels, a peripheral measure ofcentral dopaminergic activity, would predict the change in memoryperformance in patients with schizophrenia treated with clozapine.Twenty-seven male patients with schizophrenia received clozapine205

treatment for 6 weeks. Verbal List Learning-Delayed Recall (VLL-DR), a test of secondary verbal memory, was administered before andafter clozapine treatment. Blood samples to measure pHVA levelswere collected at baseline. Baseline pHVA levels were negatively correlatedwith change in performance on VLL-DR; the lower baselinepHVA level was associated with greater improvement in performanceon VLL-DR during treatment with clozapine. Baseline pHVA levelsin subjects who showed improvement in verbal memory during clozapinetreatment (n=13) were significantly lower than those in subjectswhose memory performance did not improve (n=14). The results ofthis study indicate that baseline pHVA levels differentiate betweenpatients with schizophrenia who respond to treatment with clozapinewith regard to memory performance and those who do not.Supported in part by a Fellowship and a Grant-in-Aid for ScientificResearch (No. 16591126) from the Ministry of Education and Scienceof Japan, as well as a Young Investigator Award from NARSAD.PO1.39.CLOZAPINE-INDUCED DIURNAL SLEEPINESS ISINFLUENCED BY CLOCK GENE POLYMORPHISME. Lattuada, R. Cavallaro, F. Cocchi, S. Benassi, E. SmeraldiDepartment of Neuropsychiatric Sciences, Vita Salute SanRaffaele University, Milan, ItalyDiurnal sedation or sleepiness is one of the major complaints inpatients treated with clozapine, an atypical antipsychotic indicatedfor subjects who are affected by schizophrenia who are resistant orintolerant to typical antipsychotics. This side effect is not present inall patients and is not dose-related and often persists for the firstweeks of treatment. Persistent diurnal sleepiness could be relatedboth to clozapine’s sedative side effects, mainly due to antihistaminicand antiadrenergic properties and to other mechanisms. The patternof occurrence suggests that sedative effects might precipitate diurnalsleepiness by interacting with biological traits like wake-sleep patterns.One of the candidate genes studied in disorders of the wakesleeprhythms is the CLOCK gene polymorphism. We studied aCLOCK gene polymorphism (3111 T/C substitution) in 101 patientsaffected by major psychosis. Among C homozygous subjects, 70%suffered from persistent diurnal sleepiness (p=0.015) versus 28.6% ofheterozygous and 23.8% of T (wild type) homozygous. A logisticregression with sleepiness as dependent variable, using genotype andclozapine plasma levels as independent variables, confirmed the significanteffect of CLOCK genotype on diurnal sleepiness (p=0.0093)with no influence of clozapine plasma levels. This observation supportsour hypothesis of a possible involvement of the CLOCK genepolymorphism in the diurnal sedation during clozapine treatment,which can hamper its usefulness in clinical pratice.PO1.40.INFLUENCE OF 5-HT2C PROMOTER GENEPOLYMORPHISM AND 5-HT2C RECEPTOR ONCLOZAPINE-INDUCED WEIGHT GAINE. Lattuada, R. Cavallaro, F. Cocchi, M. Rossattini, E. SmeraldiDepartment of Neuropsychiatric Sciences, Vita Salute SanRaffaele University, Milan, ItalyBody weight gain is a common side effect of some typical and atypicalantipsychotic drugs, including clozapine, with associated poortreatment compliance and morbidity rate because of obesity, cardiovasculardisease and diabetes. The molecular mechanisms responsiblefor antipsychotic drug-induced weight gain are unknown. A numberof studies focused on the interactions of antipsychotic drugs with5-HT2C serotonin receptors and on polymorphic genes coding forreceptor structure and expression, with contrasting results. The aimof this study is to investigate the relationship between the geneticvariants of the 5HT2c receptor gene and 5-HT2c receptor promotergene and clozapine-induced body weight change in a group ofpatients diagnosed with a major psychosis. A total of 133 patientsdiagnosed with major psychosis were followed in this study over aperiod of 6 months after starting a clozapine monotherapy. Bodyweight change, body mass index and clozapine plasma levels werefollowed up monthly. Analysis showed a significant associationbetween -759C/T polymorphisms of the 5-HT2C promoter gene andthe 68G/C polymorphisms of 5HT2C receptor gene in patients withclozapine-induced weight gain (p=0.0048) when considered togetheronly for a possible additive effect of both mutations. The effect wasstrongest in the male patients and not apparent in the female patients.Our findings suggest that genetic control on 5HT2c receptor expressionand structure may interact in determining weight gain susceptibilityin patient treated with clozapine.PO1.41.VALPROATE PREVENTS L-METHIONINE-INDUCEDGABAERGIC EPIMUTATIONS: IMPLICATIONSFOR SCHIZOPHRENIAL. Tremolizzo, V. Rodriguez-Menendez, M.S. Doueiri,D.R. Grayson, E. Costa, A. GuidottiDepartment of Psychiatry, University of Illinois, Chicago, IL, USACortical GABAergic inhibition orchestrates the intermittent firing ofpyramidal neuron populations by releasing a) GABA on GABA AandGABA Breceptors, and b) reelin on dendritic spine postsynaptic density,where it modulates the translation of spine resident mRNA. Inbrain of schizophrenia (SZ) patients, the expression of GAD 67andreelin mRNAs and proteins in GABAergic neurons is downregulated,but the expression of DNA-methyl-transferase 1 (DNMT1) isincreased. Theoretically, this reelin and GAD 67decrease follows theepigenetic hypermethylation of CpG islands expressed in the respectivepromoters, mediated by DNMT1. In mouse frontal cortex (FC),reelin promoter hypermethylation and the downregulation of reelinand GAD 67expression can be elicited by a protracted (7 to 15 days) L-methionine (MET) treatment (5.5 mmol/kg/s.c.). This treatment alsodisrupts the prepulse inhibition of startle (PPI) and the mouse socialinteraction in a novel environment. Hence, MET-induced mouseendophenotypes appear to model SZ symptoms. The histone (H)deacetylase inhibitor valproate (VPA, 1.5 mmol/kg/s.c.) enhances Hacetylation in mouse FC, which leads to a remodeling of the chromatinassociated with the reelin promoter. Co-administration of VPAand MET downregulates the reelin promoter hypermethylation, normalizingreelin and GAD 67mRNA expression and reverting the alterationsof both sensory gating and social interaction. The epigeneticmouse model described above may open exciting new perspectives forpharmacological interventions on epigenetic mechanisms operative inSZ, by elucidating whether the beneficial actions of VPA in SZ arerelated to pharmacological interactions involving chromatin remodelingcomplexes containing DNMT1 or inducing DNA demethylation.206 World Psychiatry 3:S1 - October 2004

PO1.42.LACK OF ASSOCIATION OF SEROTONINTRANSPORTER GENE POLYMORPHISM (5-HTTLPR)WITH ANTIPSYCHOTIC-INDUCED WEIGHT GAIN INKOREAN PATIENTS WITH SCHIZOPHRENIAS.J. Choi, B.G. Kong, Y.H. KimNeuropsychiatry Department, Inje Medical College, Busan,South KoreaWe investigated the association of sex, age, baseline body mass index(BMI) and 44 bp insertion/deletion polymorphism in 5-HT transporter-linkedpolymorphic region (5-HTTLPR) with antipsychoticinducedweight gain in patients with schizophrenia. We studied 161subjects fulfilling the DSM-IV criteria for schizophrenia, who hadtaken antipsychotics for at least 12 weeks. We recorded sex, age, BMI,body weight, the type of antipsychotics and the duration of antipsychoticmedication. We examined the genotype distribution and allelefrequency of 5-HTTLPR, using polymerase chain reaction (PCR) ofgenomic DNA with primers flanking the promotor regions of the 5-HTT gene. There was a significant increase of body weight (mean 2.37kg at 12 weeks, mean 6.92 kg at 78 weeks) in patients who werefemale, under 30 years old and under 25 of BMI. Subjects receivingatypical antipsychotics had a significant increase of body weight. Wefound no significant association between the genotype distributionand allele frequency of 5-HTTLPR and antipsychotic-induced weightgain.PO1.43.StoRMI - DIRECT SWITCHING TO LONG-ACTINGINJECTABLE RISPERIDONE IN PATIENTS WITHSCHIZOPHRENIA OR SCHIZOAFFECTIVEDISORDER: RESULTS FROM GERMANYH.-J. Möller 1 , M. Schmauss 2 , W. Kissling 3 , D.H. Naber 4 ,A. Schreiner 51 Department of Psychiatry, University of Munich;2 Department of Psychiatry, Bezirkskrankenhaus Augsburg;3 Department of Psychiatry, Technische Universität, Munich;4 Department of Psychiatry and Psychotherapy, University ofHamburg; 5 Janssen-Cilag, Neuss, GermanyThis open-label trial investigated the maintained efficacy and safety oflong-acting injectable risperidone in patients with schizophrenia andother psychotic disorders switched directly from any oral or depotantipsychotic. We present a subgroup analysis of patients from Germany.Adult patients stable on their antipsychotic regimen for at least1 month were switched to long-acting risperidone (25 mg, increasedto 37.5 mg or 50 mg, if necessary) injected every 14 days for 6 monthswithout oral risperidone run-in. Of 356 patients (55% male, mean age42 years), 290 had schizophrenia (mostly paranoid) and 58 hadschizoaffective disorder. Most patients were switched from atypical orconventional depot antipsychotics. The most common reasons forswitching were non-compliance (40%), insufficient efficacy (28%)and side effects (27%). Mean Positive and Negative Syndrome Scale(PANSS) total score at baseline was 73. 64% of the patients completedthe trial. There were significant reductions in mean scores for totalPANSS, and for all PANSS subscales and symptom factors from baselineto endpoint (p

line with the literature, PCA yielded a 5-factor solution with a negative,excitement, cognitive, depression/anxiety and positive component.All factor scores except the already initially very low scoringexcitement component improved highly significantly in both groupsand no comparison revealed a significant group difference. In eachgroup, effect size (ES) was large for improvement of negative symptoms,medium for depression/anxiety and cognitive component andsmall for positive symptoms, as expected for a non-acute sample. Forexcitement and for all comparisons of changes between groups, ESwas below 0.2. These results indicate that, besides the well establishedefficacy regarding positive symptoms, flupenthixol and risperidone areboth comparably beneficial in the treatment of negative, affective andcognitive symptoms.PO1.46.IMPROVEMENT OF EXTRAPYRAMIDAL SYMPTOMSAFTER SWITCHING SCHIZOPHRENIC PATIENTSFROM CONVENTIONAL DEPOT NEUROLEPTICSTO LONG-ACTING INJECTABLE RISPERIDONEA. Schreiner, R. MedoriDepartment of Medical and Scientific Affairs, Janssen-Cilag,Neuss, GermanyThe study aimed to evaluate the change in extrapyramidal symptomsafter switching from frequently used conventional depot neurolepticsto long-acting injectable risperidone (risperidone microspheres,Risperdal Consta) without oral risperidone run-in. This was a 12-week open-label prospective multicenter trial. After a run-in period oftwo treatment cycles on their conventional depot antipsychotic(either haloperidol decanoate, flupentixol decanoate, fluphenazine orzuclopentixol decanoate), symptomatically stable adult schizophrenicpatients were switched to long-acting injectable risperidoneadministered by gluteal injections every 2 weeks. Extrapyramidalsymptoms were assessed using the Extrapyramidal Symptom RatingScale (ESRS) at baseline and at the end of the 12-week treatmentperiod (endpoint). Adverse events, including extrapyramidal symptom-relatedevents, were recorded at each visit. 166 patients (67%male, mean age 42.9±11.6 years) were enrolled. Most patients hadparanoid (69.3%) or residual (15.7%) schizophrenia. The modal doseof risperidone was 25 mg in 86% of the patients and 37.5 mg in14%. Median total ESRS score was 5.0 (range 0–43) at baseline,decreasing to 2.0 at endpoint. Median change in total ESRS was -2.0(p

thought and anxiety/depression factors. Improvement of at least 20%in PANSS score from baseline to treatment endpoint was seen in 24%of patients. Patient satisfaction, assessed by 5-point scale, improvedsignificantly from baseline. There was a significant improvement inextrapyramidal signs; unexpected treatment-emergent adverse eventswere not reported. This subgroup analysis of the Switch to RisperidoneMicrospheres (StoRMi) trial demonstrated the maintained efficacyof injectable long-acting risperidone, which may even improvePANSS scores in patients with schizophrenia considered to be stableon their previous antipsychotic therapy. Patients reported high levelsof satisfaction with the treatment, which was well tolerated.PO1.49.EFFICACY, SAFETY AND TOLERABILITYOF RISPERIDONE IN ADOLESCENTS WITHSCHIZOPHRENIA: AN OPEN LABEL STUDYG. Zalsman, C. Einat, A. Martin, D. Bensason, A. Weizman,S. TyanoGeha Mental Health Center, University of Tel Aviv, Israel;Columbia University, New York, NY; Yale University,New Haven, CT, USAData on risperidone efficacy and tolerability in schizophrenia adolescentsare scarce. We found only one prospective open label study inthis population. The aim of this open label, prospective study, was toestimate the efficacy, safety and tolerability of risperidone treatment,in adolescents with first-episode schizophrenia. Subjects were adolescentinpatients, diagnosed with DSM-IV first-episode schizophreniaby the Schedule for Affective Disorders and Schizophrenia forChildren - patient version (K-SADS-P). Most of the patients (10/11)were drug naïve. Improvement was assessed during the first 6 weeksof treatment using Positive and Negative Syndrome Scale (PANSS),Brief Psychiatric Rating Scale (BPRS), and Clinical Global Impression(CGI) scale. Side effects were monitored using Abnormal InvoluntaryMovement Scale (AIMS), Simpson Angus Scale (SAS), BarnesAkathisia Rating Scale (BARS) and UKU side effect scale. Elevenadolescents between 15.5 and 20 (mean 17.2±1.2) years of age wereincluded in this study. Risperidone in an average dose of 3.14±1.60mg/day produced a significant improvement on the PANSS score(28%; p

PO1.52.DIRECT SWITCHING TO LONG-ACTINGINJECTABLE RISPERIDONE IN YOUNG PATIENTS(18–30 YEARS) WITH SCHIZOPHRENIA ANDSCHIZOAFFECTIVE DISORDERP.T. Saleem 1 , H. Firmino 2 , E. Parellada 3 , A. Schreiner 4 ,H.-J. Möller 51 Queen's Park Hospital, Blackburn, UK; 2 Servico Psiquiatria,Hospitais Universidade de Coimbra, Portugal; 3 Hospital Clinic deBarcelona, Spain; 4 Janssen-Cilag, Neuss, Germany; 5 Ludwig-Maximillian Universitaet, München, GermanyThe maintained efficacy and safety of long-acting injectable risperidonein patients with schizophrenia and other psychotic disordersswitched from oral or depot antipsychotic without oral risperidonerun-in was investigated (StoRMi trial). A subgroup analysis was performedin younger patients. Patients aged 18–30 years stable on theirprevious antipsychotic regimen for at least 1 month received long-actingrisperidone (25 mg, increasing to 37.5 mg or 50 mg, if necessary)injected bi-weekly for 6 months. Of 119 patients, 101 had schizophrenia,mostly paranoid, and 11 had schizoaffective disorder. Previoustherapy was mainly atypical antipsychotics (56%), and reasonsfor switching were non-compliance (47%), side effects (24%) andlack of efficacy (21%). Six patients discontinued early for adverseevents and 11 for insufficient response; 70% completed the 6-monthtreatment period. Significant reductions from baseline to endpoint(p

PO1.55.EFFICACY AND SAFETY OF INJECTABLELONG-ACTING RISPERIDONE IN OBESE PATIENTSWITH SCHIZOPHRENIA OR SCHIZOAFFECTIVEDISORDERR. Teijeiro Permuy 1 , M. St. J. Turner 2 , P. Bouhours 3 , E. Sacchetti 41 Zwolse Poort, Raalte, The Netherlands; 2 Larkfield Centre,Glasgow, UK; 3 Janssen-Cilag, Issy-les-Moulineaux, France;4 Clinica Psichiatrica, Spedali Civili di Brescia, Brescia, ItalyThe maintained efficacy and safety of long-acting injectable risperidonein patients with schizophrenia and other psychotic disordersswitched directly from any oral or depot antipsychotic was investigatedin an open-label trial. A subgroup analysis was performed in obesepatients. Adult patients with a body mass index (BMI) of at least 30kg/m 2 , stable for at least 1 month on their antipsychotic regimen, wereswitched to long-acting risperidone. Long-acting risperidone (25 mg,increased to 37.5 mg or 50 mg, if necessary) was injected every 14 daysfor 6 months without an oral risperidone run-in. Of 119 patients, 87had schizophrenia, mostly paranoid, and 24 had schizoaffective disorder.Mean weight and BMI were 98 kg and 33.6 kg/m 2 , respectively.Previous therapy was mainly classical depot (45%) or atypical (44%)antipsychotics. Reasons for switching included side effects (40%),non-compliance (35%) and lack of efficacy (31%). Mean scores fortotal Positive and Negative Syndrome Scale (PANSS), negative subscale,general psychopathology subscale, disorganised thoughts factorand anxiety/depression factor decreased significantly (p

predefined level of symptomatic remission after treatment with longactingrisperidone, suggesting that further study of these criteria is warranted.PO1.59.PATIENTS SWITCHED FROM OLANZAPINETO LONG-ACTING RISPERIDONES. Berry 1 , Y. Zhu 2 , R. Lasser 21 Johnson and Johnson Pharmaceutical Research andDevelopment; 2 Janssen Pharmaceutica Products, Titusville, NJ,USAThe study aimed to assess the safety and efficacy of switching 50symptomatically stable patients with schizophrenia directly fromolanzapine to long-acting injectable risperidone without a preliminaryperiod of oral risperidone. After a 4-week run-in period duringwhich the patients continued to receive olanzapine, long-actingrisperidone (25–50 mg) was given every 2 weeks for 12 weeks. Concomitantolanzapine was given for the first 2 of the 12 weeks and thentapered and discontinued during week 3. Forty patients (80%) completedthe study during which the mean dose of olanzapine was15.2±8.8 mg/day. A clinical response (at least 20% reduction in Positiveand Negative Syndrome Scale, PANSS total scores) was achievedby 44% of these stable patients. Mean PANSS scores were reducedfrom 60.4±1.7 to 57.8±2.2 at endpoint. Mean Clinical Global Impression- Severity (CGI-S) scores decreased from baseline to endpoint.Most frequently reported adverse events were insomnia (8 patients),rhinitis (5 patients), dizziness (4 patients), and psychosis (4 patients).No clinical adverse events associated with hyperprolactinemia werereported. The patients had a mean weight loss of 0.5 kg (1 lb) duringthe 12-week trial. In conclusion, stable patients who had been treatedwith olanzapine experienced clinical benefits with no unexpectedadverse events when switched directly to long-acting injectablerisperidone.PO1.60.LONG-ACTING RISPERIDONE IN STABLEPATIENTS WITH SCHIZOPHRENIA SWITCHEDFROM ORAL TREATMENT WITH QUETIAPINES. Berry 1 , Y. Zhu 2 , R. Lasser 21 Johnson and Johnson Pharmaceutical Research andDevelopment; 2 Janssen Pharmaceutica Products, Titusville, NJ,USAMost atypical antipsychotics are administered by daily dosing regimensthat can result in partial compliance and suboptimal outcome.This study assessed stable patients with schizophrenia who wereswitched directly from oral quetiapine to long-acting injectablerisperidone. After a 4-week run-in period during which patients continuedto receive quetiapine, long-acting risperidone (25–50 mg) wasgiven every 2 weeks for 12 weeks. Concomitant quetiapine was givenfor the first 2 of the 12 weeks and then tapered and discontinued duringweek 3. Thirty-eight patients (84.4%) completed the study duringwhich the mean dose of quetiapine was 382.8±255.8 mg/day. A clinicalresponse (at least 20% reduction in Positive and Negative SyndromeScale, PANSS total scores) was achieved by 35% of these stablepatients. Mean PANSS total scores decreased from 62.0±1.8 atbaseline to 59.6±2.4 at endpoint. Mean Clinical Global Impression -Severity (CGI-S) scores decreased significantly. Adverse eventsreported in more than 15% of patients were headache in 29% andinsomnia, agitation, and anxiety each in 16% of patients. Movementdisorder-related adverse events were reported by 4% of patients. Noclinical adverse events associated with hyperprolactinemia werereported. Mean weight change was +0.3 kg (0.7 lb). In conclusion,stable patients with schizophrenia receiving quetiapine experiencedclinical benefits with good overall tolerability when switched directlyto long-acting risperidone.PO1.61.INSIGHT IN STABLE PATIENTS WITHSCHIZOPHRENIA RECEIVING LONG-ACTINGRISPERIDONEG. Gharabawi, C. Bossie, Y. Zhu, R. LasserJanssen Pharmaceutica Products, Titusville, NJ, USAThe study aimed to examine the relationship between level of insightand measures of clinical and functional status. In an open-label study,patients with schizophrenia/schizoaffective disorder received longactinginjectable risperidone every 2 weeks for up to 50 weeks. ThePositive and Negative Syndrome Scale (PANSS) measured insight andpsychotic symptoms. Insight scores were correlated to PANSS scores,Clinical Global Impressions-Severity (CGI-S) ratings, and functionalscores (Short-Form 36 Health Survey, SF-36). Data were available for614 patients. Mean insight scores significantly improved from 2.7±1.5at baseline to 2.5±1.5 at endpoint (p=0.0002). Twenty-six percent ofpatients with impaired insight achieved normal or near normal insightafter treatment. Improvements in insight were positively and significantlycorrelated to improvements in CGI-S ratings (r=0.368; p

clustered into two distinct factors, one consisting of the PANSS scalesand the other consisting of the SF-36 scales. The overlap of the twofactors at baseline was 12% and for change to endpoint was 27%. Inconclusion, patients perceived health status and symptomatologywere improved and maintained on treatment with long-acting risperidoneinjection in symptomatically stable patients with schizophrenia.Patient reported improvement in well-being appears to be a differentoutcome dimension from investigator rated improvement of psychopathology.Given the importance of patients’ perceived improvementin well-being, it should be used in addition to symptom measuresto help measure treatment outcomes.PO1.63.OPTIMAL DOSE OF RISPERIDONE FOR CHILDAND ADOLESCENT PATIENTS OF MULTIPLECENTERS IN TAIWANL.-J. Wang 1 ,Y.-S. Huang 2 , C.-K. Chen 1 , H.-L. Chang 21 Department of Psychiatry, Chang Gung Memorial Hospital,Keelung; 2 Department of Psychiatry, Chang Gung MemorialHospital, Taoyuan, TaiwanRisperidone is an atypical antipsychotic which was widely prescribedfor many conditions of child and adolescent patients over10 years. This open-label trial was to establish the optimal dose forchild and adolescent patients in Taiwan. From July 2001 to March2002, 152 child and adolescent patients were collected from multiplemedical centers in north Taiwan. The subjects were within therange of 7-21 years old with a diagnosis of psychosis, mental retardationwith disturbing behavior and Tourette syndrome. Theyreceived risperidone treatment for 12 weeks with a maintainingdose for at least 4 weeks, and their mean age, duration of illness,dose, combined drugs and side effects were recorded. Of the 152cases, 110 were of psychosis, 29 were of Tourette syndrome and 13were of mental retardation, treated with mean doses of 3.02±1.49mg, 1.44±0.68 mg and 3.23±1.48 mg, respectively. No gender differencewas demonstrated, and the most prevalent side effects weresedation, parkisonism, dizziness and weight gain. This trial suggestedthat the optimal dose of risperidone for child and adolescentpatients with psychosis, Tourette syndrome and mental retardationin Taiwan might be slightly lower than in Caucasians.PO1.64.SAFE AND EFFECTIVE CABERGOLINETREATMENT FOR RISPERIDONE-INDUCEDHYPERPROLACTINEMIAR. CavallaroVita-Salute San Raffaele University Medical School, Milan, ItalyA previous pilot study showed the efficacy and tolerability of a lowdose of cabergoline, a D2 agonist, in the treatment of risperidoneinducedhyperprolactinemia. This study aimed to confirm results inan independent multicentric sample, also looking at the time courseof prolactin concentrations and related clinical signs after cabergolinewithdrawal. 34 male and female schizophrenic patients treatedwith risperidone and suffering from symptomatic hyperprolactinemiawere treated with cabergoline 0.125-0.250 mg/week for eightweeks, with unchanged risperidone doses. Plasma prolactin concentrationswere measured before and after cabergoline treatmentand eight weeks after its withdrawal. Plasma prolactin levelsdecrease after 8 weeks of cabergoline treatment was statistically significantand normalized in 15 patients. Prolactin-related signs andsymptoms remitted in 47%, while of 29.4% of subjects showed apartial remission. Results concerning both prolactin concentrationsand clinical remission of symptoms were maintained also after 8weeks of cabergoline withdrawal, with 4 more subjects obtainingclinical response. No side effect was observed or reported and psychopathologywas unchanged. Replication of results of the previouspilot study in an independent sample confirms efficacy and safety oflow-dose cabergoline treatment in risperidone-induced symptomatichyperprolactinemia.PO1.65.OLANZAPINE IN ADOLESCENT ANDYOUNG ADULT PATIENTS WITH SCHIZOPHRENIA:CHANGES IN BODY WEIGHT AND LEPTINR.W. Dittmann 1,2 , U. Hagenah 3 , J. Junghanss 4 , A. Maestele 2 ,C. Mehler-Wex 5 , E. Meyer 6 , M. Pitzer 7 , H. Remschmidt 8 ,D. Schlamp 9 , M. Schulte-Markwort 10 , E. Schulz 11 ,O. Weiffenbach 121 Psychosomatic Department, Children’s Hospital, Universityof Hamburg; 2 Medical Department, Lilly Deutschland GmbH;3 Department of Child and Adolescent Psychiatry, Universityof Aachen; 4 Department of Child and Adolescent Psychiatry,Josefinum, Augsburg; 5 Department of Child and AdolescentPsychiatry, University of Würzburg; 6 Department of Child andAdolescent Psychiatry, Riedstadt; 7 Department of Child andAdolescent Psychiatry, Central Institute of Mental Health,Mannheim; 8 Department of Child and Adolescent Psychiatry,University of Marburg; 9 Department of Child and AdolescentPsychiatry, Heckscher Hospital, Munich; 10 Department of Childand Adolescent Psychiatry, University of Hamburg; 11 Departmentof Child and Adolescent Psychiatry, University of Freiburg;12 Department of Child and Adolescent Psychiatry, University ofFrankfurt, GermanyThis multicenter study assessed efficacy and safety of olanzapine inadolescents (n=93) and young adults (n=3) with schizophrenia (DSM-IV). Here, we report treatment-emergent changes in body weight andleptin levels. Patients received open-label olanzapine for 6 weeks (5-20 mg/day; starting dose 10 mg/day), responders continued for additional18 weeks. Weight and leptin levels were measured regularlythroughout the study. Primary study endpoint was the change in BriefPsychiatric Rating Scale (BPRS items 1-6) scores from baseline toweek 6 (response: >30% reduction). 100 patients entered the trial (12-21 years), 96 received olanzapine, 80 reached week 6, 34/60 responderscompleted 24 weeks. The mean maximum dose was 16.7 mg/day.At baseline, 75.0% of patients had age-specific normal weight, 14.6%were overweight, 10.4% underweight. Weight gain (last observationcarried forward) was 5.1±3.7 kg at week 6, and 11.7±7.9 kg (respondersonly) at week 24 (body mass index, BMI: +1.6±1.3; +3.6±2.6kg/m2, respectively; all p

PO1.66.PRELIMINARY PHARMACOKINETIC ANDTOLERABILITY PROFILES OF OLANZAPINE20, 30, AND 40 MG/DAYW. Earley 1 , M. Mitchell 2 , R. Riesenberg 3 , M.A. Bari 4 , E. Marquez 1 ,D. Kurtz 2 , D. Falk 1 , C.C. Taylor 1 , P. Cavazzoni 11 Lilly Research Laboratories, Indianapolis, IN, USA; 2 LillyResearch Centre, Windlesham, UK; 3 Atlanta Center for MedicalResearch, Atlanta, GA, USA; 4 Synergy Clinical Research Center,Chula Vista, CA, USAThe study aimed to characterize the steady-state pharmacokineticsand assess the tolerability of three doses of oral olanzapine (20, 30,and 40 mg/day) among patients with psychiatric disorders. Thirtysevenstable inpatients with schizophrenia, schizoaffective disorder,or bipolar mania were treated with olanzapine 20 mg/day for 10 daysand were then randomized to 10 days of double-blind treatment witholanzapine 20 mg (n=12), 30 mg (n=11), or 40 mg (n=14) daily. For anadditional 10 days, 30 mg patients received olanzapine 40 mg/day(30-40 mg); all other patients remained on their same dose. To obtainpharmacokinetic data, a 7-day olanzapine wash-out period followed.Steady-state pharmacokinetics were computed using standard noncompartmentalmethods and various tolerability measures wereobtained during double-blind treatment. Olanzapine pharmacokineticsappeared linear for doses of 20, 30, and 40 mg/day, with olanzapineplasma concentrations continuing a dose-proportional increase.Doses of up to 40 mg/day of olanzapine were generally well tolerated.Two patients (40 mg) discontinued because of an adverse event(akathisia, depressed mood). The most frequently reported adverseevents were increased weight (20 mg, n=2; 30-40 mg, n=3; 40 mg,n=2) and sedation (20 mg, n=3; 30-40 mg, n=2; 40 mg, n=2). Fourpatients (40 mg) reported treatment-emergent akathisia (3 of 4 notconfirmed by Barnes Akathisia Scale scores). No clinically importantchanges were observed in QTc intervals, laboratory parameters, ortreatment-emergent extrapyramidal symptoms. Five patients (20 mg,n=3; 30-40 mg, n=2) experienced weight increase >7% from baseline.In conclusion, the pharmacokinetic and tolerability profiles of olanzapine20, 30, or 40 mg/day in patients with psychiatric disorderswere consistent with the known profiles of standard dose olanzapine(5-20 mg/day).PO1.67.COMPARISON OF OLANZAPINE TO OTHERATYPICAL ANTIPSYCHOTICS IN PREVENTINGRELAPSE IN PATIENTS WITH SCHIZOPHRENIAS.M. Roychowdhury, G. Sethuraman, S. Ahmed, G.A. Phillips,M. Enerson, P.H. Berg, A. BreierLilly Research Laboratories, Indianapolis, IN, USAThe study aimed to compare time to relapse on olanzapine with otheratypical antipsychotics in patients with schizophrenia and exploresome clinical reasons for relapse. Three double-blind studies, comparingolanzapine to risperidone (28 weeks), olanzapine to ziprasidone(28 weeks), and olanzapine to quetiapine (24 weeks), wereincluded in these analyses. Response was defined as 20% or 30%improvement in Positive and Negative Syndrome Scale (PANSS)total score at 8 weeks. Relapse was defined as 20% or 30% worseningon PANSS total score and a Clinical Global Impression (CGI)-Severityof 3 after 8 weeks in responders. Four sets of pairwise comparisonsfor response-relapse were conducted and labeled 20-20, 20-30, 30-20and 30-30. Reasons for discontinuation were examined at 30-20. Thepercent of patients achieving 20% or 30% improvement in PANSStotal score at week 8 was similar between olanzapine and each of thecomparator drugs. Olanzapine-treated patients were significantly lesslikely to relapse than risperidone-treated patients at both criteria forresponse and relapse (p≤0.001; odds ratio, OR for relapse withrisperidone ranged from 2.86 to 4.55). Olanzapine-treated patientsalso relapsed less than ziprasidone-treated patients at 20-20 and 30-20 (p≤0.01), but not at 20-30 and 30-30. OR for relapse with ziprasidoneranged from 1.79 to 2.33. Olanzapine-treated patients relapsedless than quetiapine treated (p≤0.02) patients at all defined levels ofresponse and relapse except 30-20. OR for relapse with quetiapineranged from 3.85 to 7.14. Analysis of relapsers at 30-20 showed nosignificant differences in reasons for discontinuations between olanzapineand the other atypical antipsychotics. In conclusion, olanzapinewas better at reducing relapse in patients with schizophrenia thanrisperidone, ziprasidone and quetiapine using multiple definitions ofresponse and relapse.PO1.68.RAPID ONSET OF ABSORPTION WITHOLANZAPINE ORALLY DISINTEGRATING TABLETSR.F. Bergstrom 1 , M. Mitchell 2 , J. Witcher 2 , J.P. Houston 1 ,A.L. Hill 1 , C.C. Taylor 1 , H. Liu-Seifert 1 , B. Jones 31 Lilly Research Laboratories, Indianapolis, IN, USA; 2 LillyResearch Centre, Windlesham, UK; 3 Eli Lilly Canada, Ontario,CanadaA clinical perception exists suggesting more rapid onset of action witholanzapine orally disintegrating tablet (ODT) versus olanzapine standardoral tablet (SOT). Olanzapine bioavailability data were evaluatedto assess early plasma concentration time profiles for olanzapineODT versus SOT. In three crossover bioequivalence studies of olanzapineODT (5, 10, or 20 mg) versus SOT (1 x 5 mg, 2 x 5 mg, 4 x 5mg), approximately 20 healthy subjects received single-dose ODT andthe corresponding dose of SOT (13 days between treatments). Olanzapineplasma concentrations, AUC and Cmax values were evaluatedto assess bioequivalence. Early onset of absorption was assessedusing comparative absorption profiles. Olanzapine ODT and SOTwere bioequivalent based on AUC and Cmax. Overall, plasma concentration-timeprofiles and absorption rate constants were nearlyidentical between formulations. Nonetheless, with 5 mg olanzapine,79% of ODT vs. 0% of SOT patients had measurable olanzapine concentrationsat 15 minutes. Significantly more subjects receiving ODThad higher plasma concentrations over the first hour vs. SOT (e.g.63% vs. 11% 1 ng/mL at 45 minutes). These small early concentrationdifferences became indistinguishable before reaching Cmax. Inconclusion, olanzapine ODT yields a more rapid onset of absorptionthan SOT as significantly more subjects given ODT achieved slightlyhigher olanzapine concentrations immediately after administration.The small differences are likely attributable to more rapid onset ofODT gastrointestinal absorption. These differences do not change theconclusion of bioequivalence. The relevance of earlier onset ofabsorption to clinical treatment has not been tested.214 World Psychiatry 3:S1 - October 2004

PO1.69.AMANTADINE FOR WEIGHT GAIN INOLANZAPINE-TREATED PATIENTSW. Deberdt 1 , Q. Trzaskoma 1 , C. Carlson 1 , F. Bymaster 1 ,A. Winokur 2 , M. Floris 31 Lilly Research Laboratories, Indianapolis, IN, USA; 2 Departmentof Psychiatry, University of Connecticut Health Center,Farmington, CT, USA; 3 Department of Psychiatry, Hospital Notre-Dame, Tournai, BelgiumThis study aimed to determine whether amantadine could attenuateweight gain or promote weight loss in patients who gained weightduring olanzapine therapy. The study included patients with schizophrenia,schizoaffective, schizophreniform, or bipolar I disorders, notmanic or acutely psychotic, treated with olanzapine for 1-24 months,and who had gained 5% of their initial body weight. Olanzapine(mean modal dose, 12.4 mg/day) was coadministered with doubleblindtreatment of 100-300 mg/day amantadine (Olz+Amt, n=60;mean modal dose, 235.6 mg/day) or placebo (Olz+Plc, n=65). Weightwas measured at each visit, and the Brief Psychiatric Rating Scale(BPRS) and the Montgomery-Asberg Depression Rating Scale(MADRS) were administered monthly for 16 weeks and again at 24weeks. Visitwise analysis of weight showed that weight change frombaseline (LOCF) in the Olz+Amt group was significantly differentfrom the Olz+Plc group at Weeks 8 (p=0.042), 12 (p=0.029), and 16(primary endpoint, -0.19±4.58 kg vs. 1.28±4.26 kg, p=0.045). MeanBPRS total, positive, and anxiety-depression scores improved comparablyin both groups. The Olz+Amt group had greater improvement inMADRS total score compared with the Olz+Plc group. There were noclinically meaningful between-group differences in safety parameters.In conclusion, amantadine was safe, well-tolerated, and promotedweight loss or attenuated weight gain in patients who had gainedweight during olanzapine therapy.PO1.70.QUETIAPINE REGULATES FGF-2 AND BDNFEXPRESSION IN RAT HIPPOCAMPUSF. Fumagalli, R. Molteni, F. Bedogni, G. Racagni, M.A. RivaCenter of Neuropharmacology, Department of PharmacologicalSciences, University of Milan, ItalySynaptic mechanisms involved in neuroplasticity are characterised bythe interplay of several factors, including neurotrophic molecules,and recent findings suggest that these molecules represent likely therapeutictargets for psychotropic drugs, including antidepressants,mood stabilisers and antipsychotics. Of the neurotrophic molecules,brain-derived neurotrophic factor (BDNF) and fibroblast growth factor-2(FGF-2) are factors widely distributed in the adult brain. Thesemolecules play an important role in the maintenance of neurons inresponse to cell injury and also participate in neuronal remodelingand cellular resiliency. Our hypothesis is that the impact of antipsychotictreatment on neuronal plasticity depends on the pathologicalcondition of the substrate. To achieve this, we used the N-methyl-Daspartate(NMDA) receptor antagonist MK-801 to simulate the neurotransmissiondeficits encountered in schizophrenia. Furthermore,we compared quetiapine with a conventional antipsychotic, haloperidol,in order to establish differences in these mechanisms that mayreflect therapeutic features of these drugs. Our findings show thatadministration of the atypical antipsychotic quetiapine resulted in amarked elevation of FGF-2 and BDNF mRNA levels in the rat hippocampus,but only under reduced NMDA receptor activity. Theseeffects were drug-specific, given that they were not observed with theconventional antipsychotic haloperidol; and anatomically defined,since no similar effect was observed in striatum, prefrontal or frontalcortex. In conclusion, these results suggest that quetiapine may promoteneuroplasticity via the up-regulation of neurotrophic factorswhen NMDA-mediated transmission is perturbed.PO1.71.QUETIAPINE IN SCHIZOPHRENIA-MOODDISORDER COMORBIDITYM.L. Manzone, O. Gambini, R. Muffatti, S. ScaroneDepartment of Mental Health, San Paolo Hospital, Milan, ItalyThis study reports on two patients affected from paranoid schizophrenia,with intercritical residual symptoms, associated with depressivedisorder, intra-psychotic depression and non-major depression(DSM-IV-TR). The assessment instruments were the Brief PsychiatricRating Scale and the Hamilton Rating Scales for Anxiety and Depression.Monotherapy with quetiapine (600 and 800 mg/day) proved tobe effective both on psychotic productivity (anomalies of thought,perception, behaviour) and on affective symptoms (anxiety anddepression). The tolerability was good. Quetiapine monotherapyproved to be more effective than all other previous therapies (typicaland atypical antipsychotic drugs).PO1.72.INDICATIONS AND OUTCOME OF THE USEOF QUETIAPINE IN UNIVERSITY MALAYAMEDICAL CENTRES.T. Jambunathan, S.G. Jesjeet, C.C. LowUniversity Malaya Medical Centre, Kuala Lumpur, MalaysiaAtypical antipsychotics are now preferred for use in schizophrenia andother psychotic disorders worldwide. However, guidelines for the prescriptionof these new drugs are lacking. The aims of this naturalisticstudy were: a) to assess the prescribing philosophies of doctors in UniversityMalaya Medical Centre, b) to come up with proper guidelineswhen introducing a new drug. The first 68 patients put on quetiapinewere included in the study. This study showed that there was prematurediscontinuation of the drug in 15 patients. Nine patients experiencedvarious side effects, including somnolence, rash, palpitations,chocking and in one case anaphylactic shock. Generally quetiapinewas well tolerated. However, haphazard introduction and the lack ofa follow-up plan led to the inappropriate discontinuation in manycases. The use of easily available samples also lead to the mismanagementof patients. The findings are discussed critically and a protocol issuggested based on the findings. The need for stringent guidelines fordetailed assessment and follow-up plans is emphasized.PO1.73.EFFECT OF THE SWITCH FROM HALOPERIDOL TOQUETIAPINE ON NUMBER OF HOSPITALIZATIONSAND COGNITIVE PERFORMANCEA. De Giorgi 1,2 , A. Petito 1 , C. Cammeo 1 , A. Papazacharias 1 ,A. Bellomo 1,21 Department of Medical and Labour Sciences, University ofFoggia; 2 Department of Mental Health, Local Health Unit 3,Foggia, ItalyThe aim of this study was to evaluate the impact of the atypical antipsychoticquetiapine on the number of hospitalizations, severity of the diseaseand cognitive performance in patients with serious psychotic disorders(high frequency of hospitalization/year). Six patients (males;215

mean age: 38±7 years) with a schizophrenic disorder, paranoid type(DSM-IV-TR), currently undergoing a treatment with haloperidoldecanoate (100-200 mg every 20-30 days), were switched to quetiapine(600-1000 mg/day, triple daily administration). The two therapeuticregimens were compared in terms of number of hospitalisations. Moreover,the Clinical Global Impression (CGI) Severity scores at T0 (timeof switch) and T1 (one year from T0) were compared, together with theWechsler Adult Intelligence Scale (WAIS) scores for performancescales. We found a reduction in the number of hospitalisations and theseverity of the disease and an improvement of cognitive performanceafter one year following the switch to quetiapine. No patient discontinuedthe treatment due to adverse events. The most frequent side effectreported was sedation.PO1.74.QUETIAPINE IN ACUTE PSYCHOSIS ANDPERSONALITY DISORDERS DURINGHOSPITALIZATION: ASSESSMENT OFTHERAPEUTIC RANGEM.C. Mauri, A. Fiorentini, L.S. Volonteri, S. Beraldo,B. Dell’Osso, I. Valli, R. Pirola, S.R. BareggiPsychiatric Clinic and Department of Pharmacology,University of Milan, ItalyOptimizing the clinical effectiveness of atypical antipsychotics whileminimizing side effects in the acute setting is the major goal of treatingfacilities. Further, even though the need for accurate doseresponse data is critical, very few are available. In particular, datafrom studies on the plasma concentration-response relationship canbe very useful. Thirty-seven inpatients, 31 males and 6 females, affectedby schizophrenia and cluster B personality disorders (DSM-IV criteria),age ranging from 18 to 71 years (mean 37.7±13.2 years) wereincluded in the study. After a wash-out period of at least 2 weeks,patients were given 250 to 800 mg/day of quetiapine (QTP) (mean570.7±154.4 mg), on the basis of clinical judgement, for 2 weeks.Patients were evaluated at baseline (T0) and after 15 days (T1) bymeans of the Brief Psychiatric Rating Scale (BPRS), the Positive andNegative Syndrome Scale (PANSS), the Hamilton Rating Scale forDepression (HRS-D), the Simpson and Angus Scale for ExtrapyramidalSide Effects (EPSE) and a checklist for Anticholinergic SideEffects (ACS). QTP plasma levels were determined at T1 by highpressureliquid chromatography. Psychotic symptoms showed a significantimprovement (p

score for aripiprazole-treated patients was 17.4±8.16 compared to22.2±8.67 for those receiving atypicals (p25kg/m 2 ); 2) hypertriglyceridaemia (≥15% increase,≥150 mg/dl); 3) low high density lipoproteins (≥15% decrease,

outcome measure was the proportion of patients experiencing significantweight gain (≥7% increase) from baseline to endpoint. Throughoutthe study period, significantly more patients receiving olanzapineexperienced significant weight gain (≥7% increase) than those receivingaripiprazole. Mean changes in body weight differed significantlybetween the groups at weeks 6 and 26. At week 26, there was a meanweight gain of 4.23 kg with olanzapine treatment compared with amean weight loss of 1.37 kg with aripiprazole treatment (p

ness included the Clinical Global Impression - Improvement scale(CGI-I) and Preference of Medication Scale (POMS). At study endpoint,the mean aripiprazole dose was 19.9 mg/day, with 47% ofpatients receiving the 15 mg dose. The effectiveness of aripiprazolewas demonstrated as early as week 1. Among patients completing thestudy, 69% of those in the aripiprazole group responded to treatment(CGI-I score of 1 or 2) with a mean CGI-I score of 2.17. Over 60% ofaripiprazole-treated patients and 54% of caregivers rated aripiprazoleas much better than prior antipsychotic therapy (score of 1). The onlyadverse events reported with aripiprazole treatment with an incidenceof 10% or above were nausea (14%) and insomnia (20%). In conclusion,aripiprazole demonstrated overall effectiveness in patients withschizophrenia and schizoaffective disorder in a general psychiatric setting.PO1.84.GUANOSINE-5'-O-(3-[35S]THIO)-TRIPHOSPHATEBINDING ASSAYS CAN BE INSENSITIVE INDETECTING D2 PARTIAL AGONIST DRUG ACTIVITYS. Jordan 1 , R. Chen 1 , J. Johnson 1 , K. Regardie 1 , R. Whitehead 1 ,Y. Tadori 2 , R. McQuade 3 , T. Kikuchi 21 Otsuka Maryland Research Institute, Rockville, MD, USA;2 Otsuka Pharmaceutical Co. Ltd., Tokushima, Japan; 3 Bristol-Myers Squibb Company, Princeton, NJ, USAThis study investigated whether D2 receptor partial agonist activitycould be detected for aripiprazole, its close structural analogue OPC-4392, a series of atypical antipsychotics, and the reference D2 partialagonists, (–)3-PPP and (+)terguride, in a [35S]GTPγS binding assayusing membranes expressing cloned human D2Long receptors (CHOhD2L).These drugs were also profiled in the same CHO-hD2L cellline using Flashplate® adenylate cyclase (AC) and [3H]arachidonicacid release (AA) assays. The resultant estimates of drug potency andrelative intrinsic activity (RIA) were compared between assays. Aripiprazolewas inactive in the [35S]GTPγS binding assay, although itbehaved as a potent, partial agonist in its inhibition of AC activity(pEC50 8.36±0.54; Emax 10.6±2.0%, relative to 10 µM dopamine) andstimulation of AA release (pEC50 8.13±0.23; Emax 32.4±2.9%).(+)Terguride, (–)3-PPP, and OPC-4392 displayed partial agonist activitiesin all three assays, and, in common with aripiprazole, the RIA ofeach compound was higher in the AA > AC > [35S]GTPγS bindingassay. In contrast, haloperidol, olanzapine, ziprasidone and clozapinewere inactive in all three assays. These results demonstrate that aripiprazole,unlike the other antipsychotics tested, behaved as a partialagonist at cloned human D2L receptors, although this property wasundetectable in a [35S]GTPγS binding assay that was nearly insensitiveto the reference D2 partial agonists (+)terguride and (–)3-PPP.Attempts to identify novel D2L partial agonist therapeutics may benefitfrom adopting multiple in vitro functional assays to minimise theoccurrence of false negatives that may arise due to agonist directedtrafficking.PO1.85.SHORT-TERM ARIPIPRAZOLE TREATMENTIN SCHIZOPHRENIA: EFFECTIVENESSAGAINST DEPRESSION, ANXIETY, ANDHOSTILITY SYMPTOMSR. Gismondi 1 , D. Kostic 2 , W. Carson 3 , D.G. Archibald 4 ,G. Manos 4 , J. Stringfellow 4 , S. Hardy 4 , E. Stock 2 , T. Iwamoto 51 Bristol-Myers Squibb, Rome, Italy; 2 Bristol-Myers SquibbCompany, Princeton, NJ, USA; 3 Otsuka America PharmaceuticalInc., Princeton, NJ, USA; 4 Bristol-Myers Squibb Company,Wallingford, CT, USA; 5 Otsuka Pharmaceutical Co. Ltd., Tokyo,JapanWe aimed to examine the short-term effects of aripiprazole on thesymptoms of depression, anxiety and hostility associated with schizophrenia.This analysis used pooled data from five 4- to 6-week double-blindstudies of aripiprazole in patients with schizophrenia orschizoaffective disorder. Depression/anxiety and excitement/hostilitysymptom clusters were determined using factor analysis of Positiveand Negative Syndrome Scale (PANSS) scores. Changes in factorscores were compared in patients treated with aripiprazole (n=885)and those receiving placebo (n=405). The same analysis was also performedon data from the two fixed-dose trials that included haloperidolas an active control. The mean reduction in PANSS depression/anxietyfactor was significantly greater with aripiprazole thanplacebo (p=0.001). The effect was particularly pronounced in patientswith baseline scores above the median value (–3.15 vs. –1.88,p

mg/dL and -1.24 mg/dL, respectively; p=0.01). Mean CHD risk inmen increased by 0.8% (baseline 4.2%) with olanzapine (n=55) anddecreased by 0.2% (baseline 4.5%) with ziprasidone (n=46) (p

tinuations, and adjunctive medications. Overall, subjects initiatingziprasidone at 80 mg/d demonstrated improved outcomes comparedwith subjects initiating therapy at 40 mg/d. Improved efficacy wasindicated by greater reductions in Brief Psychiatric Rating Scale(BPRS) total scores at week 1 and endpoint, and significantly lowerrates of discontinuation from lack of efficacy at week 1 (1.3% vs.4.1%, respectively; p

PO1.94.QTc VARIABILITY IN SCHIZOPHRENIAPATIENTS TREATED WITH ANTIPSYCHOTICSAND HEALTHY CONTROLSM.A. Rettenbacher 1 , U. Eder-Ischia 1 , A. Bader 2 , M. Edlinger 1 ,A. Hofer 1 , M. Hummer 1 , G. Kemmler 3 , E.M. Weiss 1 ,M. Hochleitner 2 , W.W. Fleischhacker 11 Department of Biological Psychiatry; 2 Department of InternalMedicine; 3 Department of General Psychiatry, Medical UniversityInnsbruck, AustriaQTc prolongation is associated with the administration of someantipsychotics, but the QTc interval is also known to vary physiologically.There is little published evidence about changes in QTc variabilityduring treatment with antipsychotics. In this prospectiveinvestigation, we analysed electrocardiograms (ECGs) in 61 patientssuffering from a schizophrenic disorder who were treated with differentantipsychotics and 31 sex and age matched healthy controls. Wefound no differences in QTc intervals nor in QTc variability betweenpatients and controls. Our results raise the question of the clinical relevanceof a single ECG for diagnostics of cardiac complications inschizophrenia patients and suggest the need to conduct ECG monitoringin patients at high risk for cardiac complications duringantipsychotic treatment.PO1.95.CLOZAPINE INDUCED MYOCARDITIS ISRELATED TO EOSINOPHILIC REACTION INMYOCARDIAL TISSUEF. Cocchi 1 , R. Cavallaro 1 , D. Cianflone 2 , M. Frustaci 3 ,M. Pieroni 2 , E. Smeraldi 11 Department of Neuropsychiatric Sciences and 2 Cardio-Thoracicand Vascular Department, Vita Salute San Raffaele University,Milan; 3 Cardiology Department, Catholic University, Rome, ItalyClozapine use is mostly limited by the well-known agranulocytosisrisk, but it has been also associated with more rare (and less known)but similarly unpredictable and severe cardiovascular side effects,related to sudden death. Both dilated cardiomyopathy and myocarditis,as a result of direct toxicity and drug hypersensitivity, respectively,have been described at autopsy. We report a case of a 27-years-oldchronic schizophrenic man (DSM-IV criteria), resistant and intolerantto neuroleptic drugs, treated with clozapine 250 mg/day who,after 12 days of treatment, developed a persistent fever (38.5°C) associatedwith pharingodynia and neutrophilic leukocytosis. Within 72hours the clinical picture worsened, with severe malaise and dyspnea,while chest radiogram showed a slight enlargement of cardiac silhouette.A clozapine-related myocarditis or an acute viral myocarditis followinga throat infection was then suspected and, consequently,clozapine was withdrawn. After transfer to the cardiologic semiintensivecare unit, it was possible to diagnose ‘in vivo’, throughendomyocardial biopsy, a hypersensitivity, eosinophilic myocarditissecondary to clozapine administration. Steroids treatment resolvedsuccessfully the clinical picture.PO1.96.CHANGES IN BODY WEIGHT AND BLOOD SUGAR INPATIENTS RECEIVING ATYPICAL ANTIPSYCHOTICSM. Ochiai, H. Misawa, Y. Hamazaki, F. MiyagiSagami Hospital, Kanagawa, JapanAtypical antipsychotic agents are becoming important in clinical psychiatry.They are as effective as classical antipsychotic agents on positivesymptoms of schizophrenia and some evidence suggests thatthey are more effective than those older drugs on negative symptoms.Moreover, they are less likely to produce extrapyramidal side effects.Concerns have been raised, however, about weight gain andincreased blood sugar which may be induced in some patients bysome of these agents. We studied for one year 11 patients (5 males, 6females), receiving either olanzapine or quetiapine in one of our psychiatrichospitals. We found a tendency of patients receiving olanzapineto gain weight, while patients receiving quetiapine tended to loseweight. A further follow-up and an extension of the sample are neededto take any conclusion.PO1.97.VALPROATE AUGMENTATION TO CLOZAPINE INTREATMENT RESISTANT SCHIZOPHRENIAÖ. Öztürk, D. Eraslan, B. Kayahan, B. VeznedarogluEge University Medical School, Department of Psychiatry,Izmir, TurkeyNeuroleptic resistant patients comprise 5 to 25% of all patients withschizophrenia. Clozapine can help attain response in 60% of neurolepticresistant patients, but some still cannot reach an acceptabledegree of remission, even when sufficient dosage is used for as long assix months. In such cases, supplemental agents such as valproateshould be tried. Although there has been concern about the druginteractions between clozapine and valproate, a chart study showedthat the combination is safe and efficacious. Valproate as augmentationtreatment to antipsychotics has been found beneficial in reducingpositive and negative symptoms in schizophrenic patients, but nostudy has been made on the long-term outcome of patients usingclozapine-valproate combination. In this study, the charts of 37 schizophrenicpatients who had been given supplementary valproate dueto insufficient response to clozapine were investigated. The patientswere evaluated using the Positive and Negative Syndrome Scale, theGlobal Assessment of Functioning and the Clinical Global Impression.The mean total scores on these scales showed a significantimprovement. No serious side effects, like agranulocytosis, occurred.Sedation was the most common complaint. In conclusion, valproatecan be considered as an augmentation therapy in clozapine resistantschizophrenia patients, but cautious monitoring of side effects is necessary.PO1.98.WHAT ARE THE INDICATIONS FOR I.M.ADMINISTRATION OF PSYCHOTROPICSIN EMERGENCY PSYCHIATRY?R. Teijeiro, D. WesterkampZwolse Poort Psychiatric Hospital, Raalte, The NetherlandsThe study aimed to investigate the indications for i.m. administrationof psychotropics in emergency psychiatry and to analyze the influenceof compulsory treatment, nationality and sex. It was an observationaltrial during 13 months, using a standardized questionnaire.Among a total of 193 admitted patients, 36 were administered i.m.222 World Psychiatry 3:S1 - October 2004

psychotropics (zuclopenthixol acetate or haloperidol + clorazepateor lorazepam). 24 patients of the total schizophrenia and other psychosispopulation (n=95) and 8 patients of the total mood disorderpopulation (n=19) were administered i.m. psychotropics. Of the totalsample of patients diagnosed with schizophrenia and schizoaffectivedisorders (n=64) there were 5 patients who were administered i.m.medication. From the total sample of patients diagnosed with druginducedpsychosis (n=14), there were 10 patients who were administeredi.m. medication. I.m. medication was administered to 6 out of104 patients admitted voluntarily, and to 30 out of 89 patients admittedcompulsorily. Among patients with dual diagnosis (psychiatricdisorder and substance abuse) (n=6), there were 4 patients who wereadministered i.m. medication. Apparently, there are no clear indicationsfor administering i.m. medication. It seems that patients withserious psychiatric conditions, with marked agitation and/or violence,sometimes related to drug abuse, tend to be eligible for i.m.medication in acute situations at an emergency service. Althoughmost patients administered i.m. medication are in the category of‘schizophrenia and other psychosis’, the clinical reasoning behindi.m. administration of psychotropics is not consistent.PO1.99.COMPARING THE EFFECTS OF RISPERIDONEAND HALOPERIDOL IN CHRONIC SCHIZOPHRENICPATIENTSE. Abdollahian, F. Mohareri, B. ZandiUniversity of Medical Sciences, Mashhad, IranThis study aimed to evaluate cognitive improvement in chronic schizophrenicpatients treated with risperidone or haloperidol. In a doubleblindclinical trial, 65 inpatients with DSM-IV chronic schizophreniawere randomly assigned for a treatment course of 8 weeks to eitherrisperidone (4-6 mg/day) or haloperidol (10-15 mg/day). Before, duringand after the treatment course, patients were examined by the Positiveand Negative Syndrome Scale (PANSS) and the Wisconsin Card SortingTest (WCST). On the total PANSS score and the positive and negativesubscales, risperidone was significantly superior to haloperidol. Thesame results were obtained using the Brief Psychiatric Rating Scale.Haloperidol produced significantly more parkinsonism than risperidone.Risperidone displayed an antidyskinetic effect. Risperidone wassignificantly better than haloperidol in reducing perseveration errors onWCST after 8 weeks. These data suggest that risperidone, at the optimaltherapeutic doses of 4-6 mg/day, produces significant improvement inboth positive and negative symptoms without an increase in druginduced parkinsonism and with a significant beneficial effect on tardivedyskinesia. Moreover, it produces some cognitive improvement.PO1.100.COMPARING THE EFFECT OF ATYPICAL ANDCONVENTIONAL ANTIPSYCHOTICS ON BLOODGLUCOSE IN SCHIZOPHRENIC PATIENTSE. Abdollahian, M.R. Amini, A. KhorramUniversity of Medical Sciences, Mashhad, IranThis study aimed to compare the effects of different antipsychotics onglucoregulation in schizophrenic patients. 81 inpatients with thediagnosis of schizophrenia, 43 receiving conventional antipsychoticsand 38 treated with atypical antipsychotics, underwent glucose tolerancetest. The effect of atypical antipsychotics on the first hour glucoselevel was marked (p=0.07). The effect was more pronounced inpatients receiving clozapine than in those receiving conventionalantipsychotics (p=0.06). There was a significant relation between theduration of illness and fasting blood glucose and first hour glucoselevel. Also, there was a significant relation between age and bloodglucose level. These data suggest that atypical antipsychotics have agreater effect on blood glucose level than conventional drugs.PO1.101.OLANZAPINE: DOES IT CONTROL CRAVINGFOR COCAINE?M. RigliettaAddictive Behaviour Centre, Bergamo, ItalySome studies have reported the efficacy of olanzapine in the treatmentof craving in cocaine addicts. We are presenting two case reports confirmingthat. The first patient was male, aged 29, and began using nicotineand alcohol when he was 15. He then moved on to cannabis, andwhen he was 18, stimulants like ecstasy and cocaine. When he arrivedat our centre he had been using 3-4 g of cocaine per day, 3-4 times aweek for three months. The evaluation was carried out using a visualanalogical scale (VAS) for craving (6.4 out of 10 for craving intensityand 4.3 for craving frequency), the Short Check List 90-R (SCL-90-R)(negative), the Hamilton anxiety and depression scales (negative). Hestarted with 10 mg olanzapine daily. After two weeks, urine samplescollected under supervision resulted negative for cocaine metabolites.After one month he felt better and VAS was lower than before (2.3 forintensity and 1.5 for frequency). Therapy was discontinued after threemonths, and follow-up tests resulted negative for three more months.The second patient was male, aged 36, HIV-seropositive. He has beenattending our centre since 1989 due to heroin addiction. In 1992 hebegan methadone treatment, stopped using heroin and improved hissocial functionality. In 2000, due to deep depression, he began usingcocaine i.v., soon arriving at 5 g per day. Because of the presence ofparanoid delusions, olanzapine was prescribed at 20 mg per day. After15 days, delusions disappeared and cocaine use stopped. The patientreported a significant reduction in craving.PO1.102.A NATURALISTIC STUDY OF THE TOLERABILITYOF NEW ANTIPSYCHOTICSG. De Mattia, M. De Felice, R. Marseglia, A. Raucci,G. Raucci, A. RossiMental Health Centre, Local Health Unit 2, Caserta, ItalyData from 24 patients out of 280 in treatment with atypical antipsychoticdrugs (olanzapine, clozapine, risperidone and quetiapine), notselected for pathology, attending a mental health centre have beencollected during this study. The patients have been monitored for 9months (once a month for the first six months and afterwards everythree months). The tolerability has been estimated by means of aschedule covering extrapyramidal symptoms (EPS), weight, andresults of routine laboratory tests. The subjective attitude to treatmentwith atypical antipsychotic drugs was estimated with a specific questionnaire,the Drug Attitude Inventory (DAI-10) at baseline and afternine months of treatment. The EPS incidence has been significantlylower in the patients receiving clozapine and quetiapine, whilerisperidone and olanzapine are characterized by a dependent doseincrease in EPS. The levels of prolactin were higher in patients receivingrisperidone. Concerning weight gain and hyperglycemia, quetiapinehad a more favourable profile. Somnolence and sedation, especiallyat the beginning of treatment, were more frequent in the grouptreated with quetiapine and clozapine.223

PO1.103.DIFFERENT EFFECTIVENESS OF VARIOUSANTIPSYCHOTICS IN TREATING PSYCHOTICSYMPTOMSR. Keller, F. Vischia, G. Iannoccari, P. Vaccarino, E. PirfoDepartment of Mental Health, Local Health Unit 3, Turin, ItalyEven if new antipsychotics (risperidone, olanzapine, quetiapine,clozapine) were initially compared with haloperidol as a group ofdrugs, now we clinically observe differences in effectiveness amongthese drugs not only in indications for categorical diagnosis but alsoin specificity for psychotic dimensions. To assess dimensional andcategorical differences among antipsychotics we observed the inpatientsadmitted for psychosis in our Psychiatric Unit. All inpatientswere included but not those treated before admission with long-actingantipsychotics. At the moment of admission (T0), patients weretested with the Brief Psychiatric Rating Scale (BPRS), the Scale forAssessment of Positive Symptoms (SAPS), the Scale for Assessmentof Negative Symptoms (SANS), medical examination, and routinelaboratory tests. At the moment of discharge (T1), they were testedwith BPRS, SAPS, SANS, medical examination, Clinical GlobalImpression (CGI) and Dosage Record Treatment Emergent SymptomScale (DOTES). We used risperidone, olanzapine, quetiapine, clozapineor haloperidol. All inpatients improved at T1. We did notobserve any side effect as important as requiring the change of thedrug. Dimensional differences in effectiveness (T1-T0 in BPRS, SAPSand SANS) indicate the following results. Haloperidol (29 inpatients)had a greater effect on hallucinations, delusions and paranoid projection.Quetiapine (17 inpatients) had a greater effect on affective flattening,alogia and retardation. Risperidone (27 inpatients) had agreater effect on behavioral symptoms, distortion in language andcommunication, anxiety, hostility and grandiosity. Olanzapine (22inpatients) had a greater effect on depressed mood, suicidal ideation,feelings of guilt, bizarre behavior, disorientation, hostile belligerance,stereotyped behavior. Clozapine (4 inpatients) had a greater effect onanhedonia, attentional impairment, expansive mood, bizarrethoughts, conceptual disorganization, social withdrawal, excitement,distractibility.PO1.104.EFFECTS OF SWITCH FROM LONG-ACTINGHALOPERIDOL TO ORAL OLANZAPINEM. AlessandriniG. D’Annunzio University and Center of Mental Health,Chieti, ItalyWe studied 20 patients with a DSM-IV diagnosis of schizophrenia (14males and 6 females, age range 30-65 years, mean 45.2 years) who hadbeen receiving for at least two years long-acting haloperidol (50-150mg, mean 82.5 mg, at intervals of 15-30 days, mean 21.9 days). In allthese patients, olanzapine (5 mg/day per os) was added to haloperidolfor 20 days. Then haloperidol was discontinued and olanzapine15 mg/day was administered for three months. The Minnesota MultiphasicPersonality Inventory (MMPI) was administered one weekbefore starting olanzapine treatment and at the end of the trial. Bodyweight has been measured and routine laboratory tests have been performedat the same time points. We found a significant reduction inthe scores on the scales SC (schizophrenia), PA (paranoia), PT (psychoasthenia),D (depression), SI (social introversion) and HS(hypochondriasis) at the second time point compared with the firstone. Weight gain was observed in 7 patients (mean 2 kg). No significantchanges have been observed in the glycemic and lipidic profiles.PO1.105.OFF-LABEL INDICATIONS FOR ATYPICALANTIPSYCHOTICS: A SYSTEMATIC REVIEWK.N. Fountoulakis, I. Nimatoudis, A. Iacovides, G.S. Kaprinis3rd and 2nd Department of Psychiatry, Aristotle University ofThessaloniki, GreeceWith the introduction of newer atypical antipsychotic agents, a questionemerged, concerning their use as complementary pharmacotherapyor even as monotherapy in mental disorders other than psychosis.MEDLINE was searched with the combination of each one ofthe key words risperidone, olanzapine and quetiapine with key wordsthat referred to every DSM-IV diagnosis other than schizophreniaand other psychotic disorders, bipolar disorder and dementia andmemory disorders. All papers were scored on the basis of the Jadadindex. The search returned 483 papers. The selection process restrictedthe sample to 59 papers concerning risperidone, 37 concerningolanzapine and 4 concerning quetiapine. Ten papers (7 concerningrisperidone and 3 concerning olanzapine) had a Jadad index above 2.Data suggest that further research would be of value concerning theuse of risperidone in the treatment of refractory obsessive-compulsivedisorder, pervasive developmental disorder, stuttering and Tourette’ssyndrome, and the use of olanzapine for the treatment of refractorydepression and borderline personality disorder.PO1.106.USE OF QUETIAPINE IN SCHIZOTYPALPERSONALITY DISORDER ASSOCIATED WITHTRANSIENT PSYCHOTIC FEATURESE. D'AntonioCentre for Psychiatric Diagnosis and Treatment, Local HealthUnit 7, Conegliano Veneto, Treviso, ItalyThis study is aimed at describing the case of a patient with a schizotypalpersonality disorder associated with transient psychotic features,successfully treated with quetiapine. He is 39 years of age and liveswith his mother, a past alcoholic. His youth was marked by drugaddiction and delinquent behaviours (he also spent some months inprison). Over the last few years, he has undergone several hospitalisationsin psychiatric units because of psychotic decompensations,depressive episodes, and two attempts of suicide. The index “transientpsychotic episode” determined his hospitalisation at our centre. Heappeared restless, with ideas of reference, and hallucinated. Heattacked his mother, driving her away from home. In the psychiatricward, he was sullen and solitary during the first few days; he started aquetiapine therapy with titration over five days (from 200 to 800mg/day), combined with carbamazepine (600 mg/day) and lorazepam(7.5 mg/day). After a few days, the patient improved: he became selfcriticalabout the circumstances that had led to hospitalisation andenjoyed communicating with the staff; reference and persecution ideasdisappeared. He was discharged after two weeks. The potential use ofquetiapine to treat personality disorders seems to be quite interesting.224 World Psychiatry 3:S1 - October 2004

PO1.107.QUETIAPINE IN COMBINATION WITH SELECTIVESEROTONIN REUPTAKE INHIBITORS INREFRACTORY OBSESSIVE-COMPULSIVEDISORDERM. CupillariDepartment of Mental Health, Local Health Unit, L’Aquila, ItalyThis study evaluates the efficacy of combining quetiapine, an effectiveand well-tolerated atypical antipsychotic, with a selective serotoninreuptake inhibitor (SSRI) in patients with obsessive-compulsive disorders(OCD) who did not respond to SSRI monotherapy. Tenpatients (mean age 45.7±9.06 years) with refractory OCD (DSM-IVcriteria), unresponsive to treatment with SSRI monotherapy (paroxetine,sertraline, clomipramine), received quetiapine combinationtherapy for 3 months. Efficacy was measured using the Yale-BrownObsessive-Compulsive Scale (YBOCS) and the Clinical GlobalImpression (CGI) scale every 6 weeks. Patients were treated with aninitial dose of quetiapine 50 mg/day, which was increased to a maximumof 300 mg/day by week 4. All patients responded to quetiapineadministration (mean dose 205±43.78 mg/day). The mean YBOCSscore decreased from 24.3±1.49 at baseline to 18.5±1.84 after 6 weeksand 14.5±1.5 after 3 months, with a mean reduction at endpoint of39.8%. Quetiapine, an atypical antipsychotic with placebo-likeextrapyramidal side effects, in combination with an SSRI is effectiveand well tolerated in patients with refractory OCD. This preliminarystudy suggests that this regimen could be a useful alternative for thetreatment of patients with refractory OCD.PO1.108.QUETIAPINE IN A CASE OF TREATMENTREFRACTORY PARANOID SCHIZOPHRENIAM. Alessandra, V. Cordovana, C. Gugliotta, H. Ismail,C. Mangano, S. Tortorici, V. ManganoLocal Health Unit 6, Termini Imerese, Palermo, ItalyThis study aimed at verifying the effectiveness of quetiapine in thelong-term treatment of a patient affected by paranoid schizophreniawho had already undergone treatments based on other typical andatypical antipsychotic drugs, with unsatisfactory results. The patientwas 18 years old and had a positive family history for mental disorders.He suffered from serious disorders in the contents of thought, ideas ofpersecution, and imperative auditory hallucinations with suicideattempts. He had developed extrapyramidal effects induced by neurolepticdrugs, and risperidone-induced hyperprolactinaemia andweight gain. We started quetiapine at a dosage of 400 mg/day, withrapid increases, until reaching 1800 mg (subsequently reduced to 1200mg). We reached the above dosages over a few days (considering thathospitalisation lasted for 14 days). Haloperidol and diazepam werecombined with quetiapine during the initial phase but were discontinuedas soon as the best therapeutic dosage of quetiapine was reached.In addition to the reduction of productive symptoms and the absenceof side effects (except for an initial sedative action), we also recordeda good recovery of the cognitive functions and of the relational, affective,and planning abilities (as rated by Global Assessment of Functioning).PO1.109.SAFETY OF RAPID TITRATION OF QUETIAPINEIN ACUTE PSYCHOTIC PATIENTSA. Russo, E.M. Troisi, F. FioreLocal Health Unit 2, Avellino, ItalyThis study aims at assessing the safety of rapid titration of quetiapinereaching the minimum therapeutic dosage (600 mg) at the secondtreatment day in patients with acute psychosis. 25 patients (diagnosisof schizophrenia) were treated; safety and tolerability were assessedby means of clinical laboratory tests (the standard haematologicaland chemical analyses), echocardiogram and daily vital signs measurements.Only one patient reported an adverse event (a 30 mmblood pressure decrease). This experience shows that quetiapine is anextremely flexible and safe drug. Therefore, it can be a first-choicedrug even for acute phases.PO1.110.HOSPITALIZATIONS DURING THE FIRST YEAROF SCHIZOPHRENIA TREATMENT: THE IMPACTOF RISPERIDONE AND OLANZAPINET.M. SobowDepartment of Old Age Psychiatry and Psychotic Disorders,Medical University of Lodz, PolandRisperidone and olanzapine have been demonstrated to be efficaciousand safe in the treatment of schizophrenia. They also have beenshown, while usually better tolerated, to be at least equally effective toconventional antipsychotics. Hospitalization in first episode of schizophreniarepresents a major burden to patients and generates highcosts. In this retrospective study I compared hospitalization rateswithin a one year period in a group of 67 first-episode patients treatedwith risperidone, olanzapine or conventional antipsychotics. Fifteenpatients (55.6%) from the typical antipsychotics group (n=27)were admitted to the hospital within the first year following the indexobservation compared with 5 out of 21 patients treated with risperidone(23.8%; p=0.031) and 5 out of 19 with olanzapine (26.3%,p=0.049). The observed differences were explained mostly by noncomplianceand side effects, while other factors, including initialsymptoms severity (as measured by the Positive and Negative SyndromeScale, PANSS), initial response and social status were lessimportant. In conclusion, risperidone and olanzapine may decreasethe hospitalization rate and related costs in first-episode schizophrenia.Reduced risk of hospitalization within the first year of treatmentmight represent a major advantage considering patients’ burden andlong-term compliance.PO1.111.HORMONAL STATUS OF SCHIZOPHRENICPATIENTS DURING RISPERIDONE TREATMENTL.N. Gorobets, Y.A. Kochetkov, V.S. Bulanov, P.S. KomissarovResearch Institute of Psychiatry, Moscow, RussiaThe aim of the study was to investigate the hormonal status in patientsunder risperidone treatment. We examined 16 patients (8 men and 9women) with paranoid schizophrenia who received risperidone (4mg/day) for 3 weeks. Serum prolactin, testosterone, triiodothyronine,thyroxin, and thyroid-stimulating hormone (TSH) levels were estimatedusing an immune-enzyme method before and after 21 days of treatment.In male patients there was an increase in prolactin levels from343 to 1639 nmol/L (p

increased from 420 to 3150 nmol/L (p

was conducted weekly. After 3 weeks of olanzapine treatment, clinicalimprovement was registered in 67% of patients. The clinicalimprovement was manifest in the reduction of emotional tension, ofthe intensity of delusions and hallucinations, fear and isolation aswell as the increase of socially orientated activity. Clear signs ofincreasing awareness of mental disorder accompanied by positivelychanging attitude towards treatment were considered important.There was a substantial reduction on BPRS (p

PO1.121.ACUTE MASSIVE PULMONARYTHROMBOEMBOLISM ASSOCIATED WITHRISPERIDONE AND CONVENTIONALPHENOTHIAZINESY. Kamijo 1 , S. Hamanaka 2 , H. Miyaoka 21 Department of Emergency and Critical Care Medicine;2 Department of Psychiatry, School of Medicine,Kitasato University, Kanagawa, JapanThe study aimed to assess the contribution of antipsychotic medicationin patients suffering acute massive pulmonary thromboembolism.Records of patients with idiopathic pulmonary thromboembolismassociated with antipsychotic medication who were seen in aJapanese Emergency Center from January 1996 to December 2000were reviewed. Age, gender, physical status, clinical presentation,serum antiphospholipid antibody concentration, outcome, psychiatricprofile, and antipsychotic medication use were examined. Sevenpatients had acute pulmonary thromboembolism associated withantipsychotic drug use, representing 44% of all patients with idiopathicpulmonary thromboembolism. More women than men wereaffected. In five cases, chlorpromazine and other phenothiazines hadbeen prescribed, while in two cases risperidone had been taken for 40days and 6 days. In four cases, including the patients taking risperidone,antiphospholipid antibodies were not present. The data suggestthat patients receiving risperidone, as well as conventional phenothiazines,are at risk for acute pulmonary thromboembolism, even ifotherwise healthy.PO1.122.THE HISTOPATHOLOGICAL EFFECTS OFHALOPERIDOL ON CAROTID BODYN. Aydin 1 , M. Dumlu Aydin 2 , Ö. Sahin 3 , Z. Halici 41 Departments of Psychiatry, 2 Neurosurgery, 3 Pathology and4 Pharmacology, Medical Faculty, Atatürk University, TurkeyThe carotid body is a small cluster of chemoreceptive cells. It measureschanges in the composition of arterial blood flowing past it. It isthought to be able to measure changes in the partial pressures of oxygenand carbon dioxide and is also sensitive to changes in pH and temperature.Dopamine is one of the most prominent neurotransmittersfound in the type I cell of the carotid body. Ventilatory and carotidbody responses to hypoxia have been related to the endogenousrelease of dopamine. The aim of the study was to investigate thehistopathologic effects of haloperidol on carotid body. Twenty-fiveadult male rats were used. Rats were divided into 5 groups. Haloperidolwas given to rats in 0.5, 1, 2.5 and 5 mg/kg doses, intraperitoneally,for 10 weeks. For control animals, 1 ml of distilled water wasadministered. The ethic guidelines for animals were obeyed. We usedconventional histopathology and stereological methods to estimatethe number of neurons. We observed cellular degeneration, especiallyat high doses of haloperidol. The mean number of degenerated neuronswas significantly lower in low dose group than in high dose group(p

PO1.126.CEREBROSPINAL FLUID FILTRATION IN THERAPYRESISTANT SCHIZOPHRENIA OR AFFECTIVESPECTRUM PSYCHOSES: AN ONGOING OPENCLINICAL TRIALK. Bechter 1 , H. Tumani 2 , S. Herzog 3 , V. Schreiner 11 Department of Psychiatry II, University of Ulm; 2 Department ofNeurology, University of Ulm; 3 Institute of Virology, Justus-Liebig-University of Gießen, GermanyCerebrospinal fluid filtration (CSFF) has been shown to be as effectiveas plasma exchange to treat Guillain-Barré syndrome. In patientswith therapy resistant affective or schizophrenic spectrum psychosesshowing antibodies against Borna disease virus (BDV), CSFFappeared also to be effective in experimental studies. In an open clinicaltrial, approved by the Ethical Committee of the University ofUlm, BDV seropositive patients (n=10) with therapy resistant affectiveor schizophrenic psychoses were treated by CSFF. Clinical statuswas measured over months before and after filtration by the Brief PsychiatricRating Scale (BPRS), the Hamilton Rating Scale for Depression(HAMD), the Montgomery-Asberg Depression Rating Scale(MADRS) and the Short Check List 90-R (SCL-90-R). BDV antibodieswere measured by indirect immunofluorescence. CSF was analyzedrepeatedly (cells, proteins, oligoclonal IgG bands, peptides).Medication remained unchanged from 4 weeks before, during and for8 weeks after filtration. Filtration was performed by a lumbar catheterand automatic pump system, 300 ml CSF filtered daily over 5 consecutivedays. Two-thirds of patients improved, some dramatically, withfiltration. A role of inflammation in schizophrenia and affective spectrumpsychoses was suggested by previous findings and BDV seropositivepatients may represent such subgroup. Our findings may haveimpact for developing new immune modulatory treatments in therapyresistant psychosis.PO1.127.DYNAMIC EVENT-RELATED POTENTIALS ANDRAPID SOURCE ANALYSIS REVEAL ANINTERMITTENT SHORT-LASTING DYSFRONTALITYIN SCHIZOPHRENIAJ.A. González-Hernández 1 , I. Cedeño 1 , C. Pita-Alcorta 2 ,L. Diaz-Comas 3 , L. Galan 3 , P. Figueredo-Rodriguez 11 Department of Clinical Neurophysiology and Department ofPsychiatry, Hermanos Ameijeiras Hospital; 2 Department ofPsychiatry, Manuel Fajardo Hospital; 3 National Center ofNeuroscience, Havana, CubaNeuroimaging studies have identified regional brain dysfunctions inschizophrenia, but their dynamic consequences remain unclear. Thisstudy reports the electrophysiological evaluation of medicated schizophrenicpatients during performance of the Wisconsin Card SortingTest. Using event-related potentials (ERPs), averaged after passingthrough several band pass filters, and source analysis with variableresolutionbrain electrical tomography, cerebral sources were visualizedat every latency point of the evoked potential. ERPs which differedfrom the control group were elicited principally in frontal, central,and parietal regions, within the delta and theta frequency ranges.Significant differences emerged at three different latencies (S1, S2,S3) in frontal/midline areas and at the anterior temporal electrodesite T3 for slow potentials. The left occipitoparietal region showedsignificant differences within the alpha and beta2 ranges, respectively.Medial fronto-orbital area and anterior cingulate cortex contributedto the development of the frontal ERPs and the lateral inferiorfrontal area to the temporal (T3) ERPs, while the precuneus/medialregion generated the posterior activity recorded on the scalp. Theintervals S1 and S3 were synchronous between the medial frontal andlateral inferior frontal region, while in the S2 interval the medialfrontal areas were parallel with the precuneus/medial occipitotemporalregion. A simultaneous functional imbalance between frontal subregionsand posterior areas was found. Here, we show for the firsttime an intermittent functional deficiency of specific brain areas duringtask-directed mentation in schizophrenia, which by its brevity isnot accessible by neuroimaging methods measuring hemodynamicactivity.PO1.128.BRAIN OSCILLATIONS ANALYSIS INSCHIZOPHRENIA SUPPORTS THE PRIMACYOF THE VISUAL CORTEX DYSFUNCTION IN THEGENERAL PATHOLOGY OF THE ILLNESSJ.A. González-Hernández, C. Pita-Alcorta, I.R. CedeñoDepartment of Clinical Neurophysiology and Department ofPsychiatry, Hermanos Ameijeiras Hospital, Havana, CubaCurrent knowledge provides strong support for the assumption thatoscillations reflect a basic form of communication between corticalcell assemblies and during mental task activity in human. The associationof brain oscillation analysis with neuroimage technique (VARE-TA) highly improves the understanding of the complex spatiotemporalpattern “induced” and/or “evoked” during task performances.This design provides evidence that the synchronized networks overlapprofusely with one another, and indicate that a particular regioncan participate in more than one network. It involves both “induced”and “evoked” time-locked transient oscillations. This method facilitatesseparation of these simultaneous events by their inherent oscillationsand quantification of the distinctive frequencies characterizingthe local involvement with specific task. Brain oscillation synchronyindexes a form of “communication” between cellular networksduring ongoing mental task activity, while a flaw in neural connectivity(“cell communication”) rather than neuronal deficit mayaccount for the type of dysfunctions observed in schizophrenia.Therefore the study of brain oscillations in schizophrenia based uponthe promising results showed by the method combined with the connectivityhypothesis becomes an obligation. Similarities, rather thandifferences in “cell communication” appear to be a regularity in schizophreniaduring the Wisconsin Card Sorting Test. Differences ininduced oscillation may be explained by unusual visual informationprocessing, a function that is obviously not specific to the task. Additionalanalyses of the evoked oscillation confirm the previous results,uncovering an abnormal functional asymmetry in occipital areas andan intermittent short-lasting dysfrontality attributed mostly to dysfunctionin extrastriate visual areas.PO1.129.EVENT-RELATED POTENTIALS TOPOGRAPHY ANDCORTICAL SOURCE IMAGING IN SUBJECTS WITHDEFICIT AND NONDEFICIT SCHIZOPHRENIAE. Merlotti, U. Volpe, A. Mucci, P. Bucci, S. Galderisi, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalyDifferent electrophysiological abnormalities have been reported inpatients with deficit and nondeficit schizophrenia. In the presentstudy, event-related potentials (ERPs) recordings were obtained duringa three-tone oddball task in clinically stable patients with deficit229

(DS) and nondeficit schizophrenia (NDS) and matched healthy controlsubjects (HCS). DS and NDS patients were comparable for durationof illness and severity of disorganization and positive symptoms.The N100 component did not show amplitude differences amonggroups. A topographic abnormality (rightward shift of the negativearea) was observed in the DS group, as compared to both NDS andHCS. P300 amplitude was significantly reduced over the left posteriortemporal regions only in NDS patients vs. HCS; topographic P300abnormalities, including a posterior shift of the negative area and arightward shift of the positive area, were observed only in NDSpatients. Low-resolution brain electromagnetic tomography (LORE-TA) showed that, when compared to HCS, in DS patients, N100 currentsource density was reduced in the left cingulate while, in NDSsubjects, the reduction of the P300 current source density involvedtemporo-parietal regions of the left hemisphere. According to ourfindings, subjects with DS and those with NDS show a different patternof ERP abnormalities, which suggest different etiopathogeneticmechanisms.PO1.130.SERUM HOMOCYSTEINE, FOLATE LEVEL ANDMTHFR 677,1298 GENE POLYMORPHISM INKOREAN PATIENTS WITH SCHIZOPHRENIAY. Lee, C.M. Jun, C. NaDepartment of Neuropsychiatry, College of Medicine,Chung Ang University, Young San Hospital, Seoul, KoreaIt has been postulated that high homocysteine serum levels areinvolved in the pathogenesis of schizophrenia, and it has been reportedthat some schizophrenic patients with high homocysteine levelsimproved after folate ingestion. Methylenetetrahydrofolate reductase(MTHFR) is an enzyme that reduces homocysteine levels. Some studieshave reported a high incidence of MTHFR gene polymorphism inschizophrenia. We examined serum homocysteine, folate levels andMTHFR gene polymorphism in Korean schizophrenic patients. Wecompared serum homocysteine and folate levels between a schizophreniagroup (n=234; 99 male, 135 female) and a normal controlgroup (n=236; 101 male, 135 female). The C677T and A1298C mutationsin the MTHFR gene were analyzed by polymerase chain reactionof genomic DNA by using the primer pairs. Homocysteine levelswere significantly higher among schizophrenic patients than in thenormal control group (p

schizophrenic symptoms are the surface manifestations of a single,more fundamental, deficit of metarepresentation, that is, an inabilityto represent the nature of both our own and others’ mental states.This cognitive ability termed theory of mind (ToM), when dysfunctional,hampers an adequate social interaction. In the present, controlledstudy the relationships between anxiety disorder and socialcognition deficits were investigated. Two experiments were conducted.In experiment one, 183 normal adolescents were assessed withToM tasks and a State Trait Anxiety scale. Results showed that 25%of health adolescents have ToM deficits; moreover a significant correlationbetween trait anxiety and the ability to understand ToM storieswas reported. In experiment two, twenty-two young schizophrenicpatients characterized by a remarkable deficit in ToM tasks wereassessed for premorbid adjustment using the Premorbid AdjustmentScale in order to find out cognitive vulnerability traits, if any. Resultsshowed that in schizophrenic subjects presenting social isolation as aprodromal symptom, co-morbid anxiety (53%) and attention deficithyperactivity disorder (19%) frequently occurred. Our findings suggesta relationship between ToM abilities and anxiety disorder. Moreinterestingly, anxiety and ToM dysfunction seem to be associated inthe prodromal phase of illness, thus suggesting a possible commonneural basis. Further prospective studies are needed to clarify the roleof cognitive functioning in first-episode schizophrenic subjects andthe relationships with social and clinical variables, for possible implicationsrelated to treatment planning and outcome predictors.PO1.134.A PSYCHOPATHOLOGICAL STUDY OF MILDSCHIZOPHRENIA CHARACTERIZED BYWITHDRAWALY. Hamasaki 1,3 , H. Misawa 2 , F. Miyagi 11 Sagami Hospital, Kanagawa; 2 International Medical Center ofJapan, Tokyo; 3 National Institute of Mental Health of Japan,Tokyo, JapanIn recent years, the number of adolescents with the clinical manifestationcalled “withdrawal” has been constantly increasing in Japan. Wefrequently recognize that “withdrawal” may be an early stage of mildschizophrenia as well as of adjustment disorder, mood disorder, anxietydisorder or personality disorder. In these cases, patients often show variousphysical symptoms before or right after “withdrawal” begins. Inthis study, we applied Huber’s theory of “Grundstörung” by evaluatingthree patients with mild schizophrenia showing “withdrawal” andclaiming physical incompleteness. The “Grundstörung” mainly focuseson physical and psychosomatic symptoms such as asthenia, autonomicdisorder, paresthesia, lack of concentration and memory, etc., and isconsidered a direct expression of the organic cerebral change underlyingschizophrenia. Our three cases show that patients try to describetheir cognitive alteration. They usually refer to a physical incompletenessand tend to change their psychosomatic claims from time to time.PO1.135.ANOMALIES OF SUBJECTIVE EXPERIENCE INSIBLINGS OF PATIENTS WITH SCHIZOPHRENIAA. Raballo, C. MagginiPsychiatry Section, Neuroscience Department, University ofParma, ItalyAbnormal neuropsychological and cognitive functions in non-psychoticrelatives of schizophrenics are currently a subject of intenseinterest, mainly due to the reborn attention to the theoretical constructof schizotaxia. Contextually, in recent years the issue of subjectiveexperiences has once again become central in psychopathologicalresearch. Among self-experimental disturbances, basic symptoms(BS) are considered the first, protophatic, subjective reverberation ofthe neurobiological deficit of schizophrenia. Thus BS are expected tobe detectable in non-psychotic relatives of schizophrenia patients.The aim of the present study was to compare the prevalence of suchanomalous subjective experiences in siblings of schizophrenicpatients, schizophrenia spectrum patients (schizotypals and schizophrenics)and non-clinical controls. Different profiles of BS wereobtained in the samples. An increasing gradient of BS ranging fromnon-clinical to clinical samples, with unaffected siblings in the intermediateposition, occurred for some of the BS clusters (i.e., thought,language, perception and motor disturbances; impaired bodily sensations).Other BS clusters (i.e., disorders of emotion and affect;increases emotional reactivity) were characteristic of the clinical subgroups,whereas an enhanced tolerance to normal stress significantlydistinguished the sibling sample from the other ones. The heterogeneityof these patterns suggests that BS constellations may beunderpinned by different psychopathological processes and that cognitiveand bodily BS may be target clinical phenotypes for schizotropicliability screening.PO1.136.THE OUTCOME OF SCHIZOPHRENIA IN THECOMMUNITY: A FOUR-YEAR NATURALISTICPROSPECTIVE STUDYV. Di Michele, F. BolinoState Department of Mental Health, Pescara, ItalyFifty-five patients fulfilling both DSM-IV and ICD-10 criteria for eitherschizophrenia or schizoaffective disorder were assessed by the Positiveand Negative Syndrome Scale and the Life Skills Profile and subdividedinto three groups according to their symptomatology and functionscore. They were then treated as usual by their reference psychiatrist.Social and clinical outcome was assessed four years after the studyentry and analyzed according to the tripartite classification. Patientswith high symptom and function score at baseline were more dysfunctionaland tended to relapse more frequently (p=0.009 for hospitaladmission and p=0.0001 for compulsory admission). A diagnosis ofalcohol abuse was more frequent in this group (p=0.026). These findingswere confirmed by an additional survival analysis with comparisonof distributions (Wilcoxon Gehan test), that revealed differences forhospital admission (p=0.0013), compulsory admission (p=0.0002) andalcohol related diagnosis (p=0.038) among the three groups. A furthermembership analysis was conducted on the basis of antipsychotic regimen:results support the view that atypical antipsychotics are associatedwith lower rate of relapses and alcohol related diagnosis and superiorsocial functioning and quality of life. These data suggest that the tripartiteclassification based on symptom and function score is able topredict accurately the outcome in schizophrenia.PO1.137.PREVALENCE AND SEVERITY OF AKATHISIAAMONG ACUTE SCHIZOPHRENIC PATIENTSB.J. Havaki-Kontaxaki, V.P. KontaxakisDepartment of Psychiatry, University of Athens, EginitionHospital, Athens, GreeceThe introduction of atypical antipsychotics has raised expectations ofimproved outcomes for schizophrenic patients with fewer motor sideeffects. Acute schizophrenic patients receiving atypical antipsychotics(AA) were compared with a group of patients receiving AA in combi-231

nation with conventional antipsychotics (CA) and a group of patientsreceiving CA as monotherapy, to assess the frequency and severity ofakathisia. Sixty-three acute schizophrenic patients (62% men) with amean age of 31.4±9.4 years admitted at the Eginition Hospital, Athens,during a one year period, were studied. Patients' case notes analysiswas performed surveying psychotropic drugs prescribing on the firstweek after their admission. All patients were assessed for druginducedakathisia using the Barnes Rating Scale for Akathisia (BARS).19% of the patients were on AA as monotherapy (Group A), 16% usedAA in combination with CA (Group B), while 65% were on CA(Group C). Based on the global clinical assessment scale of the BARS(score of at least 2), 15.9% of patients were rated as having akathisia.Prevalence of akathisia was 16.6% among Group A patients, 20.0%among Group B and 14.7% among Group C patients. The mean BARSscore in Group A patients was 0.62±0.85, in Group B was 0.71±1.16,and in Group C was 0.84±1.86. Comparison between the three groupsof patients regarding the prevalence and severity of akathisia did notreveal statistically significant differences. The results suggest thatakathisia may be a common side effect of all antipsychotic medications.PO1.138.SEXUAL SELF-PERCEPTION IN SCHIZOPHRENICPATIENTS IN RELATION TO SEX AND AGEM. Vucic Peitl, E. Pavlovic, A. PeitlPsychiatric Clinic, Clinical Hospital Centre, Rijeka,Hrvatska, CroatiaThe aim of this investigation was to establish the difference in sexualself-perception between acute and chronic schizophrenic patientsand healthy individuals, with regard to their sex, age, marital statusand level of education. Subjects of the investigation were a hundredacute and a hundred chronic schizophrenic individuals with an agevarying from 18 to 45 that had been treated at the Psychiatric Clinic,Clinical Hospital Centre Rijeka, and a hundred healthy individualsrandomly selected and matched for age, among citizens of Rijeka duringApril and May of 1999. Sexual self-perception was investigatedapplying a questionaire created by Bezinovic. Chronic and acuteschizophrenic patients had significantly higher scores than healthyindividuals with regard to negative emotions and sexual incompetence.There were no differences between acute and chronic schizophrenics.Male individuals from all groups showed significantly betterresults than women on scales that measure sexual self-scheme, sexualadventures and sexual pleasure. In young healthy individuals sexualself-perception is significantly related to sexual awareness, sexualreadiness and sexual pleasure. Age is not particularly significant inschizophrenic patients, whether acute or chronic.PO1.139.THE WISCONSIN CARD SORTING TEST IN PATIENTSWITH SCHIZOPHRENIA AND THEIR SIBLINGSY. El Hamaoui, M. Elyazaji, S. Yaalaoui, L. Rachidi, M. Saoud,T. D'amato, D. Moussaoui, J. Dalery, O. BattasUniversity Psychiatric Center Ibn Rushd, Casablanca, Morocco,and Université Claude Bernard Lyon I, Centre Hôpitalier LeVinatier, Bron, FranceThe first aim of this work was to verify that patients with stabilizedschizophrenia and their siblings share the same deficits in executivefunctions compared to healthy controls. The second aim was toexplore the relations between performance on the Wisconsin CardSorting Test (WCST) and the length and severity of the illness. Thestudy was conducted in 30 patients with schizophrenia, 30 of their siblings,and 30 healthy control subjects. The intensity of symptoms wasevaluated by the Positive and Negative Syndrome Scale (PANSS), andthe social functioning by the Global Assessment of Functioning(GAF). The WCST was administered to the three groups. Patients withschizophrenia and their siblings presented a significantly worse performanceon the WCST compared to control subjects. Siblings were inan intermediate position between schizophrenic patients and controls.On the other hand, there was no correlation in patients between theWCST performance and age, gender, education, length of the illness,treatment, and PANSS and GAF scores. These results suggest that performanceon the WCST may be considered like a marker of vulnerabilityto schizophrenia.PO1.140.HETEROGENEITY OF COGNITIVE DYSFUNCTIONAMONG CLINICALLY STABILIZED SCHIZOPHRENICPATIENTSE. Ermoli, M. Bechi, S. Anselmetti, S. Angelone, R. CavallaroDepartment of Neuropsychiatric Sciences, Vita Salute SanRaffaele University, Milan, ItalyThis study aimed to describe the neuropsychological profile associatedwith chronic schizophrenia and to test the hypothesis that epidemiologicaland clinical variables could affect cognitive performance.A neuropsychological battery, including tests for the assessmentof the cognitive domains usually compromised in schizophrenia, wasadministered to 94 patients with chronic schizophrenia clinically stabilizedand responder to classical antipsychotics, risperidone orclozapine, compared with a group of 71 healthy subjects, matched forage and education. Patients with chronic schizophrenia performedsignificantly worse than controls in all tests administered, but individualprofiles resulted highly heterogeneous in a wide proportion ofthe sample. Negative psychopathology was correlated to an index ofgeneral cognitive ability, defined as the number of tests badly performed,while antipsychotic treatment did not influence performance,with the exception of verbal memory, significantly impairedamong clozapine-treated patients. Previous reports of extensive andstable neuropsychological deficits associated with schizophreniawere supported by the average values of our study, but individual profilesshowed a high proportion of heterogeneity that might reflect heterogeneousphysiopathology.PO1.141.THE INFLUENCE OF COGNITIVE DEFICITSAND PSYCHOPATHOLOGY ON FUNCTIONALIMPAIRMENT OF SCHIZOPHRENIAM. Bechi, E. Ermoli, S. Anselmetti, S. Angelone, F. Cocchi,R. CavallaroDepartment of Neuropsychiatric Sciences, Vita Salute SanRaffaele University, Milan, ItalyThere has been an increasing interest in the consequences of neurocognitivedeficits of patients with schizophrenia on daily functioning,but, although the published literature in this area doubled in thelast few years, results are very inconsistent. The goal of this study wasto determine the effect of the interaction of residual psychopathology,neurocognitive deficits and clinical variables on the daily functioningof a sample of 103 chronic schizophrenic patients. The neuropsychologicaldomain was assessed by means of a battery includingthe Continuous Performance Test, the Wisconsin Card SortingTest and the Brief Assessment of Cognition in Schizophrenia. The232 World Psychiatry 3:S1 - October 2004

psychopathological domain was assessed with the Positive and NegativeSyndrome Scale (PANSS) and the daily functioning wasassessed by the Quality of Life Scale. Stepwise multiple regressionanalysis was used to explore significant effects of neurocognitive,psychopathological and clinical variables on functioning areas (personalautonomy, relationships, work). Models calculated for eachdependent functioning variable were all significant and accountedfor 32% to 36% variance. The most consistent finding was that negativesymptoms contribute significantly to all models; verbal memorycontributes significantly to relationship and work areas; workingmemory and semantic fluency contribute significantly to work area.Positive symptoms were not significantly associated with outcomemeasures. Verbal memory and working memory appear to be necessaryfor adequate functional outcome. Deficit in these areas may preventpatients from reaching optimal adaptation, so that they shouldbe addressed specifically in cognitive rehabilitation intervention programs.PO1.142.THE DEFICIT SYNDROME IN SCHIZOPHRENIAL. Kallel, R. Rafrafi, A. Zghal, L. Zaghdoudi, R. LabbaneHôpital Razi, Tunis, TunisiaThe deficit syndrome in schizophrenia is defined by the presence ofprominent, enduring and primary negative symptoms. We carried outa cross-sectional retrospective study comparing patients with a diagnosisof schizophrenia with vs. without deficit syndrome. We gathered80 patients fulfilling DSM-IV criteria for schizophrenia, in a stabilizedperiod of the course of the disease. We assessed them by thePositive and Negative Syndrome Scale (PANSS), the Schedule for theDeficit Syndrome (SDS), the Simpson Angus Extrapyramidal SideEffects (EPS) Rating Scale and the Global Assessment of FunctioningScale (GAF). Using the SDS, 34 patients (42.5%) were categorized ashaving deficit schizophrenia, and 46 (57.5%) as having nondeficitschizophrenia. Most patients with the deficit syndrome showed apoor pre-morbid adjustment (82%), an insidious onset of symptoms(76%) and a poor outcome characterized by a global dysfunction(68%). Most patients with the deficit syndrome stopped working orstudying (82%). Hence, they showed high rates of economic dependence(80%). Regarding therapeutic aspects, a frequent use of longtermhigh dose neuroleptic treatment was noted (997 mg per day as achlorpromazine equivalent mean daily level). Novel antipsychoticswere rarely prescribed (14%).PO1.143.MONITORING THE PSYCHOTIC PROCESSFROM THE ONSETM. Ienciu, I. StoicaPsychiatric Clinic, Timisoara, RomaniaPsychiatric research and everyday clinical practice have provided us,after decades of difficulties, with the nosological structure and theappropriate initial approach towards the first episode of psychosis.However, although there are a large variety of diagnostic criteria forthe psychotic process, we still do not have a clear distinction betweenepisode and illness. The aim of this study is to monitor the dynamicsof the psychotic process from the onset, and to identify the basic timestages of the process. For the clinician it is important to know whatare the unstable diagnostic groups and the moment of their metamorphosis,in order to be able to influence the illness course and accordinglymodify the therapy of patients with a diagnosis of first episodeof psychosis.PO1.144CITALOPRAM FOR DEPRESSIVE SYMPTOMS INCHRONIC SCHIZOPHRENIAH. Kim, K.-J. Lee, Y.-C. ChungDepartment of Neuropsychiatry, Ilsan Paik Hospital, Collegeof Medicine, Inje University, Goyang, Gyeonggi, KoreaThere is increasing evidence suggesting that depressive symptomsmay be associated with serotonergic dysfunction in schizophrenicpatients. This study aimed to determine the efficacy and safety ofcitalopram as a treatment for depressive symptoms in patients withchronic schizophrenia. The Calgary Depression Scale for Schizophrenia(CDSS) was used as the outcome measure. Forty-sevenpatients suffering from schizophrenia (DSM-IV) with a CDSS scorehigher than 8 were included in a double-blind, placebo-controlled, 8-week trial of citalopram. Citalopram was started at 20 mg/day; thiscould be increased to 40 mg after 4 weeks for an inadequate response.There were no significant differences between these two groups withrespect to age, education, gender and type of antipsychotic. Therewas no significant difference between the citalopram and the placebogroup in the mean baseline CDSS score (9.8±2.2 vs. 9.3±1.6, p=0.32),but after 8 weeks the mean score of the citalopram group was significantlylower (6.1±1.8 vs. 7.8±1.8, p=0.002). No clinically significantadverse effects were reported by the patients or observed by the examiner.These results suggest that citalopram is useful and safe as a treatmentfor depressive symptoms in schizophrenia.PO1.145.OBSESSIVE-COMPULSIVE DISORDER INSCHIZOPHRENIAS. McHugh, F. Doherty, F.A. O’NeillDepartment of Mental Health, Queen’s University of Belfast,Northern Ireland, UKSchizophrenia is a neuro-developmental disorder that affects 1% ofthe population. Its onset is in late adolescence and it affects a widevariety of different brain systems. The heritability is 80%. Obsessivecompulsivedisorder (OCD) is also a neuro-developmental disorderthat affects 2% of the population. Its onset is in early adolescence andit also affects a wide range of brain systems. The heritability is 40%.There is a reported incidence of 10 to 25% of OCD symptoms inchronic schizophrenia. As a part of a genetic epidemiology study, asample of 540 subjects with schizophrenia has been identified. Theyhave been interviewed by the Yale-Brown Obsessive CompulsiveScale (Y-BOCS) to look for OCD symptoms. There appears to be atrend towards poorer outcome in patients with OCD and schizophrenia.However, contrary to our hypothesis, there was a decreased levelof extrapyramidal symptoms. There are difficulties in distinguishingthe symptoms of OCD and schizophrenia: the OCD symptoms maybe distinguished by their ego-dystonic features. In this group theobsessions tend to be mostly aggressive thoughts. In conclusion,OCD symptoms are common in schizophrenia and may mark a pooroutcome subgroup. This may represent shared dysfunction in basalthalamic-corticalfunctioning. Future studies may identify sharedneuropsychological deficits and pathophysiology. It is important thatthese symptoms are identified and treated as often OCD symptomsare ignored and there is evidence that selective serotonin reuptakeinhibitors are of value in the treatment of these symptoms.233

PO1.146.BINGE EATING IN SCHIZOPHRENIC PATIENTS:A CASE CONTROL STUDYY. Khazaal, E. Fresard, V. Pomini, D. Spagnoli, F. Borgeat,D. ZullinoUniversity Department of Adult Psychiatry, Lausanne,SwitzerlandAntipsychotic induced weight gain occurs in up to 50% of patientsand can lead to a central or abdominal obesity. Binge eating disorderis a provisional new eating disorder diagnosis. This disorder, especiallyprevalent in the obese population, has an important impact ontreatment outcome. The purpose of this study was to assess whetherseverely overweight schizophrenic patients differ from controls andfrom pairs in binge eating symptomatology. Current body mass index(BMI) and the binge eating status were assessed cross-sectionally in40 schizophrenic outpatients and 40 non-psychiatric controls. Ineach group half of the subjects had a BMI ≥ 28 or were obese. Bingeeating symptomatology is significantly more prevalent in schizophrenicpatients and especially in severely overweight and obesepatients. This result may have some consequences on the understandingof weight gain associated with antipsychotics and on thetreatment and prevention of obesity in this population.PO1.147.THE ITALIAN VERSION OF THE EPPENDORFSCHIZOPHRENIA INVENTORY (ESI)G.M. Galeazzi, P. Spiliopulos, P. CurciDepartment of Neuroscience, University of Modena andReggio Emilia, Modena, ItalyThe Eppendorf Schizophrenia Inventory (ESI) is a self-administered40 item questionnaire exploring psychosis-related subjective experiences,grouped in five subscales pertaining to attention and speechimpairment (AS), auditory uncertainty (AU), ideas of reference (IR),deviant perceptual phenomena (DP), plus items (FR) controlling forfrankness and motivation in completing the inventory. The originalinstrument was translated into Italian, back-translated and discrepanciesresolved by discussion with the author of the original. The ItalianESI was administered to 50 inpatients with schizophrenia accordingto ICD-10 criteria and to 50 controls matched for sex, age, andeducational level. Patients were assessed using the Positive and NegativeSyndrome Scale (PANSS) and completed another Italian-validatedinventory of subjective experiences, the Frankfurter ComplaintQuestionnaire (FCQ). The total and each subscale scores of the ItalianESI, except FR, were significantly higher in patients. Patientsshowed significant correlations of ESI total and subscale scores withduration of illness and negative symptom PANSS scores. Significantpositive correlations were found between ESI total and subscalescores and FCQ global and subscale scores. Cronbach’s alpha for theItalian ESI and its subscales ranged from .65 to .89. The Italian versionof the ESI appears to have satisfactory concurrent validity andacceptable internal consistency; preliminary data showing discriminantvalidity between patients with schizophrenia and controls supportfurther study of its test-retest reliability and discriminant validitybetween patients with schizophrenia and other diagnostic groups.PO1.148.A MULTIDIMENSIONAL APPROACH TO ASSESSSCHIZOPHRENIA SYMPTOMS AND FUNCTIONALDISABILITYV. Di Michele, F. Bolino, P. PinciniMental Health Department, Pescara, ItalyThe present study was designed in order to verify the associationbetween schizophrenic symptoms and function according a multidimensionalapproach assessment. Forty chronic schizophrenic patientsin a stabilized phase of illness were studied by a comprehensive clinical,psychopathological and psychosocial assessment. Diagnoses weremade according to DSM-IV and ICD-10 Research Criteria. All patientswere on pharmacological and psychosocial treatment. A pervasive correlationamong symptoms and psychosocial variables emerged suggestinga unitary concept of behavior related to diagnosis. A factor analysisand a cluster analysis on factor variables associated with symptoms andfunction scores yielded the best fit (100%) with a tripartite solution. Inconclusion, schizophrenic symptoms and social functioning seem to beorganized in a tripartite and homogeneous structure, suggesting theexistence of three different syndromes. The dimensional structure ofschizophrenia needs a comprehensive and multi-domain assessmentfor deriving prediction of outcome.PO1.149.FAMILY RELATIONS OF PSYCHOTIC AND NON-PSYCHOTIC ADOLESCENTSK. WidelskaDepartment of Child and Adolescent Psychiatry, JagiellonianUniversity, Cracow, PolandThis study focuses on individuation-separation processes in familiesof psychotic patients. It was carried out in patients hospitalised forthe first time at the inpatient ward of the Department of Child andAdolescent Psychiatry, Jagiellonian University, in Cracow and in theirfamilies. Patients of both sexes, aged 14-19 years, with various psychopathologicalpictures, were examined. The examination includedpatient’s parents and siblings aged 14-20. Patients with ICD-10 psychoticdisorders (F20-F23) with their families (parents and siblings)were compared to patients with other diagnoses (‘non-psychotic disorders’).The patients and siblings were examined by Offer’s SelfImage Questionnaire for Adolescents and Cierpka’s Family AssessmentMeasure. Parents were examined by the Family AssessmentMeasure. The essential result of the study was a qualitative descriptionof specific emotional factors and parents-children dynamicscharacteristic of psychotic patients, which may be useful for the diagnostic-therapeuticprocess.PO1.150. MORBID SELF-EXPERIENCES ANDALEXITHYMIA IN SCHIZOPHRENIAA. Raballo, C. MagginiPsychiatry Section, Neuroscience Department, University ofParma, ItalySchizophrenic subjects with alexithymia display a global inflation ofpsychopathology. However, the psychopathological understanding ofsuch phenomena is still incomplete. Furthermore, the potentialsalience of not-yet-psychotic, qualitative anomalies of subjectiveexperiences to the development of alexithymia has been eclipsed byan unproblematized transposition of the alexithymia construct (originallydeveloped in psychosomatic medicine) into the field of psychosis.The aim of this study was to recontextualize alexithymia in a234 World Psychiatry 3:S1 - October 2004

detailed mapping of schizophrenic subjective psychopathology onthe epistemological basis of the Jaspersian and Schneiderian descriptivephenomenological method. 70 patients were examined with theBonn Scale for the Assessment of Basic Symptoms (BSABS) and the20-item Toronto Alexithymia Scale. Schizophrenic subjects with alexithymiadisplayed an increase of basic symptoms level, and alexithymiawas associated with elevated scores on the scales measuringdisorders of self-awareness and interpersonal uneasiness. These findingssuggest that certain anomalies of subjective experience contributeto the unfolding of alexithymia in schizophrenia and that alexithymiain schizophrenic psychopathology is better understood asindicative of a disturbed self-experience rather than as a trait-likepathoplastic feature.PO1.151.FUNCTIONAL STATUS AND QUALITY OF LIFE INLATIN AMERICANS WITH SCHIZOPHRENIAS. Assunção 1 , A. Hodge 2 , M. McBride 2 , R. Báez 3 , A. Pérez LoPresti 4 , D. Toledo 5 , M. Dossenbach 6 , on behalf of the IC-SOHOstudy group1 Eli Lilly, Brazil; 2 Clinical Outcomes and Research Institute, EliLilly, Australia; 3 1212 Ave. Muñoz Rivera Ponce, Puerto Rico;4 Atruim Centro Diagnostico, Merida, Venezuela; 5 HospitalMilitar Central, Bogotá, Colombia; 6 Eli Lilly, AustriaThe study aimed to summarise changes in functional status andhealth related quality of life (HRQoL) in Latin American (LA)patients with schizophrenia after 12 month participation in a 3 yearglobal, observational study. HRQoL (assessed by EuroQoL) andfunctional status (social, employment and residential) were determinedfor LA outpatients with schizophrenia. Data were adjusted forbaseline differences and multivariate comparisons of olanzapine,risperidone and typical antipsychotic treatment were performed.Patients who remained on their originally prescribed monotherapy ofolanzapine (n=803), risperidone (n=227) or typical antipsychotictreatment (n=183) for 12 months were compared. Following one yearof therapy, patients in all treatment groups improved, but olanzapinewas superior to typical antipsychotic treatment in terms of changes intotal EuroQoL score (p

PO1.154.SCHIZOPHRENIA IN SPAIN: MOST FREQUENTSYMPTOMS AND SUBTYPES AMONG ANOUTPATIENT POPULATIONE. Baca 1 , M. Roca 2 , C. Varela 3 , on behalf of the Abordaje Clínicode la Esquizofrenia (Clinical Management of Schizophrenia)Study Investigators group1 Servicio Psiquiatría, Clínica Puerta Hierro, Madrid; 2 Unidad dePsiquiatría-Psicología Clínica, Hospital Joan March, PalmaMallorca; 3 Global Epidemiology and Outcomes Research, Bristol-Myers Squibb, Madrid, SpainThe objective of the Abordaje Clínico de la Esquizofrenia (ACE) studyis to describe the clinical management of schizophrenia in Spain. Wedescribe here the clinical profile of the schizophrenic patients. Thestudy is a descriptive, cross-sectional, multicentric one, carried out inoutpatient mental health centers and private offices. 500 investigatorsrecruited 1969 patients with a primary diagnosis of schizophrenia; 32patients (1.6%) were excluded from the analysis by protocol violation.The most frequent schizophrenia subtype in these patients is paranoid(68.4%), followed by residual (13.9%) and undifferentiated (7.1%). Atthe study visit, most of the patients (64.1%) were stabilized, 28.6% ina process with active symptoms and 7.2% in an acute phase. 76.6% ofthe patients had been diagnosed more than 5 years before. The percentageof patients with negative symptoms was higher (87.7%) thanthe percentage of those with positive symptoms (63.5%) and differenceswere found between men and women for the former symptoms(88.8% vs. 85.2%, p

ing the risk for acute adverse effects. In this study we want to test thehypothesis that polymorphisms of short tandem repeat loci (D22S276,D22S282, D22s274) spanning the 22q13.1 region, which contains theCYP2D6, are in strong linkage disequilibrium with a major gene,whether CYP2D6 or other one, predisposing to develop TD.PO1.158.SERUM SUPEROXIDE DISMUTASE ANDTHIOBARBITURIC ACID REACTIVE SUBSTANCES INMEDICATED SCHIZOPHRENIC PATIENTSC.S. Gama 1 , M. Salvador 2 , A.C. Andreazza 2 , F. Kapczinski 1 ,P.S. Belmonte-de-Abreu 11 Departamento de Psiquiatria, Hospital de Clínicas de Porto Alegre;2 Instituto de Biotecnologia, Universidade de Caxias do Sul, BrazilImpaired antioxidant defense and increased lipid peroxidation havebeen previously reported in drug naïve, first episode and chronicallymedicated schizophrenic patients using typical antipsychotics. Wemeasured serum superoxide dismutase (SOD) and thiobarbituric acidreactive substances (TBARS) in chronic DSM-IV schizophrenicpatients under haloperidol (n=10) or clozapine (n=7), and in a group ofhealthy controls (n=15). Serum SOD and TBARS were significantlyhigher (p=0.001) in schizophrenic patients than in controls. Amongpatients, serum TBARS was significantly higher (p=0.008) in those takingclozapine (4.4329±0.7070) than in those under haloperidol, whereasSOD levels were not different (p=0.7). Further investigation of therelationship of scavenging antioxidants enzimes and lipid peroxidationwith the course of schizophrenia is warranted.PO1.159.WATER-ELECTROLYTIC DYSBALANCE,PHARMACOTHERAPY AND WORSENING OFPSYCHOSISD. Jevdic, N. IlankovicS. Bakalovic Neuropsychiatric Hospital, Vrsac; Institute ofPsychiatry, Belgrade, Serbia and MontenegroThe clinical observation that patients with psychotic disorders (schizophrenia,schizoaffective and affective psychoses) very often takeexcessive quantities of water (compulsive drinking) generated theinterest to investigate the possible pathogenic role of “water intoxication"in the appearance, worsening and maintenance of psychoticsymptoms. 41 patients have been included in the study. In all of them,water-electrolytic balance has been investigated at the time of hospitalization,through pharmacotherapy and at discharge. The worseningof psychosis was associated with a constant tendency to hypernatremia(with secondary hyponatremia) and hypercalcemia. Pharmacotherapyhad a negative influence on water-electrolytic balance. Theregular examination of water-electrolytic balance in psychoticpatients is an important part of their clinical assessment.PO1.160.ATTENTIONAL AND MNESTIC RESISTANCE TOINTERFERENCE AND THE POSITIVE, NEGATIVEAND DISORGANIZATION DIMENSIONS OFSCHIZOPHRENIA: A CORRELATION STUDYC. Cedro, L. Cortese, A. Bruno, R. Cambria, D. La Torre, M.R.A.Muscatello, G. Pandolfo, R. Zoccali, M. MeduriDepartment of Psychiatry, University of Messina, Italyimpairment of executive functions is a well-known feature of manyschizophrenic subjects. The present study has been performed withthe aim to evaluate possible relationships among interference inhibitionand the positive, negative and disorganization dimensions ofschizophrenia. 76 schizophrenic patients aged from 18 to 58 yearswere examined by the Scale for the Assessment of Positive Symptoms(SAPS) and the Scale for the Assessment of Negative Symptoms(SANS) to evaluate positive, negative and disorganization dimensions.All patients underwent a neuropsychological examination with theStroop Colour Word, which assesses selective attention by an interferencecomponent that requires the subject to inhibit an automatedresponse, and the AB-AC, a verbal learning task for the evaluation ofproactive interference. Statistically significant correlations wereobserved among the Stroop Colour Word, “odd behavior” (SAPS) and“apathy” (SANS); lesser significant correlation resulted between AB-AC and “delusions” at SAPS. Although the available data in the literaturetend to support the lack of relationships between global executivedysfunctioning and the positive, negative and disorganizationdimensions of schizophrenia, the present study suggests that such relationshipsappear when simpler neuropsychological dimensions areinvestigated. These results suggest that the assessment of simpler neuropsychologicalfunctions which concur to the organization of theglobal executive functioning may be more useful and accurate than theevaluation of global executive function alone.PO1.161.INTERFERENCE INHIBITION AND RELATIONALCOMPLEXITY IN SCHIZOPHRENIAL. Cortese, C. Cedro, A. Bruno, M.R.A. Muscatello, R. Cambria,G. Pandolfo, D. La Torre, R. Zoccali, M. MeduriDepartment of Psychiatry, University of Messina, ItalyExecutive functions are subtended by simpler neuropsychologicalorganizations as attentional resistance to interference, working memory,analysis of relational complexity and self-concepts. The aim ofthe present study was to evaluate the relationships among the singleneuropsychological functions which participate to the organizationof executive functioning in a sample of schizophrenic patients withvarious degrees of cognitive impairment. 76 schizophrenic patients(56 males and 20 females, mean age 34.32 years) underwent a neuropsychologicalassessment which involved the Stroop Colour Word(which assesses selective attention by an interference component thatrequires the subject to inhibit an automated response), the AB-AC (averbal learning task for the evaluation of proactive interference) andthe Raven’s Standard Progressive Matrices (for the analysis of relationalcomplexity). Correlations analysis (Pearson’s r) has been performedassuming p

PO1.162.SOCIAL ADJUSTMENT IN SCHIZOPHRENICPATIENTS WITH A FAMILY HISTORY OF THEDISEASEN.A. Kuleshova, A.V. SemkeMental Health Research Institute, Tomsk, RussiaRecently, the influence of a family history of the disease on the courseof schizophrenia and on the social adjustment of patients with schizophreniahas been a focus of attention. We studied 60 families withtwo or more cases of schizophrenia among first or second degree relatives.We found that that a family history of the disease, and the factof living with the ill relative, exerted an adverse impact on the age ofthe onset of the disease, on patient’s premorbid personality, on clinicalmanifestations of the disease, and on patient’s social adjustment.In families with mentally ill relatives we found peculiar dynamicsconditioning the patient’s social adjustment. The highest level ofadjustment (integrative, extrovert) was associated with positive coalition.Negative coalition was associated with an adverse type of adaptation(destructive) with a high specific burden of disability related tomental disease.PO1.163.SCHIZOPHRENIA COMBINED WITH SOMATICPATHOLOGYY.L. Maltseva, A.V. SemkeMental Health Research Institute, Russia, TomskRecently, accompanying somatic diseases have attracted attention asone of the adverse factors conditioning the clinical and social outcomein schizophrenia. The presence of accompanying somaticpathology is a characteristic of a subgroup of treatment resistantschizophrenic patients. Diseases of gastrointestinal tract and of thecardiovascular system (especially hypertension), as well as renal illnesses(especially chronic pyelonephritis), are the most frequent. Wepresent data on clinical peculiarities of schizophrenia associated withsomatic pathology, whose exacerbation leads to somatogenic reactions(anxious-depressive, hypochondriacal, anosognostic, restorationof previous psychopathological symptoms and mixed). We foundthat somatic diseases are adverse factors influencing the social functioningof these patients, as well as family functioning, manifesting inouter (family) reactions of three basic types: passive-awaiting, loyaland extremist.PO1.164.ABOUT THE DIAGNOSIS OF RESIDUALSCHIZOPHRENIAS.V. Evseyev, A.V. Semke, E.G. KornetovaMental Health Research Institute, Tomsk, RussiaResidual schizophrenia as an independent diagnosis is present ininternational classifications of mental disorders but is not broadlyused in Russia. According to the data of our group, already in the secondperiod of five years in the course of the disease, schizophrenicpatients without signs of defect cannot be found, and after the secondperiod of 10 years in the course of the disease a stabilisation of psychoticactivity is observed. Multiple types of remissions and residualstates are probably comprised under the heading of “residual schizophrenia”.According to data obtained at the Mental Health ResearchInstitute (Russia, Tomsk), this diagnostic heading in ICD-10 reflectsthe stage of the disorder marked by a relative stabilisation of theschizophrenic process.PO1.165.SOCIAL FUNCTIONING RELATES TO AGE OFONSET IN OUTPATIENTS WITH SCHIZOPHRENIAS. Ochoa, J. Usall, V. Villalta, M. Vilaplana, J.M. Haro, J.Autonell, M. Dolz, M. MarquezSant Joan de Déu-SSM, Sant Boi de Llobregat, Barcelona, SpainIn a random sample of 231 outpatients with schizophrenia attendingfive mental health centers in the Barcelona area, we evaluatedsociodemographic and clinical variables and social functioning (LifeSkills Profile, LSP). The age of onset was evaluated at first symptoms,at first contact and at first diagnosis. We subdivided the patients intothree groups according to the age of onset: early (0-17 years), middle(17 to 30 years) and late (more than 30 years). There was a preponderanceof males in the middle group (p

and neuroimaging (single photon emission computed tomography)variables. Patients with CHP had significantly lower scores thanpatients with schizophrenia for positive symptoms, negative symptomsand conceptual disorganization, but a higher score for hallucinations.As compared with healthy controls, patients with CHP hada significant regional cerebral blood flow (rCBF) increase in rightthalamus, left insula (Broadman area, BA 13), left precuneus (BA19), left superior temporal gyrus (BA 22), and occipital region bilaterally.Compared to healthy controls, the schizophrenia groupshowed a significant rCBF reduction in right medial frontal gyrus(BA 10) and right superior frontal gyrus (BA 9). The neuroimagingfindings are consistent with the “inner speech” theory of activationof an extensive network of cortical and subcortical areas in auditoryhallucinations.PO1.168.OUTCOMES OF REHABILITATIVE INTERVENTIONSIN A POST-ACUTE REHABILITATION WARD:NEUROPSYCHOLOGICAL ANDPSYCHOPATHOLOGICAL PREDICTORSS.M. Angelone, B. Papini, M. Bechi, E. Triveri, M. Fedeli,C. Calligaris, R. CavallaroDepartment of Neuropsychiatric Sciences, Vita Salute SanRaffaele University, Milan, ItalyRehabilitation programs for schizophrenic patients are usuallyintended for chronic schizophrenia and consequently most studiesaddress the treatment of this phase. Limited or no data are insteadavailable about rehabilitation programs in post-acute inpatients.These programs may have different targets, like potentiating andanticipating effects of drug treatment on behavioural competence andorganization, but may respond to the same modulating rules ofchronic schizophrenia interventions. The aim of this study was to recognizeneuropsychological and psychopathological predictors offunctional outcomes of a in-ward, post-acute rehabilitation program.50 consecutively admitted schizophrenic patients were assessed withthe Positive and Negative Syndrome Scale (PANSS) for psychopathology,the Evaluation of Abilities, Definition of Objectives(VADO) for daily functioning and a battery of neuropsychologicaltasks assessing most of the core deficits known in schizophrenia(Brief Assessment of Cognition in Schizophrenia). VADO assessmentwas repeated after 4 weeks of cognitive-behavioural treatment, beforedischarge. Preliminary results on 23 patients showed that the highlysignificant improvement of daily functioning (basal-final VADOscores change p=0.0005) was not correlated with residual acute psychopathology.On the other hand, we found a significant correlationbetween VADO-measured functional improvement and basal neuropsychologicalfunctions (working memory, p=0.02; attention,p=0.007). Our results suggest that, even in patients with residualacute symptomatology, in-ward cognitive-behavioural rehabilitationis effective and its outcomes are influenced more by neuropsychologicalperformance than by psychopathology, like in chronic schizophreniarehabilitation.PO1.169.EMOTION TRAINING IMPROVES RECOGNITION OFFACIAL EMOTIONS IN CHRONIC SCHIZOPHRENIA.A PILOT STUDYH. Silver 1,2 , C. Goodman 1 , G. Knoll 1 , V. Isakov 11 Brain Behavior Laboratory, Sha’ar Menashe Mental HealthCenter, Mobile Post Hefer; 2 Rappaport Faculty of Medicine,Technion Institute of Technology, Haifa, IsraelImpaired emotional communication may be an important contributingfactor to poor social function in schizophrenia. This pilot study examinedthe effect of emotion training exercises on the perception of facialemotional expression. 20 male chronic schizophrenia patients underwent3 training sessions using a computerized emotion training programdeveloped for teaching autistic children that was adapted to theclinical setting. Patients were assessed before and after training withvalidated tests of identification of facial emotions (Penn Emotion AcuityTest, PEAT and Emotion Rating 40, ER40), differentiation of facialemotions (Emotion Differentiation Test, EMODIFF) and workingmemory. In comparison to baseline, patients performed significantlybetter on PEAT and ER40 tests after training. No change was observedin EMODIFF or in cognitive test performance. In conclusion, briefemotion training can improve recognition of facial emotional expressionsin chronic schizophrenia patients. This may be due to increasedpatient awareness of emotional aspects of stimuli and/or improvementin specific emotional perceptual skills. Further studies of emotion trainingas a potential treatment modality are warranted.PO1.170.A SINGLE BLIND RANDOMISED CONTROLLEDTRIAL OF MUSIC THERAPY IN PATIENTS WITHSCHIZOPHRENIA AND RELATED PSYCHOSESN. Talwar, M. Crawford, A. MaratosDepartment of Psychological Medicine, Paterson Centre,London, UKThe potential value of music therapy for people who experience mentaldistress has been widely discussed but seldom evaluated. Currenttreatments for schizophrenia leave many with residual symptoms andimpaired social functioning. We therefore conducted a randomisedcontrolled trial of music therapy for people with schizophrenia andrelated psychoses in order to examine its effect on clinical and socialoutcomes. Patients aged over 18 who were being treated for nonaffectivepsychoses at one of four local hospitals were randomised toindividual music therapy (MT) plus standard care or standard care(SC) alone. We used remote randomisation with block randomisationin a ratio of MT:SC of 2:3. Music therapy sessions lasted up to 50 minutes,once a week for up to 12 weeks. Sessions were delivered bytrained music therapists who received regular supervision during thecourse of the study. Symptoms of schizophrenia (measured using thePositive and Negative Syndrome Scale, PANSS), engagement withservices, satisfaction with care, and social functioning were measuredprior to randomisation and at three and six months after. Over thecourse of six months 80 patients were randomised. Findings frompatient follow-up interviews will be presented and implications forfuture research on art therapies discussed.239

PO1.171.THE CAREGIVING EXPERIENCE OF RELATIVES OFCHINESE PATIENTS WITH SEVERE MENTALILLNESSES IN HONG KONGD. Lau 1 , A. Pang 21 Department of Psychiatry, Kowloon Hospital; 2 Department ofPsychiatry, Tai Po Hospital, Tai Po, Hong KongThis study examined the psychometric properties of the Experience ofCaregiving Inventory (ECI), a 66 items instrument with both positiveand negative appraisal of caregiving. Predictors of the caregivingappraisal were explored and the stress-coping model was re-examined.129 caregivers and 81 patients were recruited. Test retest reliability,internal consistency and the item-scale correlation of the Chineseversion of the ECI were satisfactory. Factor analysis found a 10-factor solution that was comparable with the original version. Regressionanalysis of socio-demographic and clinical predictors of ECIshowed that negative appraisal was mainly predicted by the 1 yearGlobal Assessment of Functioning (GAF) and the years of educationof the caregivers. The positive appraisal was predicted by the employmentstatus of the patients and the years of education of the caregivers.Re-examination of the stress-coping model showed that therewas significant psychological distress amongst caregivers. Ways ofcoping (especially rational problem solving) accounted for 21.8%,while negative appraisal explained 22.8% of the variance of the GeneralHealth Questionnaire. The positive correlation between negativeand positive appraisal warrants further investigation of the stress copingmodel with the concept of 'commitment' of relatives in caregiving.PO1.172.WHICH PSYCHIATRIC PATIENTS NEEDANTI-STIGMA ASSISTANCE?M. Freidl, T. Lang, M. Scherer, H. KatschnigDepartment of Psychiatry, University of Vienna, AustriaIt is well established that the general public has devaluating attitudestowards psychiatric patients. In order to avoid rejection, many ofthese patients develop coping strategies, such as withdrawal and concealingtheir treatment history. These efforts are in themselves stressing,which might have negative consequences for the course of thedisorder. It is not clear, however, how many and which patients doactually perceive the public’s stereotype as threatening and thereforeexpect rejection. 90 psychiatric patients and a sample of 1042 personsof the Austrian general population were asked whether they agreedwith five devaluating statements about mental patients contained in aquestionnaire developed by Link et al. Matched pairs comparisonsand multiple logistic regression were employed, in order to find outwhether patients agreed to the same extent with these statements asthe general public did. For the statements that psychiatric patients are“less intelligent”, “less trustworthy” and “taken less seriously”,patients thought significantly less often than the general populationthat most people devalue mental patients. For two statements (“personalfailure”, “think less of”), no difference was found. It seems thatsome psychiatric patients are less convinced than the general populationthat most people devalue psychiatric patients in specific respects;these patients might fear rejection less than other patients do. Thosewho actually fear rejection might need anti-stigma assistance moreurgently than the first group.PO1.173.HOW PATIENTS SUFFERING FROMSCHIZOPHRENIA COPE WITH ANTICIPATEDSTIGMAM.E. Seyringer, M. Freidl, M. Scherer, R. Strobl, J. Wancata,M. Weiss, H. KatschnigDepartment of Psychiatry, University of Vienna, AustriaThe present study undertook the task of exploring the strategies whichpersons suffering from schizophrenia and living in the community areusing for coping with anticipated stigma and discrimination. Link etal. have identified three such coping strategies: a) withdrawal, i.e.avoiding social contacts; b) secrecy, i.e. concealing from others the factthat one has been or is currently treated for the disorder; and c) educationof others, i.e. explaining others what the disease “really” is andthat the stereotypes are wrong. In the present study 100 patients sufferingfrom schizophrenia for an average duration of 12 years wereinvestigated by means of the discrimination-devaluation questionnaireby Link et al. and the stigma-coping questionnaire by the sameauthors. A factor analysis yielded two factors which explained 45% ofthe variance, with one factor clearly representing both the withdrawaland the secrecy strategy, and a second factor representing the educationstrategy. According to these findings two main strategies, a morepassive and a more active one, can be distinguished. Since these copingstrategies are intimately interwoven into the lives of patients livingin the community, and since they might be related both to their psychopathologyand to their help-seeking behaviour, these coping strategieswill have to be considered more intensely when treating and integratingpsychiatric patients in the community.PO1.174.THE TREATMENT OF PSYCHOSIS IN THE CONTEXTOF CHILDHOOD TRAUMAJ. ReadDepartment of Psychology, University of Auckland, New ZealandA recent review of 40 studies shows that the majority of psychiatricpatients, internationally, have been either physically or sexuallyabused as children. This paper will discuss the fast growing researchliterature demonstrating a relationship between childhood trauma(including sexual and physical abuse) and psychosis in adulthood,including recent New Zealand research. The issue of whether the relationshipis causal will also be discussed. Findings that the brains oftraumatised children show the same neurological and biochemicalabnormalities as the brains of adult schizophrenics will be summarised.It will be argued that, regardless of one’s causal beliefs concerningpsychosis, the high number of people receiving mental healthservices for psychosis who were abused as children mandates that cliniciansare equipped to offer, or prepared to refer on for, trauma-basedpsychotherapy. One way forward is an integration of psychologicaltreatments proven to be effective for psychosis and trauma-orientedtherapies currently used with non-psychotic populations.240 World Psychiatry 3:S1 - October 2004

PO1.175.DAY-HOSPITAL REHABILITATIVEPROGRAMS FOR PSYCHOTIC PATIENTS:A TWO-YEAR FOLLOW-UP STUDYR. Magnotti, F. Castiglioni, G. BaPsychiatric Unit, Internal Medicine Department, Universityof Milan, ItalyThe purpose of this study was the assessment of clinical and psychosocialoutcome of the patients undergoing the rehabilitative treatmentsdeveloped at the Day Hospital of the Psychiatric Clinic of theUniversity of Milan. Reduction of negative symptoms of psychosisand an increase in psychosocial competence are the main aims oftreatment. We analysed the outcome of 20 patients with psychoticdisorders. The rehabilitative treatment included psychopharmacologictherapy, clinical observation, monitoring and supportive interviews,and an individualized rehabilitative program comprising basicrehabilitative activities called "Occupational Therapy" and more specificgroup rehabilitative activities, using both expressive and cognitivetechniques. In order to evaluate the results gained by the patientswe considered cognitive functioning, assessed through the Mini-Mental State Examination; psychopathological symptoms, assessedthrough the Brief Psychiatric Rating Scale, the Scale for Assessmentof Negative Symptoms and the Scale for Assessment of PositiveSymptoms; global psychosocial functioning, assessed through thescale “Valutazione Globale del Funzionamento” (VGF); relapses ofdisease, indicated by the number of hospitalizations; the reach ofobjectives decided and monitored through the manual “Valutazionedi Abilità, Definizione di Obiettivi” (VADO). We report results of a24-month follow-up, showing a considerable decrease of negativesymptoms, the reduction of the number of hospitalizations and animprovement in global psychosocial functioning.PO1.176.REHABILITATIVE PROGRAMMESFOR PATIENTS WITH DUAL DIAGNOSIS:A DAY HOSPITAL EXPERIENCEC. Viganò, M. Ferri, M. Ceresa, G. BaPsychiatric Unit, Internal Medicine Department, Universityof Milan, ItalyThe integrated approach to alcohol dependence combines differentmedical and psychosocial treatments, in individual, group or familiarsettings, to achieve and support alcohol abstinence and improveglobal psychosocial functioning. These clinical goals are more difficultto achieve in psychiatric patients than in the alcoholics withoutpsychiatric diseases; psychiatric patients show low global functionallevel, few familiar and social supports, cognitive and psychologicaldisabilities, so they need more supportive personal programmes for along time. In this paper we report our experience of rehabilitativetreatments for patients with alcohol dependence and psychiatriccomorbidity. We report the 2-year outcome of 20 alcoholics with psychiatriccomorbidity treated in day hospital and 21 alcoholics withoutcomorbidity, undergoing outpatient treatment. Preliminary dataanalysis confirm international literature results: 42% of the day hospitalsample and 58% of the outpatient sample achieved and maintainedalcohol abstinence during the two years of follow-up. Thecompliance and outcome seems to be better in alcoholics with axis I(affective disorder) than axis II (personality disorders) comorbidity.PO1.177.A FIVE-YEAR ACTIVITY OF SUPPORTEDEMPLOYMENT FOR PEOPLE WITHPSYCHIATRIC DISABILITY: OUTCOMES,SATISFACTION AND SOCIAL INTEGRATIONM. Ponteri 1 , A. Bartoli 2 , A. Degrandi 2 , R. Pioli 11 Fatebenefratelli Institute; 2 Local Health Unit, Brescia, ItalyThis work is part of the World Psychiatric Association programmeagainst stigma and discrimination because of schizophrenia. Followingour first study conducted in Italy exploring the attitudes of employersand employees toward people suffering from psychiatric disability, weanalysed five years of activity in the Nucleo Inserimento Lavorativo(NIL) of Brescia, Italy. The NIL is a public agency which provides asupported employment service for people with disabilities. Within this,there is a unit specifically dedicated to people with mental illness. Since1998, the mental illness unit followed more than seventy people withserious mental illness. The percentage of people who have beenemployed and maintain their work is more than 30%. The criteria forthe admission to the service and an operational description of the differentsteps of the supported employment are described. We collecteddata about people’s satisfaction with the course of the supportedemployment and general satisfaction with work and social integration.We also involved family members to assess their satisfaction with thesituation of the relative. We finally tried to understand the level of satisfactionof employers, in general for the service provided by the NIL,and specifically for each supported employment course.PO1.178.RANDOMIZED CONTROLLED TRIALOF COGNITIVE REMEDIATION THERAPYIN OUTPATIENTS WITH SCHIZOPHRENIAR. Penadés, R. Catalán, J. Goti, O. Puig, T. Boget, M. Salamero,C. GastóClinical Institute of Psychiatry and Psychology, Hospital Clinic,Barcelona, SpainCognitive remediation therapy (CRT) is a novel psychosocial treatmentapproach designed to improve adaptative functioning by usingcognitive compensatory strategies to bypass the cognitive deficitsassociated with schizophrenia. The effect of CRT was tested on neurocognition,positive and negative symptoms and psychosocial functioning.Cognitive behavioural treatment (CBT) is a useful therapy foremotional problems that is not expected to have effects on neurocognitionand was used as a control condition. Twenty-four patients withDSM-IV schizophrenia and prominent negative symptoms were randomlyassigned for 3 months to one of the two treatment conditions:1) standard medication follow-up plus CRT, 2) standard medicationfollow-up plus CBT. Comprehensive assessments (Positive and NegativeSyndrome Scale, Life Skills Profile, Wechsler Adult IntelligenceScale-III, Wisconsin Card Sorting Test, Stroop Test) were conductedbefore and after the treatments. Significant differences were foundbetween the two treatment groups in neurocognition and psychosocialfunctioning after the treatment. Patients receiving CRT overallhad higher levels of improvement in neurocognition and psychosocialfunctioning (Lambda de Wilks 0.514; p=0.009) but not in symptomatology(Lambda de Wilks 0.673; p=0.394). Nevertheless, patientsreceiving CBT showed significant reduction in some aspects of thegeneral psychopathology after treatment. In conclusion, CRT mayimprove neurocognition and psychosocial functioning for patientswith schizophrenia. Although CBT did not improve cognition norsocial functioning it might reduce general psychopathology levels.241

PO1.179.STIGMATISATION OF MENTALLY ILLBY PSYCHIATRIC PROFESSIONALS:THE WARD-STAFF PROJECTA.E. Baumann, H. Zäske, W. GaebelDepartment of Psychiatry and Psychotherapy,Heinrich-Heine-University, Düsseldorf, GermanyDiagnostic labels can be useful tools in medicine that facilitate communicationbetween professionals, but they can also be harmful whenthey are used by non-professionals who are not familiar with the originaldefinition. Misuse of diagnostic labels can lead to stigmatisationand discrimination of people with mental illness, in the general publicas well as in psychiatric professionals. The research group “Destigmatizationof mental illness“ of the Department of Psychiatry and Psychotherapyof the Heinrich-Heine-University in Düsseldorf, Germanyis conducting anti-stigma interventions with psychiatric ward staff inthe framework of the World Psychiatric Association‘s Global Program“Fighting stigma and discrimination because of schizophrenia“. The“Ward-Staff Project” is to be implemented in collaboration with aresearch group in Zurich, Switzerland. Target group of this interventionis ward staff in academic and urban hospitals in open and closedwards. Health care professionals’ attitudes will be assessed in Germanyand in Switzerland. In addition, patients’ stigma experienceswill be assessed. On the basis of the survey results, special trainingunits to reduce discriminative thinking and behaviour in psychiatricprofessionals towards mentally ill patients will be developed.PO1.180.PUBLIC ATTITUDES TOWARDS PEOPLEWITH MENTAL ILLNESS: A COMPARISONBETWEEN GERMANY AND MACEDONIAA.E. Baumann, K. Richter, H. Zäske, G. Niklewski, W. GaebelDepartment of Psychiatry and Psychotherapy,Heinrich-Heine-University, Düsseldorf, GermanyIn Germany and Macedonia the public health care systems differ fundamentally:while deinstitutionalisation and extension of outpatientcare began in Germany in 1975, a similar process only started inMacedonia in 2000. We present the findings of an attitude survey inthe general public carried out in the two countries using the samemethods. We investigated knowledge about the causes of schizophrenia,beliefs about treatment options, symptoms and behavior ofpatients with schizophrenia, social distance towards people withschizophrenia, attitudes towards the establishment of outpatientfacilities, and the perceived social discrimination of the mentally ill.Furthermore, we explored the perception of the portrayal of peoplewith schizophrenia in the media. Differences between the two countriesshall be discussed alongside their implications on measures toreduce stigma, and discrimination, especially in the framework of theWorld Psychiatric Association’s Global Programme “Fighting stigmaand discrimination because of schizophrenia”.PO1.181.TRANSITION AND OUTCOME OFTREATMENT PATTERNS IN SCHIZOPHRENICPATIENTS IN A KOREAN GENERAL HOSPITALDURING THE LAST TEN YEARSS.-E. Shin, K. Jung, K. LeeDepartment of Psychiatry, Incheon Cristian Hospital,Incheon, KoreaThere have been many changes recently in the use of antipsychoticsin Korea. We studied the transition of treatment patterns, costs andefficacy in schizophrenic inpatients during the last ten years. Weassessed the types and doses of antipsychotics, their cost, the durationof hospitalization, and the rates of rehospitalization, drop-out,switching of drug, and return to job. The use of atypical antipsychoticsand the cost of treatment increased, but the duration of hospitalizationand the rates of rehospitalization and drop-outdecreased. A cost-effectiveness evaluation is clearly needed.PO1.182.KNOWING - ENJOYING - LIVING BETTER:QUALITY OF LIFE ORIENTED PSYCHOEDUCATIONFOR PEOPLE WITH SCHIZOPHRENIAI. Sibitz 1 , H. Katschnig 1,2 , R. Goessler 2 , A. Unger 1 , M. Amering 11 Department of Psychiatry, Medical University of Vienna;2 Ludwig Boltzmann Institute of Social Psychiatry, Vienna,AustriaFollowing the trend of integrating quality of life oriented topics intopsychoeducational group therapies, a new group program has beendeveloped for people with schizophrenia spectrum disorder, a seminarcalled "Knowing – enjoying – living better". The aim of the studywas the evaluation of the seminar as seen from the subjective perspectiveof the participants and their referring psychiatrists. Experiencesof participants with the seminar were explored in two focusgroups and analysed by means of qualitative content analysis. Psychiatristscompleted a visual analog scale to evaluate the effects of theseminar on their patients. A total of 75 questionnaires was returned.The analysis of focus group data shows that participants emphasizedpositive effects of the seminar and gave detailed and very interestinginformation about how changes were caused and which conditionswere relevant for success. Positive effects included an increase inknowledge, empowerment, improved social networks and quality oflife. Psychiatrists also noticed improvements in quality of life domainsand observed positive changes in attitudes towards medication, illnessand health behaviour and in their collaboration with the patient.In conclusion, both participants and psychiatrists appreciated theprogram and emphasized its positive effects on the quality of life. Thisform of treatment may become an attractive and cost-effective alternativeto conventional psychoeducational programs.PO1.183.ANALYSIS OF EMOTION-ASSOCIATED GESTURESIN CHRONIC SCHIZOPHRENIC PATIENTSJ. Bulucz 1 , E.A. Bertha 1 , S. Rózsa 2 , L. Simon 11 Department of Psychiatry and Psychotherapy, SemmelweisUniversity; 2 Department of Psychology, Eötvös Lóránd University,Budapest, HungaryWe carried out a study of emotion-associated gestures comparing 8chronic schizophrenics to 8 healthy control subjects. Our subjects hadto enact 4 specific life situations that we created in a standardized set-242 World Psychiatry 3:S1 - October 2004

ting. The scenarios were designed so that emotional participation wasenhanced in the subsequent life situations. Gestures of our participatingsubjects were observed and videotaped. Videotapes were evaluatedusing the Budapest Gesture Rating Scale (BGRS), a gesture coding scaledeveloped at our institution. In remarkable contrast to a healthy groupof individuals, chronic schizophrenics utilize a reduced amount of emotion-associatedgestures. This difference in non-verbal communicationis even more obvious as emotional involvement becomes stronger.PO1.184.EVALUATING PSYCHIATRIC PATIENTSUSING HIGH FIDELITY ANIMATED FACESG. Csukly 1 , L. Simon 1 , B. Kiss 2 , B. Takács 31 Department of Psychiatry and Psychotherapy, SemmeleisUniversity, Budapest, Hungary; 2 VerAnim, Budapest, Hungary;3 WaveBand/Digital Elite, Los Angeles, California, USAWe describe the development and early clinical testing of a novel psychiatricassessment tool that employs 3D animated faces of virtualhumans animated in real-time to evoke and measure emotionalresponses of psychiatric patients. The purpose of this new tool is tocreate a screening protocol where repeatable and parametric facialstimuli are presented interactively to patients in order to characterizeand later identify their respective mental disorders using their measuredresponses. The computer system, presented herein, uses photorealisticanimated 3D models of human faces that display basic emotionswhich can be most reliably recognized from facial expressions.The patients’ ability to recognize these basic expressions (neutral,happiness, surprise, fear, anger, disgust or sadness) is used as an indexof their mental health and mapped onto scientifically evaluated symptomsof the respective mental disorders. This paper presents our earlyclinical results demonstrating that the new assessment tool can beeffectively used to screen patients for a group of well defined psychiatricdisorders.PO1.185.THE IMPORTANCE OF TREATMENTFOR VIOLENCE REDUCTION IN SCHIZOPHRENIAR.S. Menezes 1 , E.A. Busnello 21 Instituto Psiquiatrico Forense Mauricio Cardoso and CentroInterdisciplinar de Saúde Mental; 2 Programa de Pós-Graduaçãoem Medicina e Ciências Médicas, Universidade Federal do RioGrande do Sul, Porto Alegre, Rio Grande do Sul, BrazilThe purpose of this presentation is to summarize two studies: a) adescriptive study on the characteristics of the whole population ofpatients of a forensic hospital of Rio Grande do Sul; b) a case-controlstudy of schizophrenic inpatients at the same hospital, focusing on factorsassociated to homicide, with emphasis on previous treatment. Thecharacteristics of 618 individuals admitted to the hospital in the year1999 are presented in the descriptive study. In the case-control study,100 schizophrenic inpatients who committed homicide were comparedwith 185 schizophrenic patients admitted for other crimes. In bothstudies, demographic, judicial, and treatment-related variables wereexplored. In the case-control study, some of these variables were studiedby uni- and bivariate analysis, and by multiple logistic regressionanalysis, constructed in a hierarchical model. The most important findingwas that the patients who did not receive previous treatment beforethe offence had higher homicide rates than those who had receivedtreatment. This finding can be important for public health care, indicatingthe need to develop a psychiatric care network.PO1.186.SCHIZOPHRENIA AND MOTHERHOOD:A CLINICAL CASEG. DanyteRepublican Psychiatric Hospital, Vilnius, LithuaniaThis paper aims to draw attention to the problem of motherhood ofwomen suffering from schizophrenia. Schizophrenia changes the wayof thinking and personality of patients as well as perception andassessment of reality and emotional reaction. There are not much academicdata about the alteration of maternal abilities of women sufferingfrom schizophrenia. It has been observed that their children areaffected by mental disorders 2.5 times more often and have lesser academicabilities than the rest of the population. Part of these childrenare raised by relatives or state institutions as their mothers are notcapable of taking care of them due to frequent hospitalisation andnegative development of their illness. Nevertheless, women sufferingfrom schizophrenia have the right to motherhood. As mentioned inthe Law on Mental Health Care of the Republic of Lithuania, “Mentallyill persons shall have all political, economic, social and culturalrights. There shall be no discrimination on the grounds of mental illness”.We describe the case of a 25 year old single female art universitystudent, having paranoid schizophrenia for 3 years. She wasbrought to our department after the third severe psychotic episodewith Kandinski-Clérambault syndrome, aggressive and inadequatebehaviour. A 5-week pregnancy was detected at the beginning of thetreatment and the patient was willing to sustain it. Her social conditionswere unfavourable (no husband, family support, job), patientwas being uncritical. What are possible treatment and preventionmeasures in such cases?PO1.187.AN INTERVENTION TO CHANGE ATTITUDESTOWARD MENTAL ILLNESS IN WORK SETTINGSM. Ponteri, C. Buizza, R. Pioli, G. RossiFatebenefratelli Institute, Brescia, ItalyThis work is part of the World Psychiatric Association programmeagainst stigma and discrimination because of schizophrenia. We carriedout one of the few Italian studies exploring the attitudes ofemployers and employees toward people suffering from psychiatricdisability. We highlighted which employers’ and employees’ characteristicsare more frequently associated with negative attitudes. Weselected a sample of 39 companies of the manufacturer sector in theprovince of Brescia, a Northern Italian town, in which there is a longestablished iron and textile industry. Two questionnaires were developedwith the purpose to analyse emotional aspects, behaviour intentionsand attitudes of employers and colleagues towards people whosuffer from mental illness. The data collected concern 284 questionnairesfilled in by employees and 39 by employers. At the moment weare making a thorough study of all data and planning specific interventionsin the factories to inform, involve and change attitudes ofemployees and employers.243

PO1.188.CRIMINALITY AND SCHIZOPHRENIA:IS THERE A RELATIONSHIP?A.I. Douzenis, D.E. Katritsis, C.K. TsopelasPsychiatry Department, Athens Medical School, EginitionHospital, Athens, GreeceA review of the recent literature, both Greek and international, wascarried out (1987-2002), using the words criminality, crime, andschizophrenia with Medline as well as a manual search of the Greekpsychiatric journals. The search found only 49 publications in Medlineand only 2 publications in Greek journals. 18-37% of schizophrenicsdemonstrate violent criminal behaviour during their involuntaryadmission to hospital for treatment. This figure decreases duringtreatment but following release from hospital there is a statisticallyhigher likelihood of criminal behaviour in relation to the generalpopulation, as can be ascertained from the arrest figures. Moreover,acute psychotic symptoms, the content of hallucinations and delusions,premorbid personality with an emphasis on antisocial disorders,alcohol or substance use, and exposure to some form of violenceduring childhood or adolescence are factors that contribute to criminalityamong schizophrenics. Schizophrenic assailants are found andarrested more frequently than non-psychotic assailants committingsimilar crimes. Among detainees, schizophrenics are six times morelikely to be violent in relation to their co-detainees. A proper socialsupport framework, good family relations, avoidance of alcohol andsubstance use, lack of physical, psychological and sexual violenceduring childhood and adolescence, as well as the quality of treatmentand compliance with courses of pharmacological treatment all contributeto limiting the appearance of criminal behaviour among schizophrenics.PO1.189.MATRICIDE AND PATRICIDE: NEW DATAA.I. Douzenis, C.K. Tsopelas, D. E. KatritsisPsychiatry Department, Athens Medical School,Eginition Hospital, Athens, GreeceA review of recent bibliography, both Greek and international, wascarried out (1987-2002), using the words matricide, patricide andmental illness. The search found only 23 publications in Medline andonly 1 publication in the Greek journals. 1 out of 10 of all homicidesare parent killings. Patricides (0.7–1.1) outnumber matricides (0.6-0.8), and 75% of the assailants are aged over 18. Among adolescents,the ratio sons/daughters is 15 to 1, while among adults the ratio is 5to 1. In both cases the victims are father to mother in a ratio of 2 to 1.Predisposing factors are: mental illness, antisocial personality disorder,alcohol and other dependence-inducing substance use, cessationof drug treatment, the availability of weapons, a background of familyviolence, abuse during the assailant’s adolescence, warnings givenbefore the crime, as well as threat of suicide. Of these people releasedfrom prison, only 8% are sentenced for another crime (but not murder).Overall, parent killers are predominantly adolescents who havebeen abused, or adult middle-aged women who lived with decrepit,autarchic mothers, fully isolated from society, or mental patients withcomorbid substance abuse.PO1.190.PSYCHOLOGICAL AND MOTIVATION DIFFICULTIESIN YOUNG PEOPLE WITH MILD SCHIZOPHRENIAR. Andrezina, M. TaubeDepartment of Psychiatry, Riga Stradins University;Psychiatry Centre of Latvia, Riga, LatviaIn the last 9 years we carried out an extensive study of outpatientswith mental disorders in one community in Riga (60,000 inhabitants)and analyzed data from mental health information system (60,924patients in year 2003). In 1995/1996 we interviewed and analyzed640 patients and their data, in 1999/2000 we interviewed and analyzed429 patients. In general, the reform of psychiatry in our countryis carried out similarly to so-called model of Canada. According tothis model, ambulatory care is implemented not only in medical careinstitutions, but also in day centers, where occupational therapy isprovided. A mathematical analysis showed that interviewed patientscan be divided into three groups. One of them consisted of youngpeople who suffered from relatively mild schizophrenic forms. Thesepeople do not have a significant disability. Several of them want towork and/or practice occupational therapy. The main problems inthese patients are lack of energy and activity and an autistic lifestyle.Social obstacles, stigmatization and lack of information in the generalpopulation represent further difficulties.PO1.191.A UNIVERSITY COLLEGE STUDENT POPULATIONSURVEY ON STIGMATISATION OF PEOPLE WITHMENTAL DISORDERS IN VARESE, ITALYC. Callegari, F. Baranzini, M. Diurni, S. VenderDepartment of Medicine and Public Health, Section of Psychiatry,University of Insubria, Varese, ItalyWe tested the attitudes of a sample of University college students towardspeople with mental disorders. The Community Attitudes to Mental Illness(CAMI) questionnaire was adapted by the study group. The studywas conducted at the Varese University College of Medicine, previouslyhosting a mental health hospital. The questionnaire was administered to180 students. Compared with the general population of the same area,students seem to have a better knowledge, a higher acceptance level, buta lower personal experience about mental illnesses.PO1.192.PREJUDICE AND TOLERANCE TOWARDS PEOPLEWITH MENTAL DISORDERS IN VARESE, ITALYC. Callegari, F. Baranzini, S. VenderDepartment of Medicine and Public Health, Section of Psychiatry,University of Insubria, Varese, ItalyAfter the promulgation of the Italian mental act in 1978, communitymental health facilities have been improved. This has led to a closerlink between psychiatric care and socio-cultural organisation. Thisstudy aimed to evaluate the prejudice ad tolerance towards people withmental disorders in a sample from the general population. The CommunityAttitudes to Mental Health (CAMI) questionnaire was adaptedby the study group. The research was conducted in two different areasand the questionnaire was administered to 300 adult people. The existenceof a link between the degree of personal or theoretical knowledgeabout mental illnesses and the tolerance level was confirmed. 80% ofall the interviewed people declared to be ready to work with peoplewho had psychiatric problems in the past. The degree of informationabout the mental health reform process was not uniform.244 World Psychiatry 3:S1 - October 2004

PO1.193.PUBLIC IDENTIFICATION OF MENTALDISORDERS IN SÃO PAULO, BRAZILE.T.P. Peluso, S.L. BlayDepartment of Psychiatry, UNIFESP, São Paulo, BrazilThe study aimed to evaluate whether the population of São Paulo cityis able to identify four mental disorders: schizophrenia, depression,alcohol dependence and dementia. A household survey was carriedout with a representative sample of 2000 residents of São Paulo city,aged 18-65 years. The interview was based on a vignette depicting aperson with one of the above diagnoses according to the DSM-IV.Only one vignette was presented to each respondent. They wereasked to identify what kind of problem the person described had andif it was a mental illness. More than 90% of the sample declared thatthe person described in the vignette had some sort of problem.Answers about the kind of problem indicated that schizophrenia wasidentified mainly as depression (23%). Only 2% correctly identifiedschizophrenia. Depression was correctly labeled by 44% of the population.Dementia was labeled as a memory problem (46%). Only 4%mentioned dementia or Alzheimer’s disease. Alcohol dependencewas identified as alcoholism by 31% and chemical/alcohol dependenceby 20%. Schizophrenia was identified as a mental illness by 57%of the sample, dementia by 39%, depression and alcohol dependenceby 19%. In conclusion, the majority of the São Paulo population isable to recognize some sort of mental or emotional problem, althougha small proportion thinks it is a mental illness. Specific diagnoses arerarely identified, especially those of schizophrenia and dementia.PO1.194.A QUALITATIVE STUDY ABOUT CONCEPTSAND ATTITUDES TOWARD MENTAL ILLNESS:20 CHILDREN OF CHRONIC MENTALLY ILLPARENTS TELL THEIR STORIESM. Aguilar, Y. FregosoMental Health Institute of Jalisco, MéxicoThe point of view of children about mental illness is rarely investigated.We studied 20 Mexican children aged 8-12 years with at least oneparent suffering from a chronic mental disorder. Their perceptionsand feelings about mental illness were explored. A semi-structuredinterview and a projective technique were applied and life storieswere collected. Inner fears, presence of guilt, and misconceptionswere observed. Some children showed interpersonal difficulties aswell as problems with attachment. Functional coping skills fromcaregivers proved to be a protective factor. We present a psycho-educationalmodel for children and their families based upon theseresults.PO2MOOD, ANXIETY AND EATING DISORDERS; CHILDPSYCHIATRY; SUBSTANCE ABUSEPO2.1.THE SOCIO-ECONOMIC BURDEN OF BIPOLARDISORDER IN THE NETHERLANDSL. Hakkaart-van Roijen 1 , M.B. Hoeijenbos 1 , E.J. Regeer 2 ,M.J. ten Have 3 , W.A. Nolen 2,4 , C.P.W.M. Veraart 5 , F.F.H. Rutten 11 Institute for Medical Technology Assessment, Erasmus MedicalCentre, Rotterdam; 2 Altrecht Institute for Mental Health Care,Utrecht; 3 The Netherlands Institute for Mental Health andAddiction, Utrecht; 4 University Hospital Groningen; 5 Eli Lilly,The NetherlandsThe Netherlands Mental Health Survey and Incidence Study(NEMESIS) is a prospective survey in the Dutch general populationamong 7,067 respondents aged 18 to 64. In a follow-up study respondentswere identified by using the Structured Clinical Interview(SCID-I) resulting in a DSM-IV diagnosis of bipolar disorder (BD).The objective was to assess the quality of life and costs to society ofpatients suffering from BD in the Netherlands. Forty persons identifiedwith a lifetime diagnosis of BD were interviewed. Data on medicalhealth care utilisation (direct costs) and production losses due toabsence from work and efficiency losses (indirect costs) as well asquality of life was collected. For the quality of life we applied validatedgeneric instruments: the EuroQol-5 Dimensions (EQ5D) and theShort-Form 36. The average direct costs per patient per year wereestimated at 897 Euro (range: 0-3200). The average indirect costs peryear was 3720 Euro (range: 0-6373) of which 86% was due to absencefrom work. The average score on the EQ5D was 0.82. The quality oflife was not significantly lower for the BD population compared tothe general population (0.87). Based on the prevalence of 5.2% thetotal costs of bipolar disorder were estimated at 1.93 billion Euro(total direct costs=480 million Euro; total indirect costs=1.45 billionEuro). In conclusion, the societal costs for bipolar disorder in theNetherlands were high, especially the indirect costs due to absencefrom work. Quality of life was not significantly decreased comparedto the general population.PO2.2.PREVALENCE OF BIPOLAR SPECTRUMDISORDERS IN UK ADULTS USING THE MOODDISORDER QUESTIONNAIREP. DeDoncker 1 , R.M.A. Hirschfeld 2 , T. Frangiosa 3 , M. Mehra 3 ,M. Reed 41 Janssen-Cilag Ltd., Beerse, Belgium; 2 University of Texas MedicalBranch, Galveston, TX, USA; 3 Johnson and JohnsonPharmaceutical Services, Raritan, NJ, USA; 4 Vendanta Research,Chapel Hill, NC, USAThe lifetime prevalence of bipolar I and II disorders in adults in theUnited States was estimated to be 3.4%, using the Mood DisorderQuestionnaire (MDQ), a screening instrument for bipolar disorder.The MDQ was mailed to a nationwide sample of 127,000 people inthe United States, with 85,358 returning usable questionnaires (67%response rate). The present study aimed to estimate the lifetime prevalenceof bipolar disorder in adults in the UK. The MDQ was mailed toa representative sample of 15,000 UK households for completion byup to two adult household members. Samples were balanced withEurostat data for age, gender, region, market size and household size.A positive MDQ was defined as seven or more symptoms, co-occur-245

ence of two or more symptoms, and moderate or severe impairment.We will report on the survey response rate, overall prevalence adjustedfor non-response bias, bipolar disorder detection/diagnosis rates,depression only misdiagnosis rate and demographic characteristics ofpositive cases.PO2.3.PREVALENCE OF BIPOLAR SPECTRUMDISORDERS IN UK ADOLESCENTS USINGTHE MOOD DISORDER QUESTIONNAIREP. DeDoncker 1 , R.M.A. Hirschfeld 2 , T. Frangiosa 3 , M. Mehra 3 ,M. Reed1 Janssen-Cilag, Beerse, Belgium; 2 University of Texas MedicalBranch, Galveston, TX; 3 Johnson and Johnson PharmaceuticalServices, Raritan, NJ; 4 Vendanta Research, Chapel Hill, NC, USAThe lifetime prevalence of bipolar I and II disorders in adults in theUnited States was estimated to be 3.4%, using the Mood DisorderQuestionnaire (MDQ), a screening instrument for bipolar disorder. Anationwide sample of 127,000 people in the United States was surveyedand 85,358 (67% response rate) participated in the study. Anadolescent version of the questionnaire has been developed and validatedin the US. This study aimed to estimate the lifetime prevalenceof bipolar disorder in adolescents in the UK. The MDQ was mailed toa representative sample of 15,000 UK households. Parental heads ofhousehold from the sample were asked to complete the questionnaireon behalf of all adolescents (age 12-17) within their homes. Sampleswere balanced with Eurostat data for age, gender, region, market sizeand household size. A positive MDQ was defined as seven or moresymptoms, co-occurrence of two or more symptoms, and moderate orsevere impairment. We will report the survey response rate, weightedprevalence for adolescents at each age, overall prevalence adjustedfor non-response bias, bipolar disorder detection/diagnosis rates,depression only misdiagnosis rate and demographic characteristics ofpositive cases.PO2.4.PREVALENCE OF BIPOLAR DISORDERIN A NATIONAL MANAGED CARE HEALTH PLANC.R. Harley 1 , R.M. Hirschfeld 2 , H. Li 3 , G. L’Italien 3 ,A.M. Walker 1 , W. Carson 41 Ingenix, Research and Data Solutions Group, Eden Prairie, MN;2 University of Texas Medical Branch, Galveston, TX;3 Bristol-Myers Squibb Company, Wallingford, CT;4 Otsuka America Pharmaceutical Inc., Princeton, NJ, USADespite significant financial burden of bipolar disorder, prevalence ofbipolar disorder, as well as comorbidities, in the privately insuredpopulation has not been reported. This study aimed to estimate treatedprevalence of bipolar disorder in a large US commercial healthplan and to assess common comorbidities. Bipolar disorder was identifiedusing ICD-9-CM diagnosis codes on insurance claims for medicalservices. Average annual prevalence was calculated for 1999-2002. Diabetes was identified using the relevant diagnosis code. Commondiagnoses were measured based on frequency of occurrence onmedical claims. Annual prevalence of treated bipolar disorder was262 per 100,000 enrollees (0.26%). Prevalence of treated diabetesamong these bipolar disorder patients was 68 per 1000 (6.80%). Generalsymptoms was the most frequent comorbidity, followed by neuroticdisorder and essential hypertension. Diabetes was the 11th mostcommon diagnosis. The prevalence of bipolar disorder found in thisstudy was lower than national estimates, and diabetes prevalencewithin the bipolar disorder population was also lower than publisheddata. These findings may reflect a healthier, insured, working-agedpopulation, misdiagnosis or underdiagnosis of bipolar disorder, andfrequency of medical services.PO2.5.PREVALENCE, INCIDENCE, AND COMORBIDITYAMONG PATIENTS WITH BIPOLAR DISORDERSIN A MANAGED CARE MEDICAID POPULATIONJ.J. Guo 1 , P.E. Keck Jr. 1 , R. Jang 1 , H. Li 2 , D. Jiang 1 , W. Carson 31 University of Cincinnati Medical Center, Cincinnati, OH;2 Bristol-Myers Squibb Company, Wallingford, CT;3 Otsuka Pharmaceutical Inc., Princeton, NJ, USAThis study aimed to identify prevalence and incidence rates of bipolardisorders, and to categorize medical comorbidities among patients withbipolar disorders in a managed care Medicaid population. Using amulti-state claims database, patients who had at least 3-months continuousenrollment and at least one bipolar diagnosis, indicated by the relevantICD-9 codes, from January 1, 1998 to December 31, 2002 wereselected. The monthly prevalence rates of bipolar disorder increasedwith age, with the peak prevalence (2.1%) occurring in the 35–49 yearage range. Of 13,396 identified bipolar patients, 64.2% were female,with an average age of 29.4±13.8 years. Lifetime bipolar diagnostic categoriesindicated 88.17% with bipolar I disorder, and 11.83% withbipolar II disorder. Analysis of patients’ last bipolar diagnoses showed4.95% with psychosis, 12.8% with mania, 58.1% with mixed state,22% with depression, and 7.1% with hypomania. Severity categorieswere: severe, 11%; moderate, 8.6%; mild, 2.1%; remission, 2.2%; andunspecified, 76.1%. Key comorbidities of psychiatric disorders included:previous major depression, 41.7%; anxiety disorder, 36.1%; alcoholuse disorder, 8.2%; substance use disorder, 9.6%; and personality disorder,4.5%. General comorbidities included: hypertension, 13%; diabetesmellitus, 7.2%; obesity, 7.9%; chronic obstructive pulmonary disease,4%; arthritis, 1.5%; neoplasm, 0.4%; ischaemic heart disease,2.2%; and cerebral vascular diseases, 1.7%. This analysis reveals theprevalence and characteristics of bipolar disorder among patients in amanaged care Medicaid population, underlining the significant healthburden associated with this disorder.PO2.6.HEALTHCARE UTILIZATION FOR BIPOLARDISORDER IN A MANAGED CARE ORGANIZATIONR.L. Knoth 1 , K. Chen 1 , E. Tafesse 21 Prescription Solutions, Costa Mesa, CA; 2 Bristol-Myers SquibbCompany, Wallingford, CT, USAThe purpose of this study was to determine the direct healthcareexpenditures incurred by patients diagnosed with bipolar disorder ina managed care organization. Continuously enrolled adult patientswith a medical claim for a diagnosis of bipolar disease between July 1,2000 and June 30, 2001 were identified. All pharmacy and medicalclaims for these patients were then examined in the one-year periodfollowing the index diagnosis. A total of 4397 patients met the inclusioncriteria. The average age of the identified cohort was 53 years,and 66.1% were female. Among these patients, a total of 91.3% wereprescribed a psychotropic medication, and average annual pharmacycosts, based on ingredient costs, totalled $1940 per person. In addition,29.7% of the patients had at least one hospital admission, 39.1%had at least one emergency department visit, and each patient averaged10.6 outpatient visits. Average annual medical costs, based onsubmitted charges, totalled $30,811 per patient and direct healthcare246 World Psychiatry 3:S1 - October 2004

expenditures for this cohort totalled more than $144 million. Theseresults demonstrate that patients diagnosed with bipolar disorder arehigh utilizers of medical services compared to the average health planmember, which indicates the need for creative and innovative programsto manage this population.PO2.7.COGNITIVE IMPAIRMENT IN ACUTEAND REMITTED BIPOLAR PATIENTSJ. Sanchez-Moreno, A. Martínez-Arán, C. Torrent, E. VietaBipolar Disorders Program, Clinical Institute of Psychiatry andPsychology, Hospital Clinic, University of Barcelona, SpainThere is increasing evidence that bipolar patients show cognitiveimpairments which are not only restricted to the acute episodes of theillness but also to remission periods. Nevertheless, there is controversyamong authors with regard to what kind of cognitive dysfunctionspersist in euthymic states. Moreover, there are some clinical factorssuch as relapses or subclinical symptoms which influence cognitivefunctioning in bipolar patients. On the other hand, recent studieshave emphasized the influence of cognitive impairment on the psychosocialfunctioning of bipolar patients. Several areas of cognitivefunctioning were examined in 30 depressed bipolar patients, 34manic or hypomanic bipolar patients and 44 euthymic bipolarpatients. The control group consisted of 30 healthy subjects withouthistory of neurologic or psychiatric disorders. A neuropsychologicalbattery assessed attention, executive function, verbal and visual memory.The three patient groups showed cognitive impairment in verbalmemory and frontal executive tasks compared with the control group.Patients with history of psychotic symptoms, bipolar I type, longerduration of illness and a higher number of manic episodes were theones that were more likely to show neuropsychological disturbances.Poor neuropsychological performance was associated to poor functionaloutcome. These results suggest that psychotherapeuticapproaches should address these cognitive impairments in order toimprove quality of life in bipolar patients.PO2.8.PREDICTORS OF TIME TO RELAPSEIN BIPOLAR I DISORDERM. Tohen 1,2 , C. Bowden 3 , J. Calabrese 4 , G. Sachs 5 , R. Risser 1 ,H. Detke 1 , H. Shen 1,61 Lilly Research Laboratories, Indianapolis, IN; 2 Harvard MedicalSchool/McLean Hospital, Belmont, MA; 3 University of TexasHealth Science Center, San Antonio, TX; 4 Case Western ReserveUniversity School of Medicine, Cleveland, OH; 5 Harvard MedicalSchool/Massachusetts General Hospital, Boston, MA; 6 IndianaUniversity School of Medicine, Indianapolis, IN, USAIn bipolar disorder, optimal treatment planning depends upon earlyprediction of illness course. The following post-hoc analyses examinedpredictors of time to relapse using pooled data from two bipolarmaintenance studies. Subjects were 779 patients who achieved symptomaticremission from a manic or mixed index episode and entereddouble-blind maintenance therapy for up to 48 weeks with olanzapine(n=434), lithium (n=213), or placebo (n=132) following 6-12weeks of acute open-label treatment with either olanzapine (Study 1)or olanzapine-lithium cotherapy (Study 2). Various patient and illnesscharacteristics were assessed as possible predictors using Coxregression analyses, adjusted for therapy. Rapid cycling course, mixedindex episode, number of mood episodes in the past year, early onset,bipolar family history, female gender, and lack of prior hospitalizationfor bipolar disorder were all significant predictors of shorter time torelapse. Stepwise analysis suggested that history of rapid cycling anda mixed index episode were the strongest predictors of time torelapse. Analysis by type of maintenance therapy also yielded differentialpredictors. In these samples, history of rapid cycling course,presenting with a mixed index episode, and >1 manic episode in thepast year were most strongly predictive of a shorter time to relapse.PO2.9.DIAGNOSIS OF BIPOLAR II DISORDER:OVERCOMING PROBLEMSF. BenazziE. Hecker Outpatient Psychiatry Center, Forlì, ItalyThis study aimed to explore the degree of agreement in the diagnosisof bipolar II disorder (BP-II) between the DSM-IV Structured ClinicalInterview (SCID-CV) and a semi-structured interview based onAngst’s hypomania checklist, and to assess priority among symptomsfor BP-II diagnosis. 102 remitted depression outpatients were interviewedwith SCID-CV and then with Angst’s semi-structured interviewfollowing DSM-IV criteria. The SCID identified 29 cases of BP-II, 26 of bipolar I disorder (BP-I), and 47 of major depressive disorder(MDD). The semi-structured interview identified 69 cases of BP-II, 33of MDD, and none of BP-I. The agreement for BP-II diagnosisbetween the two interviews was 53.9%, k=0.18. Re-analysis afterdeleting the SCID question on impact on functioning increased theagreement to 78.4%, k=0.55. Elevated mood and overactivity had thelowest kappa agreement (k=0.46, 0.49). For predicting BP-II, overactivityhad the highest sensitivity (94.2%, elevated mood had 84.0%).Multiple regression for predicting BP-II, including all hypomanicsymptoms, found that mood change and overactivity were the onlystrong and independent predictors. Overactivity plus at least 3 symptomswas present in 71, of whom 91.5% met also DSM-IV criteria forhypomania. Overactivity and elevated mood were strongly associated.These findings support a diagnosis of BP-II based on Angst’s semistructuredinterview (performed by a clinician) versus fully structuredSCID interview. While DSM-IV always requires mood change for thehypomania diagnosis, these findings suggest that overactivity couldhave at least the same priority level.PO2.10.HYPOMANIA AND MANIA HAVE DIFFERENTSYMPTOM PROFILESA. Serretti, P. OlgiatiDepartment of Psychiatry, Vita-Salute University,San Raffaele Institute, Milan, ItalyAccording to DSM-IV, manic and hypomanic episodes differ only inthe degree of severity. Yet several lines of evidence, including familyhistory, long-term diagnostic stability and linkage studies, point tobipolar I (BP-I) and bipolar II (BP-II) disorders being distinctforms. This suggests that mania and hypomania, which are the hallmarksof the two disorders, might have different symptom profiles.To test this hypothesis, we compared manic symptoms occurring intwo BP-I and BP-II groups. 280 bipolar inpatients were assessedusing the operational criteria for psychotic illness checklist with alifetime perspective. Manic or hypomanic symptoms were investigatedand compared between BP-I (n=158) and BP-II (n=122)patients. When compared with BP-II, BP-I disorder had a higherprevalence of reckless activity, distractibility, psychomotor agitation,irritable mood and increased self esteem. These five symptomscorrectly classified 82.8% of BP-I and 80.1% of BP-II patients.247

These findings suggest that mania and hypomania can be differentiatedin their clinical profiles and serve to address the question ofbipolar disorder nosography, that is whether BP-I and BP-II are thesame or two distinct diseases. In fact, the different manic profilesmight be a manifestation of a greater severity, or they might reflect adifferent physiopathology.PO2.11.PHARMACOLOGICAL TREATMENTSOF 250 BIPOLAR I PATIENTS DURING A1-YEAR NATURALISTIC FOLLOW-UP STUDYA. Piccinni 1 , A. Tundo 2 , A. Del Debbio 1 , E. Schiavi 1 ,M.C. Monje 1 , M.G. Blotta 1 , A. Mariotti 1 , A. Bianchi 1 , A. Palla 1 ,G.J. Massei 1 , F. Simonetti 1 , I. Roncaglia 1 , P.F. Indrieri 1 ,L. Dell’Osso 11 Department of Psychiatry, Neurobiology, Pharmacologyand Biotechnology, University of Pisa; 2 Institute ofPsychopathology, University of Rome, ItalyThe prevention of recurrence and the acute management of depressiveand manic episodes are the major goals in the treatment of bipolardisorder, characterized by a persistent, severe and lifelong course.Maintenance studies of lithium, divalproex and carbamazepine suggestthat these medications have efficacy in this phase of illness managementbut that only a minority of patients do well with treatmentwith any one of this agents alone. Case reports and open trials consistentlyindicate that patients who have responded inadequately to asingle drug may obtain better acute and lasting improvement whenfurther medications are added. Recent studies found that long-termlithium-based treatment is less effective in mixed mania, secondarymania and mania associated with substance abuse, as well as rapidcycling. Our aim was to evaluate the clinical features, the relapse predictorsand the maintenance therapy in a population of 250 bipolarpatients during a 1-year naturalistic follow-up study. Socio-demographicand clinical variables and maintenance treatment data werecollected. Results showed that 3.6%, 48.8% and 6.8% of patientswere treated with one, two or three mood stabilizers, respectively.58% of patients received also antidepressants, 14% typical and 37%atypical antipsychotics. There was no relapse in 31% of subjects and90% of them showed a 50% reduction of illness duration. The risk ofrelapse seemed to increase in patients with depression at the firstepisode; rapid, switching cycling and worse treatment compliance.Data suggest that combination maintenance therapy may be effectivein reducing the risk of episode recurrence and symptoms overall inbipolar patients.PO2.12.PHARMACOLOGICAL TREATMENT OFACUTE MANIA ACROSS EUROPE:BASELINE FINDINGS FROM THE EUROPEANMANIA IN BIPOLAR LONGITUDINAL EVALUATIONOF MEDICATION (EMBLEM) STUDYI. Goetz 1 , J.M. Haro 2 , I. Gasquet 3 , M. Lorenzo 1 ,J. van Os 4 , on behalf of the EMBLEM Advisory Board1 Eli Lilly and Company, Windlesham, UK; 2 Sant Joan De Deu-SSM, Barcelona, Spain; 3 Hôpital Paul Brousse, Villejuif, France;4 Maastricht University, The NetherlandsThe European Mania in Bipolar Longitudinal Evaluation of Medication(EMBLEM) is a 2-year prospective, observational study on theoutcomes of pharmacological treatment for mania conducted in 13European countries. Adult patients with a diagnosis of bipolar disorderare enrolled within the standard course of care as in- or outpatientsif they have initiated/changed oral medication (excluding benzodiazepines)for treatment of acute mania. All treatment decisionsare at the discretion of the treating psychiatrist. Patients are enrolledin 2 principal cohorts: 1) initiated/changed to olanzapine, and 2) initiated/changedto non-olanzapine treatment. 600 psychiatrists areenrolling 4000 patients between December 2002 and March 2004using the same study methods assessing demographics, psychiatrichistory, clinical status (Clinical Global Impression, Young Mania RatingScale, Hamilton Scale for Depression, Life Chart Method), functionalstatus (relationships, dependants, housing conditions, work,social contacts, Slice of Life items) and pharmacological treatmentpatterns including tolerability, compliance, and concomitant medication.Data collection is currently ongoing. At the time of writing,2,500 patients have been enrolled. We will present: 1) descriptivebaseline data of the patient population including sociodemographicand clinical characteristics and 2) comparisons between participatingcountries in terms of clinical severity, functional status and treatmentpatterns of included patients. As the biggest naturalistic study so farconducted in bipolar disorder, EMBLEM will provide invaluableinformation on important differences in patterns of care for mania inpatients receiving pharmacological treatment in routine clinical practice.PO2.13.TIME IN EUTHYMIA FOR BIPOLARPATIENTS RECEIVING OLANZAPINEOR LITHIUM MAINTENANCE TREATMENTM. Tohen 1,2 , R. Risser 1 , H. Detke 1 , T. Forrester 1 , S. Corya 11 Lilly Research Laboratories, Indianapolis, IN; 2 Department ofPsychiatry, Harvard Medical School/McLean Hospital, Belmont,MA, USAIn evaluating maintenance therapies for bipolar disorder, it is importantto consider not only time to relapse but also time in euthymia.The following post-hoc analyses compared time in euthymia forpatients receiving either olanzapine or lithium. 543 patients withbipolar I disorder, manic or mixed type (Young Mania Rating Scale,YMRS ≥ 20), with a history of at least 2 manic or mixed episodeswithin 6 years, entered the study and received open-label combinationtherapy with olanzapine and lithium for 6-12 weeks. Of these,431 patients met symptomatic remission criteria (YMRS total score≤12 and Hamilton Scale for Depression, HAMD-21 total score ≤8)and were randomized to either olanzapine (n=217) or lithium(n=214) for 12 months of double-blind treatment. Time in euthymiawas defined as the number of days in remission and free of any subsyndromalsymptoms (YMRS=13-14; HAMD=9-14) during doubleblindtreatment. Patients receiving olanzapine maintenance treatmentremained in euthymia for a median of 241 days compared with177.5 days (p=0.26) for lithium patients. Olanzapine patientsremained free of subsyndromal manic symptoms for a median of 250days compared with 186 days (p=0.34) for lithium patients. Olanzapinepatients remained free of subsyndromal depressive symptoms fora median of 241 days compared with 177.5 days (p=0.27) for lithiumpatients. Subsyndromal symptoms occurred relatively infrequently, inonly 19.8% of olanzapine patients and 21.5% of lithium patients. Inconclusion, olanzapine was similar to lithium in terms of patients'median number of days in euthymia, and subsyndromal symptomsaccounted for a small amount of patients' time while in the study.248 World Psychiatry 3:S1 - October 2004

PO2.14.LONG-TERM USE OF OLANZAPINEOR OLANZAPINE/FLUOXETINE FOR BIPOLARDEPRESSIONM. Tohen 1,2 , E. Vieta 3 , T. Ketter 4 , J. Calabrese 5 , S. Andersen 1 ,H. Detke 1 , R. Risser 1 , S. Corya 11 Lilly Research Laboratories, Indianapolis, IN, USA; 2 HarvardMedical School/McLean Hospital, Belmont, MA, USA; 3 BipolarDisorders Program, Barcelona, Spain; 4 University of Stanford, CA,USA; 5 Case Western Reserve University, University Hospitals ofCleveland, OH, USAOlanzapine/fluoxetine combination (OFC) has shown efficacy intreating bipolar depression. Present analyses examined 6-monthmaintenance data for subjects who achieved remission of depressivesymptoms following acute treatment. 379 subjects with bipolardepression completed 8 weeks of randomized, double-blind treatmentusing olanzapine (OLZ, n=179), placebo (n=145), or OFC(n=55). Of these, 192 were in remission (MADRS ≤ 12) upon enteringopen-label treatment, at which time they were switched from theiracute-phase treatment to 5-20 mg/day open-label OLZ. After 1 weekon OLZ, subjects could be switched to OFC as needed. Primary efficacymeasure was the Montgomery-Åsberg Depression Rating Scale(MADRS). Manic symptoms were monitored using the Young ManiaRating Scale (YMRS). Time to relapse (MADRS >15) was estimatedusing Kaplan-Meier survival analysis. Of the 192 remitters, 120(62.5%) remained free from relapse over the 6-month open-label period.For the 72 subjects (37.5%) who relapsed, median time to relapsewas 194 days. Mean MADRS total score at open-label endpoint was7.93 (SD 9.24, n=192) using a last-observation-carried-forward(LOCF) methodology. This open-label study suggests that OLZ andOFC may represent treatment options in the long-term managementof bipolar depression. Further studies are necessary to replicate thesefindings using appropriate controls and double-blind methodology.PO2.15.EFFECT OF OLANZAPINE/FLUOXETINECOMBINATION ON CORE MOOD SYMPTOMSIN BIPOLAR DEPRESSIONS. Corya 1 , S. Briggs 1 , M. Case 1 , M. Tohen 1,21 Lilly Research Laboratories, Indianapolis, IN;2 Harvard Medical School/McLean Hospital, Belmont, MA, USADepression scales frequently incorporate items addressing somaticsymptoms such as disturbed sleep and appetite. Patients can experienceimprovements in these physical symptoms of depression whilestill having depressed mood. This post-hoc analysis examines theeffect of olanzapine/fluoxetine combination on core mood symptomsin bipolar I depression. 833 subjects with bipolar depression wereenrolled in this 8-week double-blind study and were randomized toolanzapine (n=370), placebo (n=377), or olanzapine/fluoxetine combination(n=86). Core mood was measured by an index created fromthe sum of items 1 (apparent sadness), 2 (reported sadness), 6 (concentrationdifficulties), 8 (inability to feel), 9 (pessimistic thoughts),and 10 (suicidal thoughts) of the Montgomery-Åsberg DepressionRating Scale (MADRS). Analyses utilized a last-observation-carriedforward(LOCF) methodology. Olanzapine/fluoxetine combination (-10.4±7.4) and olanzapine (-7.5±7.9) showed greater baseline-to-endpointdecreases in core mood items than placebo (-6.2±7.6, p

egory improvement rates were 66.7% vs. 30.8% (US) (p=0.020) and81.5% vs. 56.3% (ex-US) (p

iprazole compared to placebo. This is the second study to demonstratethe efficacy and safety of aripiprazole in the treatment of acutemania in patients with bipolar I disorder.PO2.22.RELAPSE PREVENTION WITH ARIPIPRAZOLEIN A 26-WEEK PLACEBO-CONTROLLED TRIALIN BIPOLAR DISORDERR. McQuade 1 , R. Sanchez 2 , R. Marcus 2 , W. Carson 3 , L. Rollin 2 ,T. Iwamoto 4 , E. Stock 21 Bristol-Myers Squibb Company, Princeton, NJ, USA; 2 Bristol-Myers Squibb Company, Wallingford, CT, USA; 3 Otsuka AmericaPharmaceutical Inc., Princeton, NJ, USA; 4 OtsukaPharmaceutical Co. Ltd., Tokyo, JapanThe study aimed to compare aripiprazole with placebo in maintainingthe stability of patients with bipolar I disorder in a 26-week, doubleblind,relapse prevention study. Patients who had recently experienceda manic or mixed episode received aripiprazole 15–30 mg/day (startingdose 30 mg/day) for 6–18 weeks in an initial open-label stabilisationphase. 161 patients met stabilisation criteria (Young Mania RatingScale ≤10 and Montgomery-Asberg Depression Rating Scale ≤13 for 4consecutive visits or 6 weeks), and entered a 26-week, randomised,double-blind, maintenance phase during which they received aripiprazoletreatment or placebo. The primary endpoint was time to relapse ofmanic, mixed, or depressive symptoms (requiring a dosing change inpsychotropic medications other than study drug, or hospitalisation formanic or depressive symptoms). Time to relapse of symptoms was significantlyprolonged with aripiprazole compared to placebo(p=0.020). In addition, patients receiving aripiprazole experienced significantlyfewer relapses (manic, mixed, or depressive symptoms) thanthose receiving placebo (25% vs. 43%, p=0.013). The only adverseevents (≥10% incidence) more commonly reported with aripiprazolethan with placebo were anxiety and nervousness. Aripiprazole prolongstime to relapse of symptoms in stabilised patients with bipolar Idisorder who previously experienced a manic or mixed episode.PO2.23.ZIPRASIDONE IN BIPOLAR MANIA:EFFICACY ACROSS PATIENT SUBGROUPSS.G. Potkin 1 , P. Keck 2 , E. Giller 3 , K. Ice 3 , L. Warrington 4 , A. Loebel 41 University of California, Irvine, CA; 2 University College ofMedicine, Cincinnati, OH; 3 Pfizer Global Research andDevelopment, New London, CT; 4 Pfizer Inc., New York, NY, USAThe study aimed to evaluate the efficacy of ziprasidone in bipolarmania, focusing on clinically relevant subgroups. It was a secondaryanalysis of two randomized, double-blind 21-day trials comparingflexible-dose ziprasidone (40-80 mg bid) to placebo in adults withmania associated with bipolar I disorder. Changes in Mania RatingScale (MRS) and Clinical Global Impression - Severity (CGI-S) werecalculated for combined study populations and in subgroups ofpatients with manic episodes, mixed episodes, and with or withoutpsychotic symptoms. Mean daily dose was approximately 120 mg. Atlast visit (last observation carried forward, LOCF), mean change inMRS in patients receiving ziprasidone (n=268) was -11.72 (baseline26.82) versus -6.69 (baseline 26.53) in patients receiving placebo(n=131) (p

sion-Severity (CGI-S), the primary efficacy variables, continued toimprove from extension baseline up to week 12, with improvementsustained at weeks 28, 52, 76, and 104, and last visit. Concomitantmedications included anxiolytics (77.9%), hypnotics and sedatives(41.7%), antiepileptic drugs (29.9%), antidepressants (27.6%), andlithium (14.1%). Ziprasidone was well tolerated; 15 (11.8%) patientsdiscontinued due to treatment-related adverse events. Fourteen(12.5%) patients had weight gain ≥7% and 20 (17.9%) weight loss≥7%. In conclusion, ziprasidone is associated with long-term symptomand global improvement in patients with bipolar I disorder and iswell tolerated, with a weight-neutral profile.PO2.26.RETROSPECTIVE ASSESSMENT OF RISK FACTORSFOR TREATMENT EMERGENT GLUCOSEABNORMALITIES DURING RANDOMIZED, DOUBLE-BLIND CLINICAL TRIALS OF MEDICATIONS FORTREATMENT OF BIPOLAR DISORDERT.A. Hardy, C. Carlson, M. Case, X.L. Huang, P. CavazzoniLilly Research Laboratories, Indianapolis, IN, USAWe retrospectively examined a large database pooled from multiplerandomized, double-blind clinical trials of medications for treatmentof bipolar disorder. Non-fasting glucose values were used to identifypatients with treatment emergent diabetes (TED, two non-fasting glucosevalues of at least 200 mg/dl during the study, an endpoint nonfastingglucose value of at least 200 mg/dl, new clinical diagnosis ofdiabetes, or addition of anti-diabetic medications). Individuals withoutrepeated glucose values of at least 140 mg/dl were considered tohave normal glucose tolerance (NGT). Patient demographics anddiabetes risk factors (age of at least 45 years, body mass index (BMI)of at least 25 kg/m 2 , hypertension, ethnicity, and elevated randomglucose) were assessed in 1382 patients (olanzapine n=982, haloperidoln=170, divalproex n=105, placebo n=105). TED was present in1.3% of patients, with a median time to TED of 61.5 days. Comparingentry characteristics, patients subsequently identified with TED(n=18) were more obese (BMI 35.3±8.6 vs. 27.4±6.4 kg/m 2 ; p

patients with refractory type I bipolar disorders. Twenty-one outpatientswith type I bipolar disorder who had responded inadequately tostandard treatments were treated in an open-label study with ongoingmedication in combination with quetiapine (increasing doses untilclinical response, 518±244 mg/day) for 26-78 weeks. Illness responsewas assessed using the Clinical Global Impression (CGI) scale.Relapse rates before and during quetiapine treatment were comparedby computing incidence risk ratios. There were highly significant differencesbefore versus during combination quetiapine treatment in theoverall relapse rate (risk ratio = 2.9, 95% CI 1.5-5.6), the manic/mixedrelapse rate (risk ratio = 3, 95% CI 1.5-7.1), and the depression relapserate (risk ratio = 2.4, 95% CI 1.3-4.4). The mean CGI scores improvedsignificantly during quetiapine treatment (p=0.002) and remained significantlybetter over a 52-week maintenance period (p=0.036). Longtermtreatment with quetiapine combination therapy reduced theprobability of manic/mixed/depressive relapses in patients with bipolarI disorder refractory to standard treatment.PO2.30.EFFICACY OF TOPIRAMATE IN THE TREATMENTOF REFRACTORY BIPOLAR I AND II DISORDERA. Gabriel, S. Patten, G. FahimUniversity of Calgary, CanadaThe study aimed to examine the efficacy and tolerability of topiramateas an adjuvant mood stabilizer in treatment resistant bipolar I or II disorder.22 patients with DSM-IV bipolar I or II disorder deemed refractoryto an adequate trial with one or two mood stabilizers receivedadditional treatment with topiramate (average endpoint dose 230mg/day) for 12 weeks. There were 15 patients in a manic, hypomanicor mixed episode and 7 patients in a depressive episode. 11 patientswere male and 11 female; their mean age was 39 years. Efficacy oftreatment was tested on a monthly basis by the Young Mania RatingScale, the Modified Mania State Rating Scale, the Hamilton DepressionScale, and the Clinical Global Impression. Side effects, includingweight changes, were monitored. ANOVA with repeated measuresshowed a significant reduction in the mean scores of all efficacy measures.Medication was well tolerated, and the average weight droppedby seven pounds. Large scale, double blind studies are needed to furtherexplore the efficacy and tolerability of topiramate in bipolar disorders.PO2.31.OPEN ADD-ON OF LEVETIRACETAM INBIPOLAR AND BIPOLAR SPECTRUM PATIENTS:FIRST EVIDENCE OF EFFICACYG. BersaniDepartment of Psychiatric Sciences and Psychological Medicine,La Sapienza University, Rome, ItalyLevetiracetam (LEV) is a new effective antiepileptic drug, with aprevaling GABAergic mechanism of action. The study investigatedthe potential efficacy of LEV add-on to previous treatments, otherthan mood stabilizing agents, in 20 outpatients, 13 males and 7females, affected by bipolar disorder (4 type I, 6 type II) or bipolarspectrum disorders (4 cyclothymic disorder, 2 mixed mania, 4 borderlinepersonality disorder with mixed mood and conduct symptoms).The patients received LEV 500 mg twice a day orally for 60 days,added in an open design to previous antipsychotic and benzodiazepinetreatments, not modified during the study period, that hadinduced an incomplete remission of excitement. The severity ofmania and related symptoms was assessed at day 0, 15, 30 and 60 bythe Bech-Rafaelsen Scale of Mania (BRSM) and the Brief PsychiatricRating Scale (BPRS), 18 items version. Both BRMS and BPRS totaland item scores showed a rapid and significant decrease followingLEV add-on. The results provide a first indication of a positive effectof LEV in excited patients, suggesting an action of LEV on both moodand emotional features of the bipolar syndrome.PO2.32.RE-DEFINING THE PREVALENCE OFBIPOLAR DISORDERS ACCORDING TO ABROAD CLINICAL BIPOLAR SPECTRUMG. Maina, A. Ceregato, U. Albert, F. BogettoDepartment of Neuroscience, University of Turin, ItalyThe aim of the present study was to re-evaluate outpatients given adiagnosis of DSM-IV-TR mood disorder with criteria referring to abroader spectrum of bipolar disorder. All patients referring to theAnxiety and Mood Disorders Unit during a two years period wereassessed by means of the Structured Clinical Interview for DSM-IV(SCID-I). Information from psychiatric records was routinely incorporatedinto the patient’s interview, thereby ensuring a record ofhypomania (and/or mania) if or when it occurred. Patients whosemood disorder diagnosis was confirmed were re-evaluated by a differentinterviewer according to criteria set for a broader definition ofbipolar disorder spectrum, as proposed by Akiskal. 261 outpatientswere included in the present study. According to DSM-IV-TR criteria,220 (84.3%) were diagnosed as affected by a depressive disorder. 41subjects were diagnosed as bipolars (15.7% of the whole group).When patients were reclassified according to the bipolar spectrum, 86subjects switched from the unipolar to the bipolar group, yielding aproportion of unipolars and bipolars of 51.3% (n=134) and 48.7%(n=127) respectively. Therefore, a significant proportion of patientsclassified as depressives according to the DSM-IV-TR criteria couldbe re-classified as bipolars when we used the broadly defined bipolarspectrum. The proper recognition of the entire clinical spectrum ofbipolarity has important implications for the treatment of patientsaffected by mood disorders.PO2.33.BIPOLAR DISORDER IN CHILDRENAND ADOLESCENTSS. Othmani, E. Zaatir, A. Bouden, A. Belhadj, M. HalayamChild Psychiatry Service, Razi Hospital, La Manouba, TunisiaThe purpose of this study was to describe the clinical characteristicsand course of bipolar disorder in children and adolescents. It was carriedout in 54 patients hospitalized at least once during the period1996-2003. Bipolar disorder was diagnosed according to DSM-IV. Inthe first hospitalization, the patients’ mean age was 15.8 years (range12-19 years). The sex ratio was about 2:1 in favour of females. Hereditywas found in 94% of cases. In patients below the age of 16, symptomswere frequently atypical. In those above the age of 16, drugabuse was often observed. The use of mood stabilizers in combinationwith psychotherapy and sociotherapy influenced significantly thesubsequent course of the disorder.253

PO2.34.THREE CASE REPORTS ON THE USE OFRISPERIDONE IN THE LONG-TERM TREATMENTOF BIPOLAR DISORDERK.N. Fountoulakis, I. Nimatoudis, A. Iacovides, G. Kaprinis3rd Department of Psychiatry, Aristotle University ofThessaloniki, GreeceWe report on three female bipolar patients who were partial respondersto lithium, and unresponsive to other therapies (anticonvulsants,antidepressants, typical antipsychotics, various combinations). Theyhad suffered from at least one manic and one depressive episode peryear. All of them presented a complete remission of symptoms aftercombination therapy with lithium (plasma levels above 0.8 mEq/l)and risperidone 1-3 mg/day. Two of them have been asymptomatic for16 and 17 months respectively. The third patient, after several monthsduring which she was asymptomatic, discontinued lithium against thepsychiatrist’s advice and took only 3 mg of risperidone daily. For thenext 18 months the patient has been on risperidone monotherapy andasymptomatic.PO2.35.PHARMACOLOGICAL TREATMENT ANDQUALITY OF LIFE OF BIPOLAR PATIENTS:CORRELATION WITH CLINICAL FEATURESM.L. Figueira, V. Ramos, L. SeverinoDepartment of Psychiatry, Santa Maria Hospital, Universityof Lisbon, PortugalBipolar patients are reported to have a significant impairment inhealth related quality of life when compared with the general population.There are reports showing that high levels of anxiety in bipolarpatients are associated with impairment in community functioning.Also, the number of episodes, mainly the depressive ones, correlatednegatively with inter-episode functioning. There are also reports thata poor adherence to treatment is associated with a poorer outcome.Nevertheless there is still lack of data concerning the clinical correlatesof impairment, namely the type of pharmacological treatmentand adherence to treatment. The objective of our study is to explorethe relationship between health related quality of life, type of treatmentand adherence to treatment, and the relationship between clinicalfeatures such as age of first episode, length and number ofepisodes, polarity of episodes, comorbidity with anxiety, current levelsof anxiety, and quality of life. Forty euthymic patients (bipolar Iand II) with a long follow-up in a psychiatric university hospital or aprivate clinic were assessed with the Well-Being Questionnaire(WBQ) and Psychological General Well-Being Schedule (PGWBS).We recorded the type of medication, adherence to treatment, numberof episodes and hospitalizations, age at first episode, length and numberof episodes and polarity of episodes by a semi-structured interview,complemented by the consultation of the clinical records. Anxietysymptoms were assessed by the Hamilton Anxiety Scale (HAMA)and a semi-structured interview. Preliminary results indicate thatinter-episode anxiety has a strong negative correlation with quality oflife. The use of atypical antipsychotics appears to be correlated with abetter adherence to treatment, a decreased number of hospitalizationsand a better quality of life versus the use of typical antipsychotics.The length and number of depressive episodes seem to becorrelated negatively with quality of life (regardless the treatment).PO2.36.PLASMA LEVELS OF MOOD STABILIZERSAND RELAPSES IN BIPOLAR DISORDERSP. Olgiati 1 , P. D’Innella 21 Villa Cristina Clinic, Turin; 2 Department of Psychiatry,University of Eastern Piedmont, Novara, ItalyTo date most studies have emphasised the role of mood stabilizers(MS) in the prophylaxis of bipolar disorders and pointed to discontinuationof such drugs as a leading cause of illness exacerbation. Incontrast with this approach, the aim of our study was to identify bipolarpatients experiencing affective episodes in spite of regular use ofmood stabilizers and ascertain their demographic and clinical characteristics.Plasma levels of mood stabilizers (lithium, carbamazepineand valproate) were measured in fifty bipolar patients (DSM-IV diagnosis)upon hospital admission. Subjects with therapeutic and subtherapeuticMS plasma levels were compared on demographic variablesand symptom profiles assessed with the Hamilton DepressionRating Scale and Young Mania Rating Scale. Thirty percent ofpatients had therapeutic levels of mood stabilizers upon admission.These subjects did not differ from those with sub-therapeutic levels asregards demographic characteristics and type and severity of symptoms.This preliminary study suggests that affective episodes are commonamong bipolar patients who regularly take mood stabilizers.Further research is warranted to investigate the role of non-pharmacologicalfactors in bipolar disorder recurrence.PO2.37.LITHIUM AND CARBAMAZEPINE IN LONG-TERMTREATMENT OF BIPOLAR DISORDERV. Filovska, M. Jakovchevska-Kujundziska, V. AvramovaPsychiatric Hospital, Skopje, Republic of MacedoniaSeventy-eight patients with stabilized bipolar I disorder were randomlyassigned to monotherapy with carbamazepine (600-1200 mg/day),lithium (0.7-1.0 mEq/l) or placebo for 12 months. Carbamazepine andlithium were superior to placebo in prolonging the euthymic phasesand reducing the intensity of recurrences. Carbamazepine was superiorto placebo in prolonging the time to any mood episode, while lithiumwas superior to placebo in prolonging the time to a new manic orhypomanic episode. This trial confirms the previous data about themood stabilizing properties of the two drugs. Although lithium waspreviously regarded as the first choice drug in the maintenance therapyof bipolar disorder, it seems more reasonable to use it in bipolar Idisorder with predominant manic/hypomanic episodes.PO2.38.OXCARBAZEPINE IN THE TREATMENTOF BIPOLAR I DISORDERA. Berti, C. Fizzotti, C. Maberino, E. ZanelliSection of Psychiatry, Department of Neurosciences,University of Genoa, ItalyThis was a six month, open-label, prospective trial of oxcarbazepine(OXC) in six patients, 18-65 years old, with a DSM-IV diagnosis ofbipolar I disorder. Two patients were depressed, two manic, oneeuthymic and one showed a mixed state with psychotic symptoms.OXC was titrated from 150 mg/die up to 1200 mg/die. The evaluationwas made by the Young Mania Rating Scale (YMRS), the HamiltonRating Scale for Depression (HAMD) and the Global AssessmentSchedule. One manic patient showed an improvement in YMRS>50% within 2 weeks. The other manic patient dropped out because254 World Psychiatry 3:S1 - October 2004

of severe sedation. Both depressed patients had an improvement inHAMD ≥50% within 3 months. The euthymic patient had an acutemanic episode after 15 days, but responded to an increase of thedosage of OXC and was euthymic again at day 40. The patient with amixed state showed an improvement in YMRS ≥50% within 2 weeks.The side effects were mild or moderate (epigastralgia, rash, dizziness,sedation). These very preliminary data suggest that OXC has bothantimanic and antidepressant properties.PO2.39.EFFICACY OF THE COMBINATIONOF RISPERIDONE AND TOPIRAMATEIN THE TREATMENT OF PATIENTS WITHBIPOLAR DISORDERO. Kozumplik, S. Uzun, V. Folnegovic-Smalc, V. JukicUniversity Department of Psychiatry, Zagreb, CroatiaThe study investigated the efficacy of the combination of risperidoneand topiramate in patients with bipolar disorder. Thirty-nine patients(17 male and 22 female, aged 18-65 years), fulfilling DSM-IV criteriafor bipolar disorder, were recruited. They were admitted to the hospitaldue to the acute exacerbation of bipolar disorder (20 patients hada manic episode and 19 had a depressive episode). They were administeredrisperidone (4-8 mg/day) plus topiramate (100-200 mg/day).The Clinical Global Impression (CGI), the Young Mania Rating Scale(YMRS) and the Montgomery-Asberg Depression Scale (MADRS)were used in order to assess the efficacy of the combination. The firstassessment was made prior to initiation of the treatment. The secondassessment was made after three months of continuous therapy. Afterthree months, the YMRS total score improved in 11 patients. TheMADRS total score improved in 9 patients. This is a preliminary evidenceof the efficacy of the combination.PO2.40.THE PREVALENCE OF BIPOLAR DISORDERIN AN ITALIAN POPULATION LIVING IN ARGENTINA:A PRELIMINARY STUDYC. Ravassi 1 , A. Barraco 2 , P. Donda 2 , A. Rossi 21 National University of La Plata, Argentina; 2 Eli Lilly Italy, SestoFiorentino, Florence, ItalyBipolar spectrum disorders, which include bipolar I, bipolar II, andbipolar disorder not otherwise specified, frequently go unrecognized,undiagnosed, and untreated, with great social and economical consequences.To our knowledge, there are no systematic studies evaluatingthe prevalence of bipolar disorder (BD) in an Italian population. Weevaluated the prevalence of BD in the population living in Villa laAngostura (Argentina) including only people of Italian origin, meaningpeople born or with both parents born in Italy. The Mood DisorderQuestionnaire (MDQ) was administered to a total of 122 people (averageage 40.3+5.3 years; 50.8% males; 5 with elementary degree, 11medium, 38 high school, 46 with university degree, 11 ongoing students,11 did not complete university). Those with a total score of 7 ormore (n=21) were re-evaluated in a in-depth psychiatric visit, to confirmthe BD diagnosis. The crude prevalence of BD from MDQ administrationwas 13.9%. Of the 17 people with an MDQ total score of atleast 7, 12 (70.6%) were confirmed as having BD. On the other hand,36 of the 105 subjects with a total score below 7 (34.3%) showed mildto moderate psychiatric problems. Four (33.3%) of BD patients wereunaware of their condition. Six out of the 8 aware patients were treatedwith a pharmacological treatment. All patients unaware of their conditionstarted appropriate therapy during the visit.PO2.41.OLANZAPINE IN THE TREATMENTOF MANIC EPISODEI. Dan, M. SimuAl. Obregia Clinical Psychiatry Hospital, Bucharest, RomaniaAn open trial of olanzapine vs. haloperidol was carried out in 36inpatients with mania (score of at least 20 on the Young Mania RatingScale, YMRS, at baseline), aged 23-55 years, both sexes. Group A(n=17) received olanzapine (5-20 mg/day) and group B receivedhaloperidol (3-15 mg/day) for four weeks. Evaluations (YMRS;Montgomery-Åsberg Depression Rating Scale, MADRS; GeneralClinical Impression; extrapyramidal symptoms, body weight) weremade at baseline and after 3, 7, 14, 21 and 28 days of treatment. Bothgroups showed a significant clinical improvement, but the side effectprofile and compliance were better in group A. The MADRS scoreincreased during treatment in group B. Group B patients had somnolencein 43% of cases, extrapyramidal symptoms in 52% andhypotension in 13.2%. Some patients of group A presented weightgain (1-3.5 kg).PO2.42.REMISSION IN MAJOR DEPRESSION:BEYOND HAMD-17 ≤ 7M.J. Detke 1 , C. Mallinckrodt 1 , M. Wohlreich 1 , J. Xu 1 , P.V. Tran 1 ,M. Fava 21 Eli Lilly and Company, Indianapolis, IN; 2 Depression Clinicaland Research Program, Massachusetts General Hospital, andHarvard Medical School, Boston, MA, USARemission is now widely accepted as the goal of treatment for majordepressive disorder (MDD) and has been defined as a score onHamilton Rating Scale for Depression (HAMD-17) ≤ 7. Patients whoremit by this definition have been shown to have a lower risk ofrelapse and improved physical and social functioning. However, varioussymptom domains, such as physical symptoms and particularlypainful physical symptoms, are increasingly recognized as playing asignificant role in the morbid burden of depression, and no singlescale captures all of these symptom domains well. Recently collecteddata regarding distinct symptom domains and global/functionalremission metrics will be presented. Treatment of all symptomdomains is more effective in achieving remission. Remission is bestdefined by utilizing multiple scales such as global or functional ratings,at various severity cutoffs.PO2.43.THE CONSEQUENCES OF NON-REMITTEDDEPRESSION ON HEALTH CARE UTILIZATIONAND PRODUCTIVITY: A 23-YEAR FOLLOW-UPS.E. Graden 1 , R.C. Cronkite 2 , D. Roybal 2 , J. Robson 2 , G. Booster 2 ,R.L. Robinson 1 , R.W. Swindle 1 , E. Ingudomnukul 2 , I. Mabel 2 ,A. Yiu 2 , R.H. Moos 21 Lilly Research Laboratories, Indianapolis, IN; 2 Center for HealthCare Evaluation, Department of Veterans Affairs Health CareSystem and Stanford University Medical Center, Palo Alto, CA,USAThe study aimed to assess the association between remission statuson health care utilization and productivity loss of a 23-year cohort ofpatients diagnosed with major depression. A cohort of 424 patientstreated for unipolar depression in 1980 was followed longitudinally.After 23 years, 72.9% of the surviving cohort participated. DSM-IV255

depression criteria were used to establish remission status for thisanalysis. The self-reported physician visits were higher for currentlydepressed vs. currently remitted respondents (9.0/year vs. 4.5/year,p=0.007). The currently depressed utilized more antidepressants thanthe currently remitted (1.9 vs. 1.0, p

trial. In our sample, IQ scores of non-responders to treatment (n=15)showed a trend to converge under the medium IQ score of 100. Bycomparing patients with a global IQ score lower than 100 and subjectswith an IQ equal or higher than 100, we could observe significantdifferences regarding their response to fluvoxamine (p=0.024).Compared to other subjects, those with an IQ lower than 100 showeda more severe depressive symptomatology after three (p=0.03), four(p=0.018), five (p=0.03) and six weeks (p=0.049) of treatment. Afterthe inclusion in the analyses of sex, educational level, age at onsetand depression severity at the intake, results remained statisticallysignificant. The present data support a relation between intelligence(IQ) and antidepressant treatment outcome. However, the smallnumber of subjects (n=57) and of non-responders to fluvoxamine(n=15) represent major limitations of our study. Thus, further investigationson larger and independent samples are required.PO2.47.SHORT-TERM OUTCOME OFTREATMENT-RESISTANT DEPRESSIOND. Pagnin, V. De Queiroz, S. Pini, P. Medda, G.B. CassanoDepartment of Psychiatry, Neurobiology, Pharmacologyand Biotechnology, University of Pisa, ItalyThe study aimed to investigate the short-term course of depressionduring hospitalization in a group of patients who underwent electroconvulsivetherapy (ECT) as compared to a group of patients who didnot receive ECT. Twenty-seven patients with treatment-resistantdepression were consecutively ascertained during an inpatient treatment:20 patients were assigned to ECT sessions and 7 patientsreceived a third standard antidepressant treatment because they hadcontraindications to ECT or refused it. Response criteria were defineda priory: 1) a > 50% total score decrease from baseline to endpoint of17-item Hamilton Depression Rating Scale (HAM-D); 2) a score ofone or two on the Clinical Global Impression - Improvement (CGI-I).An additional criterion of response with remission was defined as 3)a total score of < 7 on the 17-item HAM-D. The ECT group presenteda significant greater proportion of responders than the psychopharmacologicalcontrol group on the HAM-D (ECT group responders 17of 20; control group responders 1 of 7; Fisher's exact test, p=0.002)and on the CGI-I (ECT group responders 17 of 20; control groupresponders 2 of 7; Fisher's exact test, p=0.01). Evaluating the morestringent criterion of full remission of depressive symptoms on theHAM-D the ECT group also responded significantly better than thecontrol group: 14 patients of the ECT group reached the remissionstate but no patient of the control group achieved remission (Fisher'sexact test, p=0.002). In conclusion, ECT continues to be an importantoption for patients with treatment-resistant depression when psychopharmacotherapydoes not achieve a full remission of symptoms.PO2.48.EARLY SYMPTOM RESPONSE DURING TREATMENTWITH DULOXETINE 60 MG QD: HAMD-17 ITEMSR. Hirschfeld 1 , C.H. Mallinckrodt 2 , J.W. Clemens 2 , M.J. Detke 21 Department of Psychiatry and Behavioral Sciences, University ofTexas Medical Branch, Galveston, TX; 2 Lilly ResearchLaboratories, Indianapolis, IN, USAUnderstanding of time to onset of response for various symptoms ofmajor depressive disorder (MDD) can be clinically useful. Data werepooled from two 9-week trials that compared duloxetine 60 mg qd(n=244) with placebo (n=251) in the treatment of MDD patients.Mean changes in Hamilton Depression Rating Scale-17 (HAMD-17)items and a visual analog scale (VAS) for pain were analyzed. Duloxetine-treatedpatients experienced greater improvement compared withplacebo-treated patients (p

that treatment of depression with tricyclic antidepressants (TCAs)increase the risk of manic switch in depression. The newer class ofagents with dual reuptake inhibition of serotonin and norepinephrine(SNRIs) have the efficacy of TCAs without the broad side effect profile.Duloxetine is a balanced and potent SNRI that is effective in thetreatment of MDD. We investigated the rate of mania/hypomania andhypomanic-like symptoms observed during placebo-controlled clinicaltrials of patients with MDD who were treated with duloxetine.This investigation included data from eight placebo-controlled, double-blind,randomized clinical trials (n=1139 for duloxetine, n=777for placebo). Adverse event data were collected throughout thecourse of the studies via investigator-elicited patient responses, aswell as spontaneous patient reports. These data were reviewed forsymptoms that were characteristic of mania or hypomania. One caseof mania occurred in the placebo groups, and two cases of hypomaniawere observed in the duloxetine-treated groups. Insomnia wassignificantly higher in the duloxetine group than in the placebogroup. Irritability approached significance, but was higher in theplacebo group. In conclusion, duloxetine was associated with a verylow incidence of treatment-emergent hypomania, mania or hypomanic-likesymptoms among MDD patients. These data suggest thatduloxetine may provide an improved risk profile for treatment-emergenthypomania, mania or hypomanic-like symptoms in the treatmentof MDD.PO2.51.COMPLETE SYMPTOMATIC RELIEF IN DEPRESSEDPATIENTS TREATED WITH VENLAFAXINE ORSELECTIVE SEROTONIN REUPTAKE INHIBITORSR. Entsuah, J. ZhangWyeth Research, Collegeville, PA, USAData from a previous pooled analysis suggested that there are differentialrates of remission among classes of antidepressants, with higherrates of remission associated with the serotonin-norepinephrinereuptake inhibitor venlafaxine than with the selective serotonin reuptakeinhibitors (SSRIs). These data were further analyzed to evaluaterates of complete relief of physical, emotional, and functional symptomsof depression. Original patient data from 31 randomized, double-blindstudies were pooled to evaluate remission rates in 7422depressed patients treated with venlafaxine/venlafaxine extendedrelease (XR) (n=3273), SSRIs (n=3217), or placebo (n=932) for up to8 weeks. Relative rates of complete symptom relief (Hamilton RatingScale for Depression, HAM-D item score = 0) on individual items ofthe HAM-D17 were compared. The last-observation-carried-forward(LOCF) method was used to handle missing data. Results at 8 weeksdemonstrated a significant (p

35.5% and 32% for venlafaxine XR and SSRIs, respectively (p=NS).Individual SSRI remission rates at day 180 were fluoxetine 36%,paroxetine 28%, citalopram 31%, and sertraline 33%. Mean maximumprescribed doses were venlafaxine XR 157 mg/day, fluoxetine55 mg/day, paroxetine 41 mg/day, citalopram 35 mg/day, and sertraline135 mg/day. These results suggest that venlafaxine XR is an effectivetreatment for MDD and may bring patients to remission earlier intreatment compared with SSRIs.PO2.54.CHANGES IN PERSONALITY CHARACTERISTICSOF DEPRESSIVE OUTPATIENTS UNDERTREATMENT WITH SELECTIVE SEROTONINREUPTAKE INHIBITORSS. Kertzman 1 , L. Luthorovich 1 , H. Grinspan 1 , M. Birger 1,2 ,I. Reznik 1,2 , B. Spivak 1,2 , A. Weizman 2 , M. Kotler 1,21 Beer Yakov/Ness Ziona Regional Mental Health Center,Beer Yakov; 2 Psychiatry Department, Sackler Faculty of Medicine,University of Tel Aviv, IsraelPrevious studies have indicated that selective serotonin reuptakeinhibitors (SSRIs) have effects on personality, which could be distinguishedfrom their effects on mood. The aim of this study was toexamine the effects of SSRI treatment on personality profiles indepressive patients. 108 patients (64 males) suffering from currentmajor depressive episode, according to DSM-IV criteria, were includedin the study. The age of the patients was 44.4±15.0 years. TheSSRIs were: paroxetine (20-50 mg/day), citalopram (20-50 mg/day)and fluvoxamine (100-200 mg/day). The Hamilton Depression RatingScale (HDRS) and the Minnesota Multiphasic Personality Inventory(MMPI) were administered before and after 8 weeks of SSRI treatment.Significant differences from baseline were found on the followingMMPI scales: F (infrequency) (p

PO2.57.COMPARATIVE EFFICACY OF SERTRALINE VERSUSVENLAFAXINE-XR IN ANXIOUS DEPRESSIONS. Vahip 1 , R. D’Souza 2 , A. Sir 3 , T. George 4 , E. Yerli 5 , T. Burt 61 Department of Psychiatry, Ege University Medical Faculty,Izmir, Turkey; 2 Mental Health Research Institute, Victoria,Australia; 3 Department of Psychiatry, Dicle University MedicalFaculty, Diyarbakir, Turkey; 4 Northwest Specialist Centre,Australia; 5 Pfizer, Turkey; 6 Pfizer Inc.The study aimed to compare the efficacy of sertraline with venlafaxine-XR in a subgroup of anxious depressed patients. It was an international,8-week, double-blind study of 161 outpatients with major depressivedisorder (MDD), randomized to sertraline (50-150 mg/day; n=79)or venlafaxine-XR (75-225 mg/day; n=82), followed by a 2-week taper.The anxious-depression subgroup was defined by baseline HamiltonScale for Depression (HAM-D) anxiety-somatization score of at least7. Intent-to-treat analyses were undertaken at week 8 using last observationcarried forward (LOCF), and repeated at week 8 amongst completers.Changes from baseline scores were analysed using ANCOVA;least square (LS) means and p values are presented. Differences inHAM-D response and remission were estimated using Cochran-Mantel-Haenszeltests. 118 (73%) of 161 outpatients met criteria for MDD,anxious subtype (73% female; mean age 36 years; mean HAM-D, 24).Among anxious-depressives, sertraline was comparable to venlafaxine-XRin mean change from baseline on HAM-D total scores forweek-8 completers (-18.7±1.0 versus -16.6±1.1; 95% CI for difference-4.6 to 0.5; p=0.11) and week-8/LOCF (-17.3±1.1 versus -14.8±1.0;95% CI for difference -5.2 to 0.2; p=0.07). At week-8/LOCF, HAM-Dresponder rates (80% vs. 66%; p=0.13) and HAM-D remission rates(59% versus 48%; p=0.29) were not significantly different for sertralinevs. venlafaxine-XR, respectively. Anxiety symptoms had responded(>50% reduction in anxiety-somatization factor) in 82% of sertralineand 67% of venlafaxine-XR patients (p=0.10). Regarding the totalsample (n=161), no significant differences were found between treatmentson these outcome measures. Sertraline and venlafaxine-XRwere found to have similar antidepressant efficacy in anxious-depression,a common clinical subtype of MDD.PO2.58.TOLERABILITY AND DISCONTINUATIONEFFECTS FOR SERTRALINE VERSUSVENLAFAXINE-XR IN DEPRESSIONA. Sir 1 , R. D’Souza 2 , S. Uguz 3 , T. George 4 , F. McIlroy 5 , W. Lam 51 Department of Psychiatry, Dicle University Medical Faculty,Diyarbakir, Turkey; 2 Mental Health Research Institute, Victoria,Australia; 3 Department of Psychiatry, Cukurova UniversityMedical Faculty, Adana, Turkey; 4 Northwest Specialist Centre,Australia; 5 Pfizer AustraliaThe study aimed to compare the safety and tolerability of sertralinewith venlafaxine-XR, including structured assessment of discontinuationsymptomatology, based on the Signs and Symptoms of DiscontinuationScale (SSDS). It was an international, 8-week, double-blindstudy of outpatients with DSM-IV major depressive disorder (MDD)(n=161; 70% female; mean age, 37; baseline Hamilton Scale forDepression, HAM-D, 23), randomized to sertraline (50-150 mg/day;n=79) and venlafaxine-XR (75-225 mg/day; n=82). Following 8 weeksof double-blind treatment, subjects tapered off medication at a ratenot exceeding 50 mg of sertraline and 75 mg of venlafaxine-XR every4 days, during a 2-week taper period. Differences in incidence rateswere tested using Fisher’s exact test. Mean week-8 doses were 105 mgfor sertraline and 161 mg for venlafaxine-XR. A greater proportion ofpatients discontinued from venlafaxine-XR compared to sertraline(28% vs. 16%; p=0.09). During tapering, patients on venlafaxine-XRexperienced more discontinuation symptomatology, with a >10%higher incidence of the following SSDS events compared to sertraline:dizziness (44% vs. 33%; p=0.065), vivid dreams (42% vs. 26%;p=0.069), fatigue (33% vs. 22%; p=0.18), and vertigo (17% vs. 6%;p=0.052). The time to completion of drug tapering was similarbetween treatments (median time, 4 days for both treatments). Inconclusion, although sertraline and venlafaxine-XR were found to bewell-tolerated in the acute treatment of MDD, clear differences in discontinuationeffects were found between sertraline and venlafaxine-XR during treatment withdrawal.PO2.59.IMPROVEMENT OF NEUROCOGNITIVECHARACTERISTICS IN DEPRESSIVE PATIENTSUNDER ESCITALOPRAM THERAPYS. Kertzman 1,3 , H. Grinspan 1 , M. Birger 1,2 , N. Shlapnicov 1 ,Z. Ben-Nahum 3 , I. Reznik 1,2 , A. Weizman 2 , M. Kotler 1,21 Beer Yakov Mental Health Center, Beer Yakov; 2 PsychiatryDepartment, Sackler Faculty of Medicine, University of Tel Aviv;3 Anima Scan Ltd, Ashdod, IsraelCognitive impairment is common in major depression. Some antidepressantshave anticholinergic side effects, which may worsen cognitivefunctions among depressive patients. The research hypothesiswas to assess the ability of escitalopram (EC) to improve cognitivefunction in depressive patients. 30 patients (23 women) sufferingfrom major depression, according to DSM-IV criteria, were includedin the pilot study. Their age was 38.8±12.1 years. Doses of EC rangedfrom 10 to 20 mg/day. The research tool was a computerized neurocognitivebattery (“CogScan” Anima-Scan Ltd) which included: TappingTest, Inspection Time, Motion Perception Test, Simple ReactionTime, Choice Reaction Time, Time-Accuracy Trade-off Test, Immediatedand Delayed Memory for Pictures, Words and Faces, Stroop Test,Digit Symbol Substitution Test (DSST), and Continuous PerformanceTest. All these tests were administered before and after 8 weeks of ECtreatment. Significant improvements from baseline were found inimmediate picture (p=0.016) and face recognition (p=0.013), timeaccuracytrade-off (accuracy only, p=0.03); selective attention(Stroop: reaction time in neutral, p=0.001; congruent p=0.001 andnon-congruent p=0.002), working memory and pair-associated learning(DSST, p=0.001). In conclusion, EC enhanced immediate recognitionand working memory in depressive patients. We also foundthat EC improved the selective attention in these patients. As far asStroop test is not only measuring selective attention, but is also anindicator of the inhibition control, its improvement could be associatedwith reduced impulsivity in these patients.PO2.60.ESCITALOPRAM VS. VENLAFAXINE XRTREATMENT OF MAJOR DEPRESSIVE DISORDERS.A. Montgomery 1 , M. Mancini 2 , R.J. Bielski 31 Imperial College, London, UK; 2 Lundbeck, Rome, Italy;3 Summit Research Network, Okemos, MI, USAEscitalopram is a highly selective serotonin reuptake inhibitor (SRI)antidepressant. In contrast, venlafaxine is a non-selective SRI that alsoinhibits noradrenergic reuptake. Two randomised, double-blind, 8-week trials compared the efficacy and tolerability of escitalopram withthat of venlafaxine in major depressive disorder (MDD). The primary260 World Psychiatry 3:S1 - October 2004

efficacy variable was the mean change from baseline in Montgomery-Åsberg Depression Rating Scale (MADRS) scores. In the study in generalpractice in Europe, 10-20 mg/day escitalopram (n=148) was atleast as effective as 75-150 mg/day venlafaxine (n=145), with a superiorside effect profile. Survival analysis of sustained response and sustainedremission showed escitalopram to be significantly superior tovenlafaxine (p

PO2.64.OLANZAPINE/FLUOXETINE COMBINATIONFOR TREATMENT-RESISTANT DEPRESSIONS. Corya 1 , M. Case 1 , S. Briggs 1 , M. Tohen 1,21 Lilly Research Laboratories, Indianapolis, IN; 2 Department ofPsychiatry, Harvard Medical School/McLean Hospital, Belmont,MA, USAOlanzapine/fluoxetine combination (OFC) has shown effectiveness inpatients with treatment-resistant depression (TRD). The present posthoc subanalyses examined OFC in TRD patients who had experiencedat least two treatment failures in their current episode, one while on aselective serotonin reuptake inhibitor (SSRI). Such a group is likelyrepresentative of TRD patients in clinical settings. Subjects had a diagnosisof unipolar, non-psychotic TRD. Study 1 was an 8-week randomized,double-blind trial comparing OFC, olanzapine, fluoxetine,and nortriptyline in subjects (n=500) with retrospective SSRI failureand prospective nortriptyline failure. Study 2 was a 12-week randomized,double-blind trial comparing OFC, olanzapine, fluoxetine, andvenlafaxine in subjects (n=483) with retrospective SSRI failure andprospective venlafaxine failure. A mixed-effects model repeated measuresregression analyzed the subsample of patients who had experiencedan SSRI failure in their current depressive episode (Study 1:n=324, Study 2: n=350). In Study 1, the OFC group had significantlygreater mean baseline-to-endpoint reduction in Montgomery-ÅsbergDepression Rating Scale (MADRS) total score (-9.08) than the olanzapinegroup (-5.58, p=0.005), but was not different from the nortriptylinegroup (-7.10, p=0.176) or the fluoxetine group (-7.87, p=0.325). InStudy 2, the OFC group (-14.64) had significantly greater mean baseline-to-endpointreduction than the olanzapine (-9.42, p

PO2.67.RESULTS FROM THE OPEN-LABEL PHASEOF AUGMENTATION WITH RISPERIDONE INRESISTANT DEPRESSION (ARISe-RD)N. Smith 1 , C. Canuso 2 , I. Turkoz 2 , G. Gharabawi 21 Janssen-Cilag Ltd., High Wycombe, Bucks, UK; 2 JanssenPharmaceutica Products, Titusville, NJ, USAAugmentation with Risperidone in Resistant Depression (ARISe-RD)is an ongoing trial evaluating risperidone augmentation of citalopramin patients with major depression who have failed to respond adequatelyto available antidepressants. Patients who had not respondedto at least one antidepressant in the past nor to 4–6 weeks of treatmentwith citalopram received risperidone (0.25–2 mg/day) pluscitalopram in a 4–6-week open-label trial. Patients in remission(Montgomery-Åsberg Rating Scale for Depression, MADRS ≤12)after augmentation continued in a 6-month, double-blind, placebocontrolled,relapse-prevention phase. Of the 502 subjects, 88.8% didnot respond (≤ 50% Hamilton Scale for Depression, HAM-D reduction)to citalopram monotherapy. During risperidone augmentation(n=386), mean total scores improved significantly from baseline toendpoint on HAM-D (–11.1±6.9; p

Rating Scale (HDRS) and neuropsychological test at admission andafter two, four and eight weeks. The second group (n=23) was testedevery week from the admission day to the third week. The cognitivevariables were sensible to the improvement of depressive symptomatologydue to treatment, evaluated with Hamilton’s scale. Bothdepressive syndrome and neuropsychological functioning significantlyimproved during treatment. Depressive syndrome, as rated onHDRS, showed the first significant change at week 1, while the onlynot significant difference was between the fourth and the eighthweek. Neuropsychological variables showed a significant ameliorationparticularly at week 8 (self-attribution of positive elements,p

PO2.74.SEROTONIN AND NORADRENALINEREUPTAKE INHIBITORS DIFFERENTIALLY AFFECTSLEEP-WAKE BEHAVIOUR IN RATSC. SánchezLundbeck, Copenhagen, DenmarkIn this study, we investigated the effects of the selective serotonin reuptakeinhibitors (SSRIs) escitalopram and paroxetine, the selectivenoradrenaline (NA) reuptake inhibitor reboxetine and the non-selective5-HT and NA reuptake inhibitors duloxetine and venlafaxine onsleep EEG in rats by means of radiotelemetric techniques. The studieswere conducted in compliance with EC Directive 86/609/EEC andwith Danish law regulating experiments on animals. The transmitterwas implanted in the peritoneum and EEG leads were placed supradurally,2mm anterior to lambda and 2mm on either side of the midlinefor the frontal electrodes and 2mm anterior to bregma and 2 mm oneither side of the midline for the parietal electrodes. The electromyographicleads were sutured in place on either side of the musculus cervicoauricularis.Drugs were tested one week post-surgery in the lightpart of the diurnal cycle. The EEG data were scored as wake (W), lightslow-wave sleep (SWS-1), deep slow wave sleep (SWS-2) or paradoxicalsleep (PS, which corresponds to rapid eye movement sleep inhumans). The EEG recordings for each animal (minimum 8 per treatmentgroup) were scored manually, in 10s epochs. Escitalopram (2.0mg/kg) significantly increased SWS-1, whereas paroxetine (2.0 mg/kg)produced a significant decrease in PS. Reboxetine (20 mg/kg) significantlyincreased W and decreased SWS-1 and PS. Venlafaxine (20mg/kg) and duloxetine (7.7 mg/kg) significantly increased W anddecreased PS. The present study demonstrates that inhibitors of NAreuptake significantly increase the arousal state. This might predictproblems when patients suffering from insomnia use these drugs. Furthermore,SSRIs differentially affect the sleep-wake cycle.PO2.75.MODAFINIL FOR MAJOR DEPRESSION WITHATYPICAL FEATURESK. Connor, K. Gadde, W. Zhang, V. Payne, J. DavidsonDepartment of Psychiatry and Behavioral Sciences,Duke University Medical Center, Durham, NC, USAAugmentation with psychostimulants benefits some patients withtreatment refractory depression, particularly those with significantfatigue and hypersomnia. The novel stimulant modafinil has shownbenefit as adjunctive therapy in anergic depression and is approved forexcessive daytime sleepiness in narcolepsy, suggesting a potential rolein atypical depression. This study examined modafinil as monotherapyin adult outpatients with major depression with atypical features.Subjects with atypical depression were treated with open-labelmodafinil for 12 weeks. Efficacy assessments included measures ofdepression, fatigue, and sleep. Safety evaluation included changes invital signs and weight and emergence of adverse events. Preliminaryanalysis of subjects enrolled to date (n=37) revealed a study samplethat was predominantly female (n=36), Caucasian (n=27), and unmarried(n=23), with a mean age of 41 years. Thirty subjects (81%) completedthe treatment period. Significant improvement in depressionwas observed in both the intention-to-treat and completers’ samples(p

PO2.78.TRANSCRANIAL MAGNETIC STIMULATIONMODIFIES THE PROCESSING OFEMOTIONAL STIMULI IN SUBJECTS WITHA MAJOR DEPRESSION EPISODEA. Santoro, M. Florita, F. Benedetti, A. Lucca, C. Colombo,E. SmeraldiDepartment of Psychiatry, Vita-Salute University, San RaffaeleInstitute, Milan, ItalyNeuropsychological studies of depression showed that the speed ofprocessing of emotionally characterized stimuli varies in function ofthe mood level. In depressed patients the preferential processing is fornegative stimuli, while normal subjects are more likely to process positivestimuli. Our group has developed a computerized test to measurethe time of performing negative and positive adjectives. Every timesubjects press “Q” key, for negative adjectives, or “P” key, for positiveadjectives, our program finds the reaction time to recognition of emotionalconnotation. Through the ratio of latency (negative to positivestimuli), we obtained a good index of depression severity. 21depressed patients have been administered the test before and afterthe application of rapid transcranial magnetic stimulation (TMS) (15Hz, 2 sec, 10 trains of pulses with a intertrain interval of 30 sec). Thesame patients were also treated with slow TMS characterized by 300pulses at 1 Hz. We divided the patients into a group 1 with highertime of latency (ratio >1) and a group 2 with lower times (ratio 1) and 14 subjects(ratio

PO2.82.MEDICAL CONSEQUENCES OF MAJORDEPRESSION IN PREMENOPAUSAL WOMEN:LESSONS LEARNED FROM THE POWER STUDY,A PROSPECTIVE STUDY OF BONE TURNOVERG. Cizza for the POWER Study GroupNational Institute of Health, Bethesda, MD, USAMajor depressive disorder (MDD) is the most common psychiatric illnessin adults. Subjects with MDD often exhibit hypercortisolism andother endocrine changes that may predispose them to low bone massand other metabolic and immune alterations. The POWER (premenopausal,osteoporosis, women, alendronate, depression) study is aprospective study of the natural history of bone density in premenopausalwomen, aged 21 to 45 years, with MDD. We haveenrolled and followed, for more than 12 months, 90 women withMDD and 44 matched controls. We report here some of the most interestingfindings: a) women with MDD had a greater prevalence of lowbone mineral density (BMD) at the femoral neck (16% in the MDDgroup vs. 2% in the controls; p= 0.02) with a trend of greater prevalenceat total femur and spine. The changes in BMD observed at anyof these sites examined between baseline and 12 months, in the subgroupof subjects that have already completed 12 months of follow-up(MDD, n= 56; controls, n= 26), were not greater than 1%; smoking,dietary calcium intake and level of physical conditioning were similarbetween patients and controls; b) after adjusting for weight, womenwith MDD had significantly greater waist circumference (p=0.01) andabdominal percent fat (p=0.03). In addition, plasminogen activatorinhibitor–1, an index of cardiovascular disease (p=0.02) and fVIII levels(p=0.02) were significantly higher in the MDD group; c) in womenwith MDD, average 24 hr plasma pro-inflammatory cytokines (IL-1,IL-2, IL-6, TNF-alpha) and chemokines (MIP-1a, MCP-1, RANTES,IP-10, IL-8) were significantly higher, while anti-inflammatorycytokines (IL-10 and IL-13) were significantly lower than controls; d)adrenocorticotropin hormone (ACTH) levels were significantly higherin patients with atypical MDD than in controls. In conclusion, MDDis associated with clinically important medical consequences includingbone loss, increased cardiovascular risk and immune changes suggestiveof sub-clinical inflammation, in a sample of young, mildlydepressed subjects. These findings underlie the importance of consideringMDD also as a disease of the body and not only as a disease ofthe mind and call for early detection and treatment of these medicalconditions in women with MDD.PO2.83.PERSONALITY DIFFERENCES BETWEENDYSTHYMIA AND MELANCHOLIC ANDNON-MELANCHOLIC REMITTED MAJORDEPRESSIONR. Catalán, R. Penadés, J. Jaén, S. Andrés, C. GastóInstitut Clínic de Psiquiatria i Psicología, Hospital Clínic,Barcelona, SpainWe explored personality differences between patients with nonmelancholicmajor depressive disorder (NMDD), melancholic majordepressive disorder (MMDD) and dysthymia (DD) by using the Temperamentand Character Inventory (TCI). All patients (NMDD, n=60;MMDD, n=33; DD, n=30) were treated with selective serotonin reuptakeinhibitors. Nobody was receiving psychotherapy at the momentof the assessment. TCI was administered after 12 weeks of pharmacotherapy,when the score on Hamilton Rating Scale for Depression(HRSD) was below 8. Profiles in NMDD and MMDD exhibited asimilar pattern. Significant differences in persistence were foundbetween the two subtypes of major depression. DD patients had higherscores on harm avoidance and lower scores on self-directedness,empathy, and resourcefulness scales. Our data suggest a possible relationshipbetween the character dimensions of Cloninger’s model andchronicity of depressive disorder.PO2.84.HOW HIGH IS THE PREVALENCE OF MIXEDANXIETY-DEPRESSION ACCORDING TO THEDSM-IV RESEARCH CRITERIA?S.-P. NeumerRegional Center for Child and Adolescent Psychiatry, Oslo,NorwayCombined states of anxiety and depression are common in clinicalpractice and several authors have estimated a high prevalence for thissub-threshold disorder. Empirical data on this syndrome is, however,sparse. Estimates of the prevalence are highly variable, particularly inclinical studies. Mixed anxiety-depression was first included as aresearch diagnosis in the DSM-IV. This presentation will provide areview of the prevalence of mixed anxiety-depression in clinical settingsand in the general population. Further, new results on the use ofDSM-IV research criteria in a random sample (n=2064) of youngwomen will be presented. For the first time, an estimation of theprevalence of mixed anxiety-depression according to the DSM-IV criteriais made available. The findings suggest that this condition is lessfrequent than originally expected.PO2.85.THE RELATIONSHIP OF ANXIETYAND DEPRESSIONJ.G. Stefansson 1 , H. Kolbeinsson 1 , T. Thorgeirsson 2 ,K. Stefansson 1 , H. Oskarsson 31 National University Hospital; 2 deCode Genetics; 3 Therapeia,Reykjavik, IcelandThe study aimed to explore the relationship between anxiety disordersand depressive disorders. It was based on the screening for anxietyand depression in a population sample, followed by diagnosticwork-up of prospective cases by the computerized version of theComposite International Diagnostic Interview (CIDI Auto). Of 2647interviewed subjects, 1234 had an anxiety disorder and 1160 a majordepressive disorder. There is high comorbidity among the anxiety disordersand the major affective disorders. The anxiety disorders startearlier than the affective disorders. Only generalized anxiety disorder(GAD) has the same mean age of onset as the affective disorders, 28years. Simple phobia has the lowest mean age of onset (16.5 years),followed by social phobia (17.5 years) and agoraphobia (20.6 years).Panic disorder has a mean age of onset of 22.1 years and alcoholabuse and dependence have a mean age of onset of 25 years.PO2.86.ANXIETY PRECURSORS OF MAJORDEPRESSIVE DISORDER: IMPACT ON SEVERITYH. Oskarsson 1 , H. Kolbeinsson 2 , J.G. Stefansson 2 , E. Líndal 2 ,T.E. Thorgeirsson 3 , J. Gulcher 3 , K. Stefansson 31 Therapeia; 2 Landspitali-University Hospital; 3 deCode Genetics,Reykjavik, IcelandThis study examines the impact of anxiety on the severity of majordepressive disorder (MDD), with the hypothesis that its onset before267

that of MDD may define a specific endophenotype of MDD. A largepopulation sample was screened for anxiety and depression, followedby further diagnostic work-up with the Composite InternationalDiagnostic Interview. The probands met ICD-10 diagnostic criteriafor MDD, single episode or recurrent, with age of onset (AGO) at age13 or later. Our analysis was based on severity of illness, AGO ofMDD, prevalence and AGO of five co-morbid anxiety disorders andtheir relationship with MDD. The cohort consists of 1,042 individualsdiagnosed with MDD (male/female ratio 1:2.9). Those with severeMDD (36.9%) have an earlier onset (p

PO2.90.QUALITATIVE AND QUANTITATIVE DIFFERENCESOF DEPRESSION SYMPTOMS ACCORDING TO SEX,AGE AND SEVERITYK. Dailianis, E. Panagoulias, D. MalidelisMental Health Center of Peristeri, Athens, GreeceThe purpose of this study was the evaluation of possible differences inthe clinical presentation of depressive mood according to sex, age andseverity of the depressive syndrome. We reviewed 45 cases of patientswith a diagnosis of depressive disorder according to DSM-IV criteria.All of them had filled in the Beck Depression Inventory (BDI) duringthe first contact with us. We divided them into subgroups accordingto the score on Beck’s Inventory (minor, moderate and severe depression)and the age (young, middle and old age). The severity of depressionand the clinical presentation were the same for both sexes,except for the presence of prominent despair in men. In all cases themore intensive symptoms were sadness, loss of pleasure, indecision,negative self-judgment, intense irritation, loss of energy, fatigue andloss of interest for the others. Significant differences were demonstratedamong patients with different age and severity of depression.PO2.91.COGNITIVE APPRAISAL OF SHAME AND GUILTIN PATIENTS SUFFERING FROM DEPRESSIONE. Szily, Z. Unoka, L. SimonDepartment of Psychiatry and Psychotherapy, SemmelweisUniversity, Budapest, HungaryWe assessed cognitive appraisal of shame and guilt in depressedpatients compared with healthy controls. Our work is based onScherer’s cognitive appraisal theory and the International Survey onEmotional Antecedents and Reactions (ISEAR) questionnaire, whichtargets all five components of the appraisal process (intrinsic pleasantness,novelty, goal-hindrance, coping-ability, norm and self-compatibility).80 depressed patients under clinical treatment and 120healthy controls filled the ISEAR questionnaire. The Short CheckList-90, revised (SCL-90-R) was used for the screening of the individualsin the control group. We found significant differences betweenthe two groups concerning coping potential, goal-hindrance, normand self-compatibility. Depressed patients stated that they are unableto influence the outcome of the given situation more often than controls(shame, coping potential: 56 vs. 29%, p=0.001; guilt, copingpotential: 56 vs. 22%, p=0.001). They also estimated more often thenegative impact of the listed events then the control group (shame,goal-hindrance: 72 vs. 40%, p=0.001; norm-compatibility: 48 vs.20%, p=0.001; self-compatibility: 75 vs. 53%, p=0.010; guilt, goalhindrance:80 vs. 40%, p=0.001; norm-compatibility: 35 vs. 17%,p=0.031; self-compatibility: 71 vs. 52%, p=0.014). In conclusion, inline with the cognitive theories of depression, we found thatdepressed patients’ situation appraisal differed from that of controlpersons (underestimation of coping ability, misjudgement of anevent’s negative effects on one’s needs and goals). This inappropriatenessof appraisal processes may well have a role in developing inappropriateemotional states and possibly damaged social functioningleading to affective disorders.PO2.92.THERAPEUTIC APPROACH TO COTARD’S DELIREDE NEGATION: A REPORT ON FIVE CASESS. Pappa, C. Mantas, K. Kotsi, T. Hyphantis, V. MavreasDepartment of Psychiatry, Medical School, University ofIoannina, GreeceThe “delire de negation” was first described in 1880 by Cotard, whobelieved it to be a new type of agitated melancholia. It has long beendebated whether this is a syndrome which may be associated with anumber of psychiatric conditions, most notably depression, or a separateclinical entity. We report on five patients with Cotard’s syndromein a context of an affective disorder. The psychopathological,clinical and therapeutic aspects of the syndrome are reviewed. Weparticularly focus on the potential significance of a subdivision of thesyndrome into diagnostic types, as proposed by Berrios and Lugue, orstages, as introduced by Vamada and colleagues. These classificationsmay be useful, as treatment would, in each case, be different.PO2.93.DEPRESSION DURING PREGNANCY AND AFTERCHILDBIRTHA. Uno, S. Sasaki, S. Nakajima, S. Kato, Y. Saijo, F. Sata, R. KishiDepartment of Public Health, Hokkaido University GraduateSchool of Medicine, Sapporo, JapanPostnatal depression is a common cause of morbidity. A number ofstudies have focused on early detection of depression during postnatalstage, however the onset of depression may be during pregnancy.This study aimed to investigate depressive symptoms during pregnancyand after childbirth in Japan. A cohort study was conducted at theSapporo Toho Hospital in Hokkaido, Japan. The study recruited subjectswho attended the hospital for regular check-up between 26 and34 weeks of pregnancy. Subjects who consented to the study wereinvestigated for depressive symptoms by the Edinburgh PostnatalDepression Scale (EPDS) on two occasions: during pregnancy and at4 weeks after childbirth. Since June 2002, 187 women completed thequestionnaire at one month postpartum. A score above the cut-offpoint of 9 on the EPDS for depressive symptoms was observed in5.3% of the women during pregnancy and 12.8% of the women atone month postpartum. There was a significant association betweenantenatal and postnatal depression. Five of the ten women who weredepressed antenatally had also been depressed in the postpartum. Inconclusion, not only the postnatal period, but also the antenatal periodcan offer an opportunity to identify women at high risk for depressionby screening and promoting psychological well being duringpregnancy.PO2.94.DEPERSONALIZATION SYMPTOMATOLOGYIN DEPRESSIVE PATIENTSJ. Matejic, O. ZikicClinic for Mental Health Protection, Nis, Serbia and MontenegroDepersonalization symptomatology can be manifested within the continuumranging from very mild, which could appear even in healthypopulation, up to the extremely prominent symptomatology in schizophreniaand depersonalization disorder. The objective of our researchwas to explore the existence of a specific increase of the depersonalizationdimension in patients suffering from depression. Experimentaland control group numbered 25 members each. A structured questionnairefor obtaining socio-demographic and medical history data269

was used. The Patient Health Questionnaire-9 (PHQ-9) was utilizedfor determining the level of depressive disorder (mild, moderate, moderatelyhigh, high). Depersonalization symptomatology was estimatedaccording to the Cambridge Depersonalization Scale (CDS). Resultsindicate that patients with depression have much higher levels ofdepersonalization in comparison to the healthy population (p=0.001).Depression intensity stands in positive correlation to levels of depersonalization(p=0.0029). Depersonalization is more prominent inmore severe depression (moderately high and high). There are no significantcorrelates in terms of education, episode duration, illnessduration, illness history and the modality of onset of the illness (gradualor abrupt).PO2.95.THE FACTORIAL STRUCTURE OF THE CES-D INCLINICAL SETTING IN JAPANT. Maruta, Y. Pan, T. Yamate, M. Sato, M. Nakano, K. Ito,M. IimoriDepartment of Psychiatry, Tokyo Medical University, Tokyo,JapanThe Center for Epidemiologic Study Depression Scale (CES-D),developed by the National Institute of Mental Health, is a 20-iteminventory that has been widely used in assessing depressive symptoms.Radloff examined the factor structure of the CES-D and identifiedfour factors: depressive affect, positive affect, somatic complaintsand interpersonal problems. These four factors have been replicatedin predominantly Caucasian populations. However, some researchersreported that there were differences among cultures and races. Concerningfactor analysis of the Japanese version of the CES-D, therewas no research using depressive patients although there were studiesthat examined non-clinical samples. Then, we are investigating thefactorial structure of the Japanese version of the CES-D from the firstintake at the outpatient clinic in the Department of Psychiatry ofTokyo Medical University for three years. In addition, we report differencesby generation and differences of total score by severity ofdepression.PO2.96.THE EFFECT OF VENLAFAXINE TREATMENTON SERUM BRAIN-DERIVED NEUROTROPHICFACTOR LEVELS IN DEPRESSED PATIENTSO. Aydemir 1 , A. Deveci 1 , F. Taneli 21 Department of Psychiatry and 2 Department of Biochemistry,Celal Bayar University, Manisa, TurkeyRecent studies suggested the role of brain-derived neurotrophic factor(BDNF) in depression. This study was aimed to test the effect of venlafaxinetreatment on serum BDNF levels in patients with majordepressive disorder. We studied ten patients with major depressivedisorder, two of whom had their first episode and were drug-naïve,and the others were drug-free for at least 4 weeks. Depression wasrated by Hamilton Scale for Depression (HAM-D). The control groupconsisted of ten age- and sex-matched subjects. Blood samples werecollected at baseline and after 12 weeks of venlafaxine treatment(during remission). Serum BDNF was assayed with an ELISA kit(Promega; Madison, WI, USA). In statistical analysis, Mann-WhitneyTest and Wilcoxon Test were performed. The mean age of the studygroup was 31.8±14.3 years and 8 of the ten patients were female. Atbaseline, mean serum BDNF level was 17.9±9.1 µg/ml and meanHAM-D score was 23.2±4.6. Serum BDNF level of the study groupwas significantly higher than the control group (p=0.007). Venlafaxinetreatment was started with a dose of 75 mg/day. Final venlafaxinedose was 225 mg/day in two patients, 150 mg/day in three patients,and 75 mg/day in the rest. At the end, mean serum BDNF level(34.6±7.1 µg/ml, p=0.007) increased while mean HAM-D score(8.2±3.9, p=0.005) decreased significantly, and serum BDNF level atremission was not different from the control level (p=0.43). In conclusion,this study suggests that venlafaxine treatment of depressionimproves serum BDNF level as well as HAM-D score.PO2.97.PROTEIN S100B CORRELATES WITHMONOAMINERGIC FUNCTION IN MAJORDEPRESSIONG. Hetzel 1 , O. Moeller 1 , S. Evers 2 , A. Erfurth 2 , G. Ponath 1 ,V. Arolt 1 , M. Rothermundt 11 Department of Psychiatry; 2 Department of Neurology, Universityof Muenster, GermanyS100B is an astrocytic, calcium-binding protein which exerts neuroprotectiveand regenerating effects on neurons and glia cells atnanomolar concentrations. In cell culture and animal experimentsS100B has been shown to be regulated by serotonin via 5-HT1Areceptors. We hypothesized that the increased S100B concentrationdetected in major depression might depend on the functionality of theserotonergic system. In 18 patients with major depression, S100Bserum concentration was determined and monoaminergic functionwas measured by oral citalopram (n=10) and reboxetine (n=8) challengetests. S100B serum concentration correlated significantly withthe serotonergic function. In addition, a negative correlation betweennoradrenergic function and S100B concentration was observed. Thisstudy provides evidence that not only in cell culture and animalexperiments but also in a clinical setting S100B concentrations mightbe influenced by the serotonergic system in depressed patients. Therole of noradrenaline in this respect needs further clarification.PO2.98.DIFFERENT PROTEIN EXPRESSION LEVELSAFTER ANTIDEPRESSANT TREATMENT ON EBVCELLS OF DEPRESSED PATIENTSP. Zill, T.C. Baghai, S. de Jonge, K. Neumeier, M. Ackenheil,H.-J. Möller, B. BondyDepartment of Psychiatry, Ludwig-Maximilians-University,Munich, GermanyIn recent years it became obvious that the targets of antidepressantdrug action are more likely to lie beyond the receptor level. Althoughthe molecular loci of antidepressant drug action have not yet beenfully established, it is known that antidepressant treatment modulatesgene expression at the genomic level. The aim of the present studywas to investigate the effects of mirtazapine, reboxetine and fluoxetineon the protein expression levels in Epstein-Barr virus transformed(EBV) cells of depressed patients as a peripheral model usingantibody microarrays (“protein chips”). Lymphocytes were preparedfrom whole blood and immortalized via EBV transformation. Thecells were incubated with the medium plasma level concentration ofeach antidepressant drug for 48 hours and compared with an untreatedsample of the same cell line. The protein chips contained 380 monoclonalantibodies on glass slides (proteins of signal transduction,cell-cycle regulation, gene transcription, apoptosis, oncogenesis).First results show clear differences in the protein expression. Especiallythe levels of three proteins (neurogenin 3, K-channel a, JNK1),which play a role in signal transduction processes, were altered after270 World Psychiatry 3:S1 - October 2004

incubation with each antidepressant. Our data suggest that mirtazapinetreatment modulates to a great extent the expression of proteinsinvolved in signal transduction and neuronal plasticity. These resultshave to be validated in further studies.This project is supported by the German Federal Research Ministrywithin the promotional emphasis “Competence Nets in Medicine”.PO2.99.HORMONE REPLACEMENT THERAPY WITHANDROGEN AS AN ADJUNCTIVE TREATMENTTO TREAT POSTMENOPAUSAL DEPRESSIONR.S. Dias, F. Kerr-Corrêa, R.A. Moreno, L.A. Trinca, A. Pontes,H.W. Halbe, A. Gianfaldoni, I.S. DalbenBotucatu Medical School and São Paulo University MedicalSchool, Sao Paulo, BrazilAndrogens improve libido and cognition, although there are few studiesin depression. This study aimed to evaluate hormone replacementtherapy (HRT) with and without androgens in menopausal depressivewomen. Seventy-two depressive (DSM-IV) women, mean age 53.6years, followed for 24 weeks, were all treated with venlafaxine (37.5 –225 mg/day) and randomized according to a double blind design intofour HRT groups: G1 (n=20) - estrogen (0.625 mg) plus medroxyprogesteroneacetate (2.5 mg) and methyltestosterone (2.5 mg); G2 (n=20)- estrogen (0.625 mg) plus medroxyprogesterone acetate (2.5 mg) andmethyltestosterone placebo; G3 (n=16) - estrogen placebo plusmedroxyprogesterone acetate placebo and methyltestosterone (2.5mg); and G4 (n=16) - estrogen placebo plus medroxyprogesteroneacetate placebo and methyltestosterone placebo. Outcomes measuredby Montgomery-Asberg Depression Rating Scale (MADRS) were analyzedby repeated measures technique, after using multiple imputationfor missing responses due to drop outs. At baseline, the mean MADRSscore was 30.7. No significant difference was observed between groupson drop-out rates (p=0.43). A statistical difference among the groupswas observed for remission rates at the end of the study: G1 100%; G286.7%; G3 77.8%; G4 55.6% (p=0.023). These results suggest a betterpatient outcome with HRT plus androgens added to venlafaxine totreat postmenopausal women with depression.PO2.100.ANTIPSYCHOTICS IN THE TREATMENT OFDEPRESSIVE EPISODE AND RECURRENTDEPRESSIONI. Riec˘anský 1,2 , L. Vavrus˘ová 1 , M. Koníková 11 Department of Psychiatry, Ruz˘inov Hospital;2 Institute of Normal and Pathological Physiology,Slovak Academy of Sciences, Bratislava, Slovak RepublicWe evaluated the rationale for the prescription of antipsychotics(APs) in depressive episode and recurrent depression. We analyzeddata from inpatients at the Department of Psychiatry, Ruzinov Hospital,Bratislava, Slovakia, in years 1999-2001. Overall, 149 patientswere hospitalized with the ICD-10 diagnosis F32 (n=35) or F33(n=114). We found the use of APs and choice of AP type (typical oratypical) independent of the diagnosis and severity of the disorder.Overall, 44% of patients were treated with APs, 26% with typicaland 22% with atypical drugs. Duration of hospitalization was significantlylonger in patients using APs and was unrelated to theseverity of the disorder (tested for F33). The type of AP did notinfluence the duration of hospitalization. The number of patients rehospitalizedin one-year interval after discharge was unrelated toAP treatment or AP type. Treatment with APs did not yield differentimprovement on the Clinical Global Impression Scale (CGI) whenassessed one year after release from hospital (in F33). ConsideringCGI scores, typical and atypical APs were equally effective. Ourdata do not confirm an unequivocal benefit from AP treatment forpatients with depressive episode and recurrent depression. However,the findings suggest that APs may be used in patients with insufficientresponse to antidepressants and perhaps in patients expressingcertain disorder-related symptoms. In such cases the use of APsmay well be justified.PO2.101.EFFICACY AND TOLERABILITY OF ST. JOHN'SWORT EXTRACTS IN MAJOR DEPRESSIVEDISORDERP. SchulteMental Health Services,Department De Dijk, Heiloo, The NetherlandsThere is ongoing controversy on the efficacy of St. John's wort extracts(hypericum) in major depression. We performed a systematic reviewand meta-analysis of all randomised-controlled trials with a DSM-III/IV or ICD-10 diagnosis of major depressive disorder and responseratios measured by >50% improvement on HDRS or final score ≤8.We found 13 comparisons with placebo, and seven with tryciclics(TCAs) and selective serotonin reuptake inhibitors (SSRIs) each.There were three three-arm trials comparing hypericum with placeboand a standard antidepressant. Attrition was not significantly differentbetween hypericum and placebo or SSRIs, but was significantly lowerin comparison to TCAs (absolute risk reduction, ARR 5%, 95% CI 14-33). There was no significant difference in number of patients reportingside effects in the meta-analyses of the placebo and hypericumgroups. The ARR in comparison to SSRIs was 9% (95% CI 8-20) andin comparison to TCAs was 22% (95% CI 4-5). Although four placebo-controlledtrials did not show superiority in respect to response,the meta-analysis shows an ARR of 16% in favour of hypericum (95%CI 6-7). The ARR with respect to response with TCAs or SSRIs was4% and 3%, respectively. One of the three-arm trials could not showantidepressant superiority of the standard medication above placeboand was excluded from the meta-analysis. The ARR for the remainingtwo studies was 23% (95% CI 3-6). In conclusion, in outpatients withmild to moderate major depressive disorder, hypericum extracts combineexcellent tolerability with antidepressant efficacy comparable tostandard antidepressants. This may be interesting for patients withintolerable side effects on traditional antidepressants and for lowincome countries.PO2.102.UTILIZATION OF ANTIDEPRESSANT DRUGS:A LONG-TERM RETROSPECTIVE ANALYSISIN PRIMARY CAREP. Russo 1 , S. Paragoni 2 , F. Baiardi 2 , E. Degli Esposti 3 ,G. Carmosino 41 Department of Human Physiology and Pharmacology,La Sapienza University, Rome; 2 CliCon, Ravenna; 3 Local HealthUnit, Ravenna; 4 Health Care Research, Lundbeck, Milan, ItalyThe objective of the study was to investigate the utilization of antidepressantdrugs (ADs) in primary care. An observational cohort studywas conducted among all population (356,000 inhabitants) listed inthe databases of the Local Health Unit of Ravenna and exposed toADs from 1996 to 2000. Pharmaco-utilization profile was defined271

according to the mean number of renewed prescriptions per year, calculatedon the interval between the first and the last prescription; theexposure was categorized as continual (≥5) non-continual (between1.5 and 5) or occasional (≤1.5). A cohort of 27,139 patients was retrospectivelyevaluated. Part of them (n=5,989, 22.1%) received a variabletreatment combination including heterocyclics or selective serotoninreuptake inhibitors (SSRIs) or other drugs. With reference tomonotherapy, 39.1% of patients (n=10,612) were exposed to heterocyclics,7.3% to SSRIs (n=1,990), and 31.5% (n=8,548) to differentdrugs. Among evaluated patients, 18.6% (n=5,044; mean age 63±17years; 65% female) were exposed to a continual treatment, 23.1%(n=6,271; mean age 61±18 years; 69% female) to a non-continualtreatment, and 58.3% (n=15,824; mean age 54±20 years; 63% female)to an occasional treatment. In the groups with a continual exposure,we found the lowest percentage of patients treated with heterocyclics(21.8%; p

PO2.106.TEMPORARY RESPONSE OF A TREATMENTRESISTANT DEPRESSED PATIENT TO ACOMBINATION OF VENLAFAXINE PER OSAND INTRAVENOUS CLOMIPRAMINEK.N. Fountoulakis, S.G. Kaprinis, A. Iacovides, G.S. Kaprinis3rd Department of Psychiatry, Aristotle University ofThessaloniki, GreeceWe report the case of a 33-year old woman with major depressionrefractory to treatment. The patient had received various adequate trialswith many different agents and all of them had lasted at least fourmonths. Therefore, it was decided to try a more aggressive treatmentwith high doses of i.v. clomipramine in combination with venlafaxineper os. The maximum dose reached at day 15 was 6 amp clomipraminei.v. plus 225 mg venlafaxine per os. The patient responded on day 15,with a dramatic remission of symptoms, almost to normothymic state.This remission lasted for 37 days, and then the patient attempted suicideby swallowing tablets. These 37 days were the only normothymicdays of her last 7 years.PO2.107.IMPROVEMENT OF COGNITIVE FUNCTIONSAFTER TRANSCRANIAL MAGNETICSTIMULATION IN A PATIENT WITH TREATMENTRESISTANT MAJOR DEPRESSIONS. Volkaviciute, Z. Alseikiene, J. NeverauskasNeuromeda Medical Center, Kaunas, LithuaniaA 79 years old woman who had been suffering from major depressionfor the last 2 years, and had been treated unsuccessfully with sertraline(150 mg/day) and venlafaxine (150 mg/day), underwent transcranialmagnetic stimulation (rTMS). At admission the HamiltonDepression Scale (HAMD-17) score was 18. The score of the clockdrawingtest was 3. The patient was not able to name the exact day ofthe month. Before rTMS, in order to avoid seizures, the dose of venlafaxinewas decreased to 75 mg/day. The parameters of the performedleft prefrontal rTMS were 10 Hz, 20 trains, 5 sec., number ofpulses – 50, 110 % MT. After 10 procedures, the dose of venlafaxinewas restored up to 150 mg/day and rTMS procedures were continued.After 5 additional procedures the psychomotor activity of the patientincreased significantly and the score of the HAMD-17 became 9. Shebegan to smile; speech was fully understandable, the contact with thepatient became easy. The score of the clock-drawing test became 4.Two months after the procedures, the patient preserved the same conditionusing the same medications. Thus, the 15 sessions of rTMSmarkedly improved not only the depressive symptoms of this patientwith drug resistant depression but also her cognitive functions.PO2.108.HEART RATE VARIABILITY AS A PREDICTOR OFRESPONSE TO ELECTROCONVULSIVE THERAPY INMAJOR DEPRESSIVE DISORDERP.L. Gupte 1 , N. Janakiramaiah 1 , N. Jagadisha 1 ,A.G. Ramakrishnan 2 , B.N. Gangadhar 21 Department of Psychiatry, National Institute of Mental Healthand Neurosciences; 2 Department of Electrical Engineering, IndianInstitute of Science, Bangalore, IndiaThe aim of the study was to test the hypothesis that heart rate variabilitycould predict response to electroconvulsive therapy (ECT). 40consecutive patients who gave consent were recruited. After the diagnosiswas confirmed, Beck’s Depression Inventory (BDI) was usedfor rating severity and response to treatment. Digital electrocardiogram(ECG) was acquired in standard conditions and analysed usingShow ECG version 2.0 software. The heart rate, root mean successivedifferences and high-frequency power were studied. All patientsreceived modified, right unilateral thrice-weekly ECT. Twenty-fivepatients completed the protocol. At the end of two weeks, patientswere divided into two groups - “remitted” and “not remitted” - andtheir baseline values were compared. The patients who completed theprotocol were not significantly different from those who did not.Patients improved significantly after receiving ECT. Remission wasdefined as a BDI score of 9 or less. Of the parameters studied, higherhigh-frequency power (p=0.01) predicted remission at the end of twoweeks. This finding suggests that high frequency power can potentiallybe used as a prognostic measure for response to ECT.PO2.109.A COMPUTERISED INTEGRATED PATHWAYFOR ELECTROCONVULSIVE THERAPYG. Fergusson, L. Cullen, C. Freeman, J. HendryScottish ECT Audit Network, UKThe Scottish ECT Audit Network (SEAN) has been established for sixyears. Data on all patients having electroconvulsive therapy (ECT)are routinely collected from all 28 clinics in Scotland, including informationon demographics, process and outcome. We have developedan integrated care pathway, initially on paper and now electronically,which covers the steps from the decision to give ECT, through theECT process to assessing outcome including side effects. The electronicpathway only allows ECT to be given once the appropriatechecks, for example legal status and consent, have been entered. ECTin Scotland is given at a rate of 142 treatments per 100,000 population,mainly to white (99%) adult patients with a diagnosis of depressiveillness (87%). The ratio of females to males is approximately 2:1and ECT is not given disproportionately to the elderly. The majorityof patients (82%) are able to give consent, the remainder being treatedunder legal provisions. Equipment and facilities are of a high standard.Outcome data using verified scales shows a definite improvementin over 72% of patients. Early analysis of data suggests a correlationbetween indication for ECT and outcome.PO2.110.A NEW METHOD FOR MONITORING OUTCOMEFROM ECT USING THE ANCHORED VERSIONOF THE BRIEF PSYCHIATRIC RATING SCALEG. Iverson, R. Lange, C. Strangway, N. KangUniversity of British Columbia and Riverview Hospital,Vancouver, CanadaThe Brief Psychiatric Rating Scale (BPRS) is frequently used as an outcomemeasure for electroconvulsive therapy (ECT) in both clinicalpractice and research. The purpose of this study was to develop andapply a psychometrically sophisticated method for determiningwhether a patient undergoing ECT has improved, remained stable, ordeteriorated. Inter-rater reliability estimates for the BPRS anchoredversion (BPRS-A) individual items and total score, reported by Lacharet al., were used to calculate the standard error of difference and reliablechange confidence intervals (70%, 80%, and 90% CI). A newquick reference reliable change table was used to evaluate 20 patientsundergoing an index or maintenance course of ECT. Their mean agewas 62.5±17.7 years. On average, the patients evidenced a significantimprovement in global psychiatric symptoms, as measured by the total273

score (pre-ECT: 48.5±14.7; post-ECT: 38.3±9.4; p

evaluated using the Hamilton Depression Rating Scale (HAMD), astructured interview regarding the quality of life during the treatmentperiod and the Sexual Health Inventory for Men (SHIM). At the timeof admission, all patients had erectile dysfunction. Trazodone treatmentwas initiated at 150 mg/day and the SSRI was discontinued. Wefound a decrease in HAMD mean score (from 24.6 at the time ofadmission to 16.4 at two weeks after the switch of the drug), animprovement in the quality of life and a decrease in SHIM mean scorefrom 18 to 7. After two weeks of trazodone treatment, 4 patientsreported a marked improvement in sexual dysfunction (SHIM scorebetween 7 and 12), one presented a moderate improvement (SHIMscore of 14) and the rest of patients reported no change in their sexualfunctioning. These data suggest that trazodone is a useful treatmentfor depression-associated sexual dysfunctions and can be helpful forSSRI-induced or aggravated sexual symptoms.PO2.115.TIANEPTINE IN THE TREATMENT OF MIXEDANXIETY AND DEPRESSION DISORDER IN THEELDERLYT.M. SobowDepartment of Old Age Psychiatry and Psychotic Disorders,Medical University of Lodz, PolandMixed anxiety and depression disorder (MAD) has been recognized inICD-10 as a diagnostic group including those anxious and depressedpatients who do not fulfill criteria for any major axis I disorder. Clinicalexperience indicates that MAD might be particularly prevalent ingeriatric patients. The treatment of MAD in the elderly represents aspecial challenge mostly due to tolerability issues. Tianeptine, a relativelynovel antidepressant, has been shown to possess both antidepressantand anxiolytic-like properties and is usually well tolerated bythe old. We conducted a retrospective analysis of treatment effectivenessand tolerability of tianeptine (25 mg bid) in 26 MAD geriatric subjects(mean age: 73), with or without accompanying cognitive deficits.Twenty-two of 26 (85%) completed an 8 week trial of tianeptine. Twopatients discontinued due to side effects (dry mouth and nausea) and2 due to drug-unrelated reasons. At week 8, 19 patients (73% of initiallyrecruited and 86% of completers) were considered responders(Clinical Global Impression score 1 or 2). The response rate did notdiffer in subjects with a score on Mini-Mental State Examination(MMSE) lower than 25 points (n=11). In conclusion, tianeptine mightrepresent an alternative option in the treatment of MAD in the elderly,with or without cognitive deficits.PO2.116.MANAGEMENT OF DEPRESSION INPATIENTS WITH SUBSTANCE ABUSEC. Andre, J.A. Jaber-Filho, C. Jullien, M.C.L. CarvalhoClinica Jorge Jaber, Rio de Janeiro, BrazilPatients admitted between July and December 2001 to a rehabilitationcenter for substance abuse were assessed on admission and dischargeusing the Mini-Mental Exam and the Hamilton Depressionscale (HAM-D21). Demographic data and details on the extent andnature of drug use were also obtained. 64 patients were admitted duringthis period: 24 were excluded from analysis due to psychiatric comorbidity,7 were excluded due to their abandoning treatment prematurely.Of the 33 remaining, 16 had a HAM-D21 score of ≥15. 3 werediagnosed with bipolar disorder or psychotic depression, and excludedfrom further analysis. 12 of the 13 patients without co-morbiditywere treated with antidepressants and a combination of therapeutictechniques including the 12-Step Program, support groups, individualand family therapy. There was a marked reduction in the symptomsof depression during inpatient treatment. In 11 cases, the HAM-D21 score fell to ≤8. Demographic characteristics, cognitive performanceand type(s) of drugs used did not influence the results.PO2.117.DEPRESSION IN PEOPLE OF PAKISTANI FAMILYORIGIN AND WHITE EUROPEANS IN UKR. Gater, N. Chaudhry, G. Dunn, M. Ghangrakar, S. Hijazi,N. Husain, J. Jackson, G. MacFarlane, M. Munawar, C. Percival,W. Waheed, F. CreedUniversity of Manchester, UKDepressive disorders are a major cause of disability and distressworldwide. There is evidence that people of ethnic minority groups inUK and USA experience more depression than white Europeans. Thisprospective epidemiological study is investigating the prevalence,associations, service use and 6-month outcome of depression in peopleof Pakistani family origin and white Europeans in the UK. Baselinescreening for common mental disorders using the Self RatingQuestionnaire (SRQ) has been completed with 928 people of Pakistanifamily origin and 947 white Europeans. Based on SRQ score, astratified sample of 332 people of Pakistani family origin and 316white Europeans have been assessed using the Schedules for ClinicalAssessment in Neuropsychiatry (SCAN) diagnostic interview andLife Events and Difficulties Schedule (LEDS). Baseline findings indicatea high prevalence of depression among Pakistani women (32%),compared with European women (19%), European men (13%) andPakistani men (9%). Pakistani women have a higher prevalence ofdepressive disorder than the other groups at all ages. Among thoseaged 50 years or more, 65% of Pakistani women have depressive disordercompared with less than 20% in each of the other groups. Possiblereasons for this high prevalence, including chronic social difficulties,generational effects and access to health and social serviceswill be presented.PO2.118.PAIN SCORE AND DEPRESSION IN PEOPLEOF PAKISTANI FAMILY ORIGIN AND WHITEEUROPEANS IN UKC. Percival, R. Gater, N. Chaudhry, G. Dunn, M. Ghangrakar,S. Hijazi, N. Husain, J. Jackson, G. MacFarlane, M. Munawar,W. Waheed, F. CreedUniversity of Manchester, UKThere is a close association between pain and depression in populationsurveys. We assessed whether there was any difference in the relationshipbetween depression and pain in two ethnic groups in the UK.This cross-sectional population-based study assessed depression usinga two-phase design with the Self Rating Questionnaire (SRQ) and theSchedules for Clinical Assessment in Neuropsychiatry (SCAN). Painwas assessed by asking respondents to mark on a manikin any pointsin their body where they experienced persistent pain. Scores used inthe analysis were a simple count of the pain marks and separate scoreson the SRQ for psychological items (max 12 items) and somatic items(8 items). Data were collected from 928 people of Pakistani family originand 947 white Europeans. The correlation coefficients for SRQsomatic and psychological score were almost identical for the fourgroups: Pakistani women, European women, European men and Pakistanimen (0.61-0.7). The correlation coefficients for SRQ psychologicaland pain score were similar for Pakistani and white European275

women (0.41 and 0.42) and for the men of each ethnic group (0.39 and0.29). Depressed women had significantly higher pain scores thannon-depressed women and this held within each ethnic group. Therewas no significant difference between the pain scores for depressed vs.non-depressed men in either ethnic group. In conclusion, the patternof association between pain and depression differs in men andwomen, but the patterns are similar across people of Pakistani familyorigin compared to white Europeans.PO2.119.DEPRESSION IN LATER LIFED.C. Domocos, A.M. DomocosAna Aslan National Institute of Gerontology and Geriatrics,Bucharest, RomaniaDeveloping depression in elderly patients results from imbalancebetween predisposing, precipitating and protective factors. The predisposingfactors for depressive disorders in old age are representedby increasing levels of disability and chronic disease. The increasingprevalence of minor depression in later life is related to risk factorsassociated with the stress of growing old: loss of life partner andfriends, living in large cities, poor health, functional limitation,decrease in social networks. Organic causes of late life depression arebecoming significant with the increased understanding of brain function:neurodegenerative changes in the periventricular areas and subcorticalwhite matter, reduction in cerebral monoamine oxidase anddecreased levels of depression neurotransmitters, the high incidenceof cerebrovascular disease. The symptoms of depressive disorders inthe elderly differ from adults because of an increased emphasis onsomatic complaints in older people. The major goals of the pharmacologicaltreatment in elderly patients are to improve the quality oflife, maintain people in community, delay or avoid the placement innursing homes. As a general rule, the lower possible dose should beused to obtain the therapeutic effect, so that the individualization ofdosage is essential in geriatric psychopharmacology.PO2.120.DEPRESSIVE DISORDERS IN PATIENTSWITH EPILEPSYT.V. KazennykhMental Health Research Institute, Tomsk, RussiaWe studied the prevalence and nature of mental disorders in patientswith epilepsy observed in the epileptological room of our Institute.Among 102 patients with epilepsy, 59.4% presented an affectivesymptomatology, consisting of irritability, depressed mood, emotionallability, anxiety. “Somatic” complaints were frequent: headache ofvarious character and intensity, feelings of fatigue, unpleasant sensationsin different parts of the body, general weakness. In 7 patients(6.9%) a psychogenic precipitant of depression could be found,including the diagnosis of epilepsy in four cases, and the separationfrom the partner in the others.PO2.121.EPILEPSY, DEPRESSION AND RISK FOR SUICIDEM. Mazza, F. Orsucci, R. Lacerenza, P. Urbano, P. Madia, S. De RisioInstitute of Psychiatry, Catholic University, Rome, Italysuicide. Among people with epilepsy, psychiatric comorbidity iscommon, with an elevated rate of major depression. A review of theliterature about the association between epilepsy, depression andsuicide highlights the lack of evaluation of intensity, pervasivenessand characteristics of suicidal ideation in epileptic patients comparedwith patients with a diagnosis of major depression. Ourstudy investigated a sample of patients with temporal lobe epilepsyand one of patients with a diagnosis of major depression accordingto DSM-IV, using the Beck Depression Inventory, the ZungDepression Rating Scale, the Hamilton Depression Rating Scale,the Montgomery-Asberg Depression Rating Scale and the Buss-Durkee Hostility Inventory. Current suicide risk was quantified bythe suicidality module of the Mini-International NeuropsychiatricInterview. Preliminary results show in epileptic patients the presenceof suicidal ideation independently from the severity of depressivesymptoms.PO2.122.SEASONALITY IN THE COURSEOF AFFECTIVE DISORDERSG.G. SimutkinMental Health Research Institute, Tomsk, RussiaThe study aimed to assess the prevalence and character of seasonalpattern in recurrent and bipolar depression. 133 patients with recurrentand bipolar depression (ICD-10 research criteria) were investigated(101 women and 32 men; mean age 46.2±11.9). An accuratechronological analysis showed that 41 patients (30.8%, 33 women and8 men) fulfilled DSM-IV diagnostic criteria for seasonal affective disorder(SAD). A steady seasonal course of the affective disorder wasfound in 43.7% of patients. The seasonal pattern was more frequent inbipolar affective disorder. The seasonal pattern most frequentlyappeared from the onset of the disorder (54.4%). The most frequentlyoccurring variant of SAD was the winter type (28.2%). A “dissociated”bipolar SAD was observed, in which depressive phases had a seasonalpattern and hypomanic phases did not.PO2.123.MULTI-ANNUAL SOLAR ACTIVITYAND AFFECTIVE DISORDERSO. NicoaraPsychiatric Clinic, Timisoara, RomaniaThis study takes into consideration two variables: the multi-annualoscillations of the solar activity (i.e., the solar cycle) and the multiannualoscillations of affective disorders. By studying all cases with adiagnosis of affective disorder (F30-F33 in the ICD-10) admitted tothe Timisoara Psychiatric Clinic between 1986 and 1996 (the periodcovering a complete solar cycle of 11 years), we have found there is acorrelation between the number of admissions for bipolar affectivedisorder (both manic and depressive) and the intensity of the solaractivity during the multi-annual cycle (number of sunspots). Therewere no significant correlations between the number of admissionswith a diagnosis of unipolar depressive disorder and the intensity ofsolar activity.Compared to the general population, the suicide rate in epilepsy is5-fold increased. In particular, patients with temporal lobe epilepsyhave an 8-fold increased risk of suicide. Certain psychiatric disorders,including primary mood disorders, also increase the risk for276 World Psychiatry 3:S1 - October 2004

PO2.124.THYROID DYSFUNCTION IN NEUROTICDEPRESSIONN.G. Babayan, M.G. BadalyanNational Institute of Health of Republic of Armenia, Yerevan,Republic of ArmeniaOut of 55 patients with neurotic depression (according to ICD-10), 33women and 22 men, a screening by auricolodiagnostics identified 17cases (15 women and 2 men, age between 15 and 65 years) of suspectthyroid dysfunction. Further clinical and laboratory investigations ofthis group detected 2 cases of clinical hypothyroidism, 6 of subclinicalhypothyroidism and 9 of secondary (central) hypothyroidism. Thesepatients received L-thyroxin (75-100 mcg per day) as the only therapy,and depression improved in all cases. These results confirm the importanceof the assessment of thyroid function in neurotic depression.PO2.125.SEXUAL DYSFUNCTIONS INDUCEDBY NEWER ANTIDEPRESSANTSS. GentileLocal Health Unit, Cava de’ Tirreni, Salerno, ItalySexual dysfunctions (SD) are common during treatment with newantidepressants. Rates observed in clinical practice may be higherthan those reported in product information. We analysed availableliterature data on this topic. Published studies suggest that between30% and 60% of patients treated with selective serotonin reuptakeinhibitors experience some form of SD. The mechanisms involved arethe interference with 5-HT pre-synaptic facilitation of sympatheticactivity; the inhibitory effect on the orgasm mediated by central 5-HT2 activation; the effects on smooth musculature involved in orgasmiccontractions, due to increased peripheral 5-HT levels; the antidopaminergicindirect effects; the inhibition of nitric oxide synthetase(NOS), the elevation of prolactin levels, and the cholinergic andalpha1-adrenergic receptor blockade. Paroxetine is the only agentwhich exerts a NOS inhibition. This activity explains data reported byseveral authors of higher incidence of SD during paroxetine treatment.SD occur in 10% of patients treated with venlafaxine and11.7% of those treated with bupropion.PO2.126.PAROXETINE AUGMENTATION TO TIANEPTINETREATMENT CAUSES EXACERBATION OFDEPRESSIVE SYMPTOMS: PRESENTATION OF TWOCASESÖ. Öztürk, D. Eraslan, B. KayahanDepartment of Psychiatry, Ege University Medical School,Izmir, TurkeyAlthough tianeptine has structural similarities with tricyclic antidepressants,unlike tricyclic agents or selective serotonin reuptakeinhibitors, it enhances 5-HT reuptake, leading to decreased availabilityof the transmitter in synaptic cleft. Thus, efficacy of tianeptine asan antidepressant agent caused a challenge to the concept of serotonergicdeficit theory in depression. Paroxetine and tianeptine are foundequally effective in treatment of major depression, but no data isavailable for combined use of these two agents. Two patients withmoderate to severe depression were administrated 37.5 mg/day oftianeptine. As they had insufficient response, paroxetine 20 mg/daywas given as augmentation therapy to tianeptine. A slight exacerbationof symptoms was observed after this drug was added. Both medicationswere stopped and clomipramine 125 mg/day was administered,which resulted in remission. The inverse pharmacologicalmechanisms of actions of paroxetine and tianeptine might be responsiblefor the exacerbation of depressive symptoms in the acute phaseof combination treatment. We believe this clinical feature of tianeptineand paroxetine combination is very important and needs confirmationby randomized and controlled studies with larger samples.PO2.127.DYNAMICS OF ANXIOUS DEPRESSION UNDERTIANEPTINE AND SERTRALINE TREATMENT:COMPARATIVE CLINICAL-BIOCHEMICALINVESTIGATIONN.M. Maximova, O.P. Vertogradova, M.G. UzbekovResearch Institute of Psychiatry, Moscow, RussiaWe studied the dynamics of anxious depression under tianeptine andsertraline treatment. 61 patients whose diagnosis was F32.1 (n=21),F33.1 (n=38), and F34.1 (n=2) were investigated. The presence ofanxiety in the clinical picture of depression was the inclusion criterion.31 patients received tianeptine (37.5 mg/day) and 30 received sertraline(50 mg/day). The percentage of responders was 74% fortianeptine and 77% for sertraline. In tianeptine responders, the meanglobal score of the Hamilton Depression Rating Scale decreased from21.8 (baseline) to 6.7 (2 weeks of therapy) to 0.9 (4 weeks of therapy).The corresponding figures for sertraline were 24.6, 6.3 and 1.4. Thefigures on the Hamilton Anxiety Rating Scale were 30.0, 8.2 and 0.6for tianeptine and 30.8, 5.5 and 1.3 for sertraline (all p

PO2.129.BIOCHEMICAL PROFILE IN PATIENTS WITHANXIOUS DEPRESSION UNDER TIANEPTINEAND SERTRALINE THERAPYM.G. Uzbekov, N.M. Maximova, E.Y. Misionzhnik,O.P. VertogradovaResearch Institute of Psychiatry, Moscow, RussiaThe aim of the study was to compare the biochemical profiles ofpatients with anxious depression under treatment with tianeptine, aserotonin reuptake enhancer and sertraline, a selective serotoninreuptake inhibitor. Platelet monoamine oxidase (MAO) and serumamine oxidase (AO) activities, level of middle molecules (MM) andparameters characterizing functional properties of serum albuminwere investigated in 43 patients with anxious depression (F32.1 andF33.1). In comparison with healthy controls, patients with anxiousdepression showed a significant increase in MAO activity and thelevel of MM and a significant decrease in AO activity and functionalalbumin activity. In responders to tianeptine and sertraline treatment,the therapeutic effect was accompanied by changes of all investigatedparameters in the opposite direction. In nonresponders receivingtianeptine, metabolic changes were more similar to those of respondersthan in nonresponders receiving sertraline. This study is the firstto demonstrate these changes in a comparative clinical-biochemicalinvestigation of the effects of serotonergic antidepressants with differentmechanisms of action.PO2.130.SERUM DEHYDROEPIANDROSTERONESULFATE AND CORTISOL LEVELS IN PATIENTSWITH DIFFERENT TYPES OF DEPRESSIONL.N. Gorobets, Y.A. Kochetkov, K.B. BeltikovaResearch Institute of Psychiatry, Moscow, RussiaDehydroepiandrosterone sulfate (DHEAS) is a circulating steroidwith various important neurophysiological functions. It has beenhypothesized that DHEAS is a more sensitive parameter for the evaluationof the severity of depression than cortisol. The aim of the studywas to investigate cortisol and DHEAS levels in different types ofdepression. We examined 11 patients with a depressive episode(F32.1; DE) and 21 patients with recurrent depressive disorder(F33.1; RDD). Serum cortisol and DHEAS levels were measuredusing an immune-enzyme method before antidepressant treatment. Inpatients with depressive episode, DHEAS levels (1.97±0.25 µg/ml)were significantly higher (p

lue and Bluevoices is about presenting these measuring sticks todrive mental health reform. This is an Australian story about partnerships,advocacy and empowerment from the lived perspective. Thispresentation will demonstrate that persons and their carers with thelived experience of depression and anxiety related disorders can makea difference.PO2.133.ANXIETY RESPONSES TO CO2 INHALATIONIN SUBJECTS AT HIGH RISKFOR PANIC DISORDERW. Coryell, D. Pine, A. Fyer, L. Dindo, D. KleinUniversity of Iowa College of Medicine, Iowa City, IA, USAA number of reports have shown that patients with panic disorderhave greater anxiety responses to the inhalation of enhanced carbondioxide mixtures than do well controls or patients with other psychiatricillnesses. Three earlier studies have shown that well individualswho have first-degree relatives with panic disorder also experiencemore anxiety following CO2 then do controls without such a familyhistory. The following was undertaken to confirm and extend thesefindings. Well subjects at high risk for panic disorder (HR-P, n=132)had a first-degree family member with treated panic disorder but nopersonal history of panic attacks. Low-risk subjects (LR-C, n=85) hadno such family history. All underwent a diagnostic interview with theSchedule for Affective Disorders and Schizoprhenia and completed abattery of self-rating scales before undergoing two CO2 challenges.One involved a single vital capacity breath of air and then of 35%CO2 and the other five minutes of air and then five minutes of 5%CO2. In comparison to the LR-C group, HR-P subjects had higherscores on self-ratings of anxiety and depression and were more likelyto have a lifetime diagnosis of major depressive disorder (MDD) or ofan anxiety disorder. NEO neuroticism and a history of MDD were themost important of these measures in separating the high-risk and lowriskgroups. As predicted, the HR-P subjects experienced more anxietyfollowing 35% CO2 exposure. The removal of individuals withlifetime diagnosis of MDD or of an anxiety disorder eliminated therelationship of neuroticism to CO2-induced anxiety and strengthenedthe relationship between the CO2 response and a family history ofpanic disorder. Anxiety following exposure to five minutes of 5%CO2 did not distinguish HR-P from LR-C subjects. For both 35% and5% exposures CO2 dose correlated significantly with anxiety for thehigh-risk subjects but not for the control subjects. These results confirmearlier findings indicating that a family history of panic disorderconveys a liability to experience anxiety with CO2 exposure. Theyalso suggest that this anxiety may reflect several discrete diatheses ofrelevance to the heritability of panic disorder.PO2.134.SHORT-TERM TREATMENT OF PANIC DISORDERWITH VENLAFAXINE XR: A PLACEBO-CONTROLLEDSTUDYM. Liebowitz 1 , G. Asnis 2 , E. Tzanis 3 , T. Whitaker 31 New York State Psychiatric Institute, New York, NY; 2 MontefioreMedical Center, Bronx, New York, NY; 3 Wyeth Pharmaceuticals,Collegeville, PA, USAThis study aimed to evaluate the efficacy, safety, and tolerability of venlafaxineXR in short-term treatment of panic disorder. In this multicenter,double-blind study, 343 adult outpatients with DSM-IV panicdisorder (with or without agoraphobia) were randomly assigned toflexible-dose venlafaxine XR (75-225 mg/day) or placebo for 10 weeks(n=155 per group, intention-to-treat population). The primary outcomemeasure was the percentage of panic-free patients (Panic andAnticipatory Anxiety Scale, PAAS). Key secondary measures includedPanic Disorder Severity Scale (PDSS) score and Clinical GlobalImpression-Improvement (CGI-I) response (score 1 or 2). Additionalsecondary efficacy measures included reduction in full-symptom panicattack frequency, mean CGI-I and CGI-Severity (CGI-S) scores,assessments of anticipatory anxiety and limited-symptom panicattacks (PAAS), and fear and avoidance factors of the phobia scale. Atendpoint (final on-therapy evaluation), there was a trend toward agreater percentage of panic-free patients in the venlafaxine XR group(51%) vs. placebo (41%; p=0.056%). Mean change from baseline inPDSS total score was significantly greater with venlafaxine XR treatment(-8.90) vs. placebo (-7.36; p=0.020), and significantly more venlafaxineXR-treated patients achieved CGI-I response (71%) vs. placebo(59%; p=0.031). When adjusted for baseline severity, reduction infull-symptom panic attacks was significantly greater for venlafaxineXR vs. placebo (p=0.040). Venlafaxine XR was associated with significantimprovements vs. placebo on four additional secondary efficacymeasures (mean CGI-I and CGI-S scores, and fear and avoidance factorsof the phobia scale). Venlafaxine XR was generally safe and welltolerated. Discontinuation rates due to adverse events were low (venlafaxine6% and placebo 5%). In conclusion, venlafaxine XR waseffective, safe, and well tolerated in short-term treatment of panic disorder.PO2.135.THE RESPONSE TO CLOMIPRAMINE IN PANICDISORDER PATIENTS AND CONTROLSF. Cosci, F. Rotella, M. Ciampelli, F. Alari, M. Marinoni,C. FaravelliDepartment of Neurological Science and Psychiatry,University of Florence, ItalySerotonin neurotransmission is thought to play a central role in thepathophysiology of panic disorder. This hypothesis seems to be confirmedby the observation of an initial exacerbation of symptomsinduced by selective serotonin reuptake inhibitors in the treatment ofpanic disorder patients, by the results of tryptophan depletion studiesand by the evidence that the relatively selective serotonin reuptakeinhibitor clomipramine produces anxiety-like symptoms in panic disorderpatients. The present study is an attempt to replicate these findingswith the aim to reinforce the role of serotonin system in the pathogenesisof panic disorder and the importance of the challenge withclomipramine to induce panic like symptoms under laboratory controlledconditions. According to a double blind, case-control design,healthy volunteers and patients with panic disorder underwent theinfusion of placebo and clomipramine. Blood pressure, heart rate, respiratoryrate, subjective and objective anxiety were measured. Bothhealthy volunteers and drug free panic disorder patients reacted to theclomipramine challenge showing mild to moderate anxiety or severeanxiety. On the contrary, treated panic disorder patients did not reactand presented high level of anxiety surrounding the challenge. In conclusion,clomipramine challenge is a valid method to induce paniclikesymptoms in healthy volunteers and panic disorder patients underlaboratory controlled settings and this confirms the central role ofserotonin in the pathogenesis of anxiety.279

PO2.136.DOSE RESPONSE EFFECTS OF LORMETAZEPAMIN THE TREATMENT OF DEPRESSIVE INSOMNIAA. Pontiggia, F. Benedetti, A. Bernasconi, C. Colombo, M. Florita,S. DallaspeziaDepartment of Psychiatry, Vita-Salute University, San RaffaeleInstitute, Milan, ItalyBenzodiazepines can shift the phase of circadian rhythms in mammalianspecies, but few data are available on their phase-responseeffects in humans and on the possible link between timing of administrationand clinical effects. On the other hand, clinical studies aboutmanipulations of the sleep-wake rhythm in mood disorders suggestthat advancing the sleep phase exerted rapid antidepressant effects.These studies suggest that hypnotic medications in major depressionshould be timed in order to obtain a phase advance of night sleep. Thepurpose of the present study is to evaluate if hypnotic benzodiazepinesphase-advance sleep in depressed patients, if there is a relationshipbetween phase-shifting and hypnotic effect of these drugs and if theacute phase shifting effect is coupled with an antidepressant effect.With a placebo-controlled cross-over design, we evaluated the hypnoticeffect of lormetazepam 0.03 mg/kg and placebo in a sample of 38inpatients affected by a major depressive episode. Patients were dividedin three groups, which received treatments at 18:00, at 20:00, or at22:00. All subjects were free of any psychotropic medication for atleast 1 week before study outset. Sleep-wake rhythm and daytimesleepiness during treatment were assessed by a daily administration ofPittsburgh Sleep Quality Index (PSQI), a sleep diary, Epworth SleepinessScale and Stanford Sleepiness Scale. Patients showed a significantamelioration in sleep latency, duration and efficiency, and in benefitfrom hypnotic medication, with no significant change in daytimedysfunction. These ameliorative effects were indipendent of severity ofdepression, which remained unchanged. A two-way repeated measuresanalysis of variance with time and treatment groups as independentvariables and PSQI scores as dependent variable showed that timeof treatment administration did not influence the effect oflormetazepam on PSQI score. Timing of treatment did not influencethe overall hypnotic efficacy, but influenced changes in sleep phaseobserved with active treatment. Patients who received treatment at20:00 showed a phase-advance of sleep onset; patients who receivedtreatment at 22:00 showed a phase-delay of morning awakening andpatients who received treatment at 18:00 showed a non-significanttrend in the same direction. Despite this absence of a group effect onhypnotic efficacy, phase-advances of sleep onset after lormetazepamwere significantly correlated with improvement of PSQI score (SpearmanR=0.399, t=2.61, p=0.012). Similar correlations were observedwith sleep diary variables. The present results suggest that effects oflormetazepam on the phase of the sleep-wake rhythm of patientsaffected by a major depressive episode depend upon timing of administration,and, given the possible relationship between changes inphase of biological rhythms and patophysiology of major depression,warrant interest for the definition of a phase-response curve for benzodiazepinesin depressive insomnia.PO2.137.EFFECTIVENESS AND TOLERABILITYOF MELATONIN IN ADULTS AND CHILDRENWITH SLEEP DISORDERSG. BartonBuckinghamshire Mental Health Trust, Bucks, UKMelatonin is a neurohormone secreted by the pineal gland in higherconcentration after the onset of darkness, when it promotes sleep.Since it was first isolated, it has been studied in sleep disorderedadults and children. Some trials with small numbers of developmentallydelayed and visually impaired children reported improvements,but one study using lower doses found no improvement. Most studiesreported no adverse effects, but one study described an increase inseizure frequency in epileptic children treated with melatonin. This ismainly a retrospective study of a series of patients prescribed melatonin.New patients are still being added. Data are being collected onpatients’ age, sex, diagnosis, type of sleep disorder, concomitant medication,effective and ineffective dose, length of treatment and reportedside effects. To date 38 patients have been prescribed melatonin.28 have used it for at least a week. 14/28 reported a complete normalisationof their sleep pattern and 11/28 reported partial improvement,2/28 patients have not yet reported back, and 1/28 found itunhelpful. The maximum effective dose was 15 mg in children and 20mg in adults. Even with long-term use (up to 6.5 years) no adverseeffects were reported and no increase in seizure frequency. The experiencesuggests that higher doses than are commonly used may beeffective and safe, even after long-term use.PO2.138.HYPERACTIVE EXECUTIVE CONTROLIN OBSESSIVE-COMPULSIVE DISORDER:A NEUROPSYCHOPHYSIOLOGICAL INVESTIGATIONP. Bucci, U. Volpe, E. Merlotti, A. Mucci, S. Galderisi, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalyIn patients with obsessive-compulsive disorder (OCD), a dysfunctionof fronto-subcortical circuits has been reported by several neuropsychological,brain imaging and neurophysiological studies. However,the functional meaning of the observed dysfunction in the pathogenesisof OCD is still debated. In the present study, the hypothesis thatthis dysfunction might be related to a hyperactive executive control isexplored by means of neuropsychological and neurophysiologicalmeasures. The experimental sample included 32 drug-free patientswith DSM-IV OCD and 32 healthy controls, matched with patientsfor age, gender and handedness. Multilead quantitative EEG (QEEG)characteristics were investigated in both groups. Neuropsychologicalperformance on tests exploring executive functions, attention, shorttermmemory and the ability to learn supraspan recurring sequenceswas investigated in the patient group. Group comparison on QEEGindices showed a reduction of the slow alpha band power in OCDpatients with respect to healthy subjects. The correlation analysisbetween neuropsychologial and neurophysiological indices in thegroup of patients showed a negative association between the slowalpha band power and the time to complete a neuropsychological testexploring executive functions: the more reduced the slow alpha bandpower, the slower the performance on this test. The hypothesis of ahyperactivity of attention/executive control mechanisms in patientswith OCD is supported by these findings.280 World Psychiatry 3:S1 - October 2004

PO2.139.NEUROPSYCHOLOGICAL INDICES IN SUBJECTSWITH OBSESSIVE-COMPULSIVE DISORDERBEFORE AND AFTER TREATMENT WITHSEROTONIN REUPTAKE INHIBITORSP. Bucci, G. Piegari, R. Di Benedetto, S. Garramone, A. Mucci,S. Galderisi, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalySeveral studies reported that patients with obsessive-compulsive disorder(OCD) are slower than healthy controls in performing neuropsychologicaltests. To our knowledge, no study has investigated theeffects of serotonin reuptake inhibitor (SRI) treatment on neuropsychologicalperformance in OCD patients. A neuropsychological batteryincluding tests assessing executive functions and incidental learningwas administered to 52 drug-free patients with DSM-IV OCD and52 matched healthy controls. Psychopathological evaluation includedthe Yale-Brown Obsessive-Compulsive Scale (YBOCS) and theHamilton Depression Rating Scale. In 18 patients, neuropsychologicaland clinical assessments were repeated after 6 months of treatmentwith SRI. Group comparison on neuropsychological indices showedthat patients were slower than controls in the execution of tasksassessing executive functions: the spatial and non-spatial conditionalassociative learning tasks (SCAL, NSCAL) and the self-ordered pointingtask for drawings (SOPT-D). Significant changes observed afterSRI treatment included an improvement on all items of the YBOCS, areduction of the mean time on the SCAL and the SOPT-D, and animprovement of the mean perseveration index on the SOPT-D. No significantcorrelations were observed between cognitive and clinicalimprovement. Cognitive improvement observed after SRI treatmentdoes not seem to be related to aspecific factors, such as the repetitionof the test battery, since it is confined to tasks assessing executive functions,and might be mediated by increased levels of serotonin in thefronto-subcortical circuits. The absence of correlations between clinicaland neuropsychological improvement suggests that neurocognitiveimpairment in OCD is not secondary to psychopathological aspects ofthe syndrome.PO2.140.NEUROPHYSIOLOGICAL INDICES ANDRESPONSE TO TREATMENT WITH SELECTIVESEROTONIN REUPTAKE INHIBITORS IN SUBJECTSWITH OBSESSIVE-COMPULSIVE DISORDERP. Bucci, U. Volpe, E. Merlotti, A. Mucci, S. Galderisi, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalyObsessive-compulsive disorder (OCD) is, among psychiatric syndromes,one of the most refractory to treatment, and the identificationof response predictors is highly needed. In the present study weinvestigated quantitative electroencephalography (QEEG) mappingcharacteristics in 26 drug-free subjects with a DSM-IV diagnosis ofOCD, and 23 sex- and age-matched healthy controls (HC); patientswere assigned to treatment with either fluoxetine or fluvoxamine. Acomprehensive psychopathological, electrophysiological and neuropsychologicalevaluation was carried out at baseline and after 10weeks of treatment. The electrophysiological indices investigatedincluded the log transformed values of both absolute and relativepower (LAP and LRP, respectively). Correlations between baselineneurophysiological indices and treatment-induced psychopathologicalchanges were evaluated. At the baseline, the slow alpha LAP andLRP were reduced in OC patients with respect to HC and the differenceswere more pronounced in the anterior brain regions. In thepatient group, the slow alpha band showed a significant negative correlationwith the mean speed on neuropsychological tests exploringfrontal and fronto-temporal functioning: the greater the reduction inthe slow alpha band, the slower the tests execution. Electrophysiologicalmeasures did not show any significant correlation with clinicalchanges observed after 10 weeks of treatment. According to thesepreliminary findings, baseline QEEG characteristics tend to confirman involvement of frontal lobe in OCD, but do not predict clinicalresponse to treatment with selective serotonin reuptake inhibitors.PO2.141.GROUP COGNITIVE BEHAVIOURAL THERAPYIN OBSESSIVE-COMPULSIVE DISORDER:A TRIAL CONTROLLING FOR GROUP EFFECTSN.A. Fineberg 1,2 , A. Hughes 1 , T. Gale 1,21 Department of Psychiatry, QEII Hospital, Welwyn Garden City;2 Department of Psychology, University of Hertfordshire, Hatfield, UKCognitive behavioural therapy (CBT) is known to be effective in thetreatment of obsessive-compulsive disorder (OCD) and, in this context,there has been much recent interest in whether this treatmentremains effective in a group setting. Initial results have been promisingbut there is a dearth of properly controlled trials in this area. Inthe only large controlled trial to date, group CBT was similarly effectiveto individual CBT, but this particular study did not include a controlcondition for group effects. In this study we compared group CBTwith group relaxation therapy (RT). Individual RT is known to be aneutral treatment in OCD, so using group RT as a control conditionallowed us to measure the benefits of regular group interaction thatmight be expected to occur, and to ascertain whether group CBTexerted additional improvements above and beyond this. Forty-oneparticipants with OCD took part in the study and there were 6 groupsin total (3 for each condition). The drop-out rate was considerablyhigher in the group RT condition, suggesting that patients may findgroup CBT to be a more acceptable treatment. However, there wereno differences in terms of improvement on the primary outcomemeasure (Yale-Brown Obsessive Compulsive Scale or any of the secondarymeasures). We conclude that the apparent benefits of groupCBT arise through group mechanisms that are independent of thetherapy itself.PO2.142.INTERPERSONAL PSYCHOTHERAPY FOR POST-TRAUMATIC STRESS DISORDERJ.C. MarkowitzCornell University Medical College, New York, NY, USAThis paper describes pilot testing of interpersonal psychotherapy (IPT)adapted to treat post-traumatic stress disorder (PTSD). Unlike mostpsychotherapies for PTSD, IPT is not exposure-based, but insteadfocuses on interpersonal sequelae of trauma. Fourteen subjects withDSM-IV chronic PTSD from various traumas were treated in an open14-week IPT trial. They received no pharmacotherapy. Treatment waswell tolerated. All subjects reported declines in PTSD symptomsacross all three symptom clusters. After 14 weeks, 12 of 14 subjects nolonger met full diagnostic criteria for PTSD. Depressive symptoms andanger reactions also improved. Eight subjects reported improved interpersonalfunctioning. Treating the interpersonal sequelae of PTSDappears to improve other symptom clusters. IPT may be an efficaciousalternative for patients who do not want repeated exposure to past281

trauma. This represents an exciting extension of IPT to an anxiety disorder.PO2.143.VENLAFAXINE XR, SERTRALINE, AND PLACEBO INTHE TREATMENT OF POST-TRAUMATIC STRESSDISORDERJ. Davidson 1 , A. Lipschitz 2 , J. Musgnung 21 Department of Psychiatry and Behavioral Sciences, DukeUniversity Medical Center, Durham, NC; 2 Wyeth Pharmaceuticals,Collegeville, PA, USAThe study aimed to compare the efficacy of venlafaxine XR and sertralinein reducing symptoms of moderate-to-marked post-traumaticstress disorder (PTSD). Adult outpatients (n=537) with a primary diagnosisof DSM-IV PTSD, PTSD symptoms for ≥6 months, and the 17-item Clinician-Administered PTSD scale (CAPS-SX17) score ≥60 wererandomly assigned to treatment with placebo, flexible-dose venlafaxineXR (37.5-300 mg/day) or flexible-dose sertraline (25-200 mg/day)for 12 weeks. After day 5, the minimum daily doses of venlafaxine XRand sertraline were 75 mg and 50 mg, respectively. The primary efficacymeasure was the change from baseline to endpoint in the CAPS-SX17 score. Secondary assessments included remission rate (CAPS-SX17 ≤20), symptom-free days, and changes from baseline to endpointin CAPS-SX17 symptom cluster scores. Mean baseline-to-endpointchanges in CAPS-SX17 scores were -41.8, -39.4, and -33.9 for venlafaxineXR (p

group, 4) functioning in a public space, 5) work, and 6) party. Thesefactors were differentially associated with different areas of disability.Escitalopram was, however, significantly superior to placebo for allfactors: factors 1,2,3,4,6 (p

(anterior cingulate, bilateral crus anterior capsulae internae, MD andVL thalamic nuclei, area of substantia innominata) were selectedaccording to a clinico-physiological approach. 18F-FDG positronemission tomography (PET) revealed a decreased metabolism in thecaudate heads in 9 patients before stereotactic effects. In 3 patientsthere was a hypermetabolism in the anterior cingulate. A clear reductionof anxiety-obsessive symptoms was observed in 18 patients afterstereotactic surgery. A worsening of clinical state or surgical complicationswere not observed in any case (catamnesis from 2 to 14 years).Metabolic changes detected by 18F-FDG PET positively correlatedwith clinical state in all cases after stereotactic surgery.PO2.152.ATTACHMENT STYLES AND ALEXITHYMIA IN PANICDISORDERA. Tonni, D. Sorrentino, R. Di Benedetto, S. Garramone, A. Mucci,S. Galderisi, M. MajDepartment of Psychiatry, University of Naples SUN, Naples,ItalyFew studies have investigated the implications of an insecure attachmentstyle and alexithymia for treatment planning. This study, evaluatingattachment style and alexithymia in subjects with panic disorder(PD), is aimed to obtain information about intervention planning.Twenty subjects with PD were compared to matched healthy controls.Attachment styles were investigated with the Bartholomew Scale(BS), the Attachment Style Questionnaire (ASQ) and the ParentalBonding Instrument (PBI). Alexithymia was evaluated with theToronto Alexithymia Scale-20 items (TAS-20). A thorough psychopathologicalevaluation was also carried out. PD subjects, as comparedto healthy controls, showed: a) lower “confidence” and higher“emotional overinvolvement” on the ASQ; b) a greater difficulty inthe identification and description of feelings on the TAS-20. An insecureattachment style and a higher degree of alexithymia might underliedifficulties experienced in the initial phase of psychotherapeuticintervention by PD patients. An intervention targeting emotionalexperience, to increase the ability to identify and express differentemotions, might be highly advisable in patients with PD.PO2.153.STRESSFUL LIFE EVENTS IN PANIC DISORDERWITH AND WITHOUT AGORAPHOBIAM. Katagami, T. Iketani, K. Nagao, N. Minamikawa, A. Shidao,H. Fukuhara, M. Isaka, E. Fukumoto, N. KiriikeDepartment of Neuropsychiatry, Osaka City University MedicalSchool, Osaka, JapanThe presence of agoraphobia in patients with panic disorder is typicallyassociated with impairment in social and vocational functioning,and with the subsequent severity of course of the disorder. In thisstudy, the Social Readjustment Rating Scale (SRRS), a questionnairemeasuring major life events, was administered to 130 subjects withpanic disorder with or without agoraphobia. We compared the clinicalcharacteristics between high (150>) and low (100

PO2.156.NOCTURNAL PANIC AND RECENT LIFE EVENTSU. Albert, C. Bergesio, G. Maina, F. BogettoDepartment of Neuroscience, University of Turin, ItalyNocturnal panic (NP) refers to waking from sleep in a state of panic.Recurrent nocturnal (= sleep) panic attacks occur in 18% to 45% ofpanic disorder patients. Biological and cognitive models have beenproposed and some studies support the notion that NP represents aspecific subtype of panic disorder with its own characteristics. There issome evidence for a relationship between trauma and NP: panic disorderpatients with histories of traumatic events are more likely to reportnocturnal panic attacks than patients without such histories, but therelationship between life events and the onset of the disorder has notbeen examined to date. The purpose of this study was to investigatewhether NP is associated with a higher frequency and/or a higherseverity of life events prior to panic disorder onset (in the year beforethe onset). Our sample was comprised of 125 outpatients with a principalDSM-IV diagnosis of PD, verified by the Structured Clinical Interviewfor DSM-IV (SCID). All patients were assessed using a semistructuredclinical interview for the collection of socio-demographic andclinical variables. For the evaluation of recent life events, patients wereassessed with the Paykel’s schedule for life events. Patients with a historyof sleep panic were compared to patients without NP. Twenty-eightpercent of patients (n=35) reported having recurrent nocturnal panicattacks. No differences were found between the groups in the frequencyand severity of life events occurring in the year before the onset ofpanic disorder. In conclusion, our study failed to support the hypothesisthat recent life events predispose to nocturnal panic onset.PO2.157.AGE OF ONSET OF PANIC DISORDER WITH VS.WITHOUT COMORBID ANXIETY DISORDERSM. Latas, V. Starcevic, G. Trajkovic, G. BogojevicInstitute of Psychiatry, Clinical Center of Serbia, Belgrade,Serbia and MontenegroThis study aimed to compare the age of onset of panic disorder andagoraphobia (PDA) with vs. without comorbid anxiety disorders(CAD) - specific phobia, generalized anxiety disorder, and social phobia.124 consecutive outpatients with PDA participated in the study.Diagnoses of PDA and (lifetime and/or current) CAD were made onthe basis of the Structured Clinical Interview for DSM-IV (SCID-I).The age of onset was defined as the age when patients first met DSM-IV criteria for panic disorder. The comparison of patients with onlyone CAD and patients without CAD did not show statistically significantdifferences, although patients with CAD were somewhat olderat onset. PDA patients with jointly comorbid specific phobia, generalizedanxiety disorder and social phobia were significantly older atonset than PAD patients without CAD.PO2.158.A COMPARISON OF SERTRALINE AND THECOMBINATION OF SERTRALINE WITH COGNITIVEBEHAVIOUR GROUP THERAPY IN THE TREATMENTOF PANIC DISORDERD. Bonevski, A. Novotni, M. Jeremik, S. Pejkovska, V. Filovska,M. Kujundziska, M. KosticPsychiatric Hospital, Skopje, Republic of MacedoniaForty patients meeting ICD-10 criteria for panic disorder were allocatedto sertraline, and treated over 12 weeks. A fixed dose medicationprocedure was used. Twenty of them (two groups of ten) wererandomly assigned to cognitive-behavioral group therapy during thesame period of 12 weeks. The sessions (12 for each group) were runregularly once a week and lasted 2 hours. The treatment response andoutcome measures included Panic Disorder Severity Scale (PDSS)and Clinical Global Impression Scale (CGI). A decrease of the numberof panic attacks and of their intensity as well as of the level of anxiety,depression and worry about attacks was found in most of thepatients in both groups, but outcome measures at the end of treatmentand at six month follow-up revealed the superiority of the combinedtreatment with respect to treatment with sertraline only. Thegroup with combined treatment revealed a lower incidence of subsequenttreatment interventions at six month follow-up.PO2.159.INTEGRATED TREATMENT FOR PANIC DISORDER:A 3-YEAR FOLLOW-UP STUDYC. Viganò, A. Carozzi, E. Pagliarulo, A. Bielli, G. BaPsychiatric Unit, Internal Medicine Department, Universityof Milan, ItalyWe have developed a model of integrated treatment of panic disorderthat is a combination of three therapies: pharmacological therapy(selective serotonin reuptake inhibitors), cognitive-behavioural therapy(according to G. Andrews’ model) and short-term psychodynamicoriented psychotherapy. In this study we analyse the results of 50patients with panic disorder with or without agoraphobia (DSM-IVcriteria) recruited after a clinical and instrumental assessment andrandomized to either the integrated treatment or psychopharmacologicaltherapy alone. At 36-month follow-up, the integrated treatmentseems to be more effective than the control in reducing panicsymptoms and avoidance. Patients receiving integrated treatmentshow an early and clear physical, emotional and social improvement.PO2.160.INTEGRATED TREATMENT FOR PANIC DISORDERD. Charismas, S. Masetti, B. Viviani, F. GalassiDepartment of Neurological and Psychiatric Sciences,University of Florence, ItalyComparative clinical trials and meta-analytic studies provide a growingbody of evidence that two treatment strategies, pharmacotherapyand cognitive-behavior therapy (CBT), are effective for the treatmentof panic disorder. However, few studies tried to investigate and developan integrated treatment model. During the last 7 years we haveoffered an integrated treatment strategy to patients with panic disorder.The purpose of this prospective study was to assess the advantagesof an integrated treatment in a sample of subjects with panic disordertreated in our outpatient unit. Ninety-nine consecutive patientswith DSM-IV panic disorder were studied. Treatment consisted of 1hour individual sessions conducted bi-weekly for 6 months. The maintreatment components are pharmacological therapy with paroxetine(dosage increase to a maximum of 40 mg/day, with a weekly incrementof 10 mg/day); psychoeducation; emotions and beliefs monitoring;cognitive intervention (cognitive restructuring); exposure interventions;relapse prevention. Degree of phobic avoidance, state andtrait anxiety, depressive symptoms and social disability were assessedat baseline and end of treatment. There was a significant improvementin all areas. Integrated treatment appears to be effective as suggestedby short-term results. However, a study to assess the stability ofthe advantages and long-term effects is warranted.285

PO2.161.THE EFFECTIVENESS OF COGNITIVEBEHAVIOURAL THERAPY VERSUS PAROXETINEIN THE TREATMENT OF PANIC DISORDER:A FOUR YEAR FOLLOW-UP STUDYF. Mazzi, M. Rigatelli, G.P. GuaraldiUniversity of Modena and Reggio Emilia, Modena, ItalyThere are few long-term outcome studies of panic disorder in theusual clinical setting. The aim of this study was to evaluate the longterm follow-up of patients with panic disorder with agoraphobiatreated with cognitive behavioural therapy (CBT) or paroxetineaccording to a standardized protocol. A sample of 139 consecutivepatients with DSM-IV panic disorder with agoraphobia were partiallyrandomized to receive paroxetine or CBT. Sixty-seven were treatedwith CBT, 72 with paroxetine (20-60 mg/die). Forty-one (61%)became panic free after 15-20 weekly CBT sessions and 48 (66%)after 6-8 month paroxetine treatment. A 2 to 6 year (median = 4 years)follow-up was performed. Patients were assessed every two years withthe Panic Disorder Severity Scale, the Marks-Sheehan Phobia Scaleand the Montgomery-Asberg Depression Rating Scale. Kaplan-Meiersurvival analysis was employed to characterize the clinical course ofpatients. Eighteen of the 48 patients (37%) who received paroxetineand seven of the 41 patients (17%) who received CBT had a relapseof panic disorder at some time during follow-up. The relapse prevalentlyoccurred during the first two years. In conclusion, CBT wasfound to be significantly more effective than paroxetine in reducingrelapse rate, during a 4 year follow-up.PO2.162.NEUROPSYCHOPHYSIOLOGICAL-ORIENTEDPSYCHOTHERAPY IN THE TREATMENT OFGENERALIZED ANXIETY DISORDER AND PANICDISORDERC. Persegani, I. Vallini, C. Carucci, E. Palombo, L.L. Papeschi,M. TrimarchiBrain Health Centre, Rome, ItalyNeuropsychophysiological (NPP)-oriented psychotherapy is basedon the understanding of the differential functioning of the two cerebralhemispheres and on the stimulation of their respective abilities inan integrated way. Only the knowledge of the mechanisms that producethoughts and emotions enables us to single out the pathologicalcomponent of a patient’s way of thinking and to stimulate those abilitieshe or she is lacking, as well as to inhibit the automatism, fosteringa conscious activity in the management of information processing.In the present study we will describe the therapeutic principles ofthe NPP psychotherapy and its effects in the treatment of generalizedanxiety disorder and panic disorder.PO2.163.COGNITIVE BEHAVIOUR THERAPY PREVENTSRELAPSE IN PANIC DISORDER AFTERDISCONTINUATION OF PHARMACOTHERAPYF. Priftis, S. Kyprianos, L. Iliopoulou, A. FotiadouDepartment of Psychiatry, G. Hatzikosta General Hospital,Ioannina, Greecewith or without agoraphobia, were treated with CBT (approximately16 sessions) and paroxetine (30-40 mg daily) for a maximum of 6months. At 18-month follow-up all patients were panic-free. In a furthergroup of 21 patients with the same diagnosis, we used CBTalone. We added four more sessions (total of 20). The process of therapywas more difficult, and in these patients we had to add medication(for 6 months). At 18-month follow-up, all patients were panicfree.Finally, in a group of 10 patients with the same diagnosis, weused medication alone for 1 year. All but two patients relapsed. Thesedata seem to suggest a prophylactic effect of CBT in panic disorderafter discontinuation of pharmacotherapy.PO2.164.REFLECTIONS ON THE PSYCHOPATHOLOGYOF PANIC ATTACKSM. Diallina, M. MarkantonakiPsychiatric Clinic, G. Gennhmatas General State Hospital,Athens, GreeceIn this report we examine whether panic attacks represent an individualpsychopathological entity or just a symptom, a signal that mayindicate biological promptness, but also accompany different diseaseentities, mainly depressive disorders. From 1990 until today, we studied20 patients with panic attacks and different personality structuresand symptoms who underwent psychoanalytic psychotherapy with orwithout medications. In this report we examine the psychodynamicsof these patients with the help of Mentsos’ three-dimensional modelof symptom’s creation (ego maturation, walking through the conflict,traumatic fixation). Individuals characterized by pseudo-autonomicbehavior tend to react with panic in situations of conflict betweendependence and autonomy. Because traumatic fixation can happen ina long period of time (individualization-separation phase), thesepatients can express different ego maturation and use defense mechanismsof different maturity. This explains the appearance of panicattacks in persons with different personality structure and differentcoexisting symptoms (from hysteria to bipolar disorder).PO2.165.DRAMATHERAPY IN PANIC DISORDERS. Krasanakis, L. GiotisPrivate practice, Athens, GreeceWe use dramatherapy as a therapeutic approach to panic disorder. Wework on either known texts and role parts or on stories and role partscreated by the patients themselves. A play which is especially suitableis “A delicate balance” by Edward Albee, where a pair of role partspresent panic disorder. Whilst panic is a condensed experience, duringthe dramatherapy procedure, the possibility is given for it to“spread” in space and time and to be worked through. Through therole playing, panic is embodied and therefore it is possible to controlit. Through the team’s holding, the individual faces the avoidingbehavior, that develops under the state of panic. On the cognitivelevel, it is possible to investigate alternative solutions through the creationof different scenarios. Panic itself can take the form of a role ora symbolic object and a dialogue can develop with it, thus creating a“transitional space”. The procedure of playing itself creates a meaningand fills in the psychic gap which often exists in panic disorder.The aim of this study was to examine the relapse rate of patients withpanic disorder who received cognitive behaviour therapy (CBT) andpharmacotherapy, after discontinuation of drugs. 20 patients (17females and 3 males), who fulfilled ICD-10 criteria for panic disorder286 World Psychiatry 3:S1 - October 2004

PO2.166.VULNERABILITY TO ANXIETY: STAI-T AS AMEASURE OF CLINICALLY SIGNIFICANTCHANGE IN GENERALIZED ANXIETY DISORDERFOLLOWING PSYCHOLOGICAL THERAPYO. Puig, J. Guarch, T. Mitjanes, R. Penadés, M. SalameroClinical Institute of Psychiatry and Psychology, Hospital Clínic,Barcelona, SpainSeveral studies have proposed generalized anxiety disorder (GAD) asa condition of vulnerability to suffer anxiety. The Trait version of theSpielberger State-Trait Anxiety Inventory (STAI-T) has been consideredas a good measure of this vulnerability and a valid instrument toassess change after treatment. We applied a structured cognitivebehavioraloriented group therapy programme and evaluated its efficacyin a sample of 48 outpatients who meet the DSM-IV criterion forGAD, in a mental health primary care setting. Jacobson’s metodologyto define clinically significant change was used to assess the rate ofclinically significant change in the T version of STAI, administeredbefore treatment and at the last session. The degree of clinic improvementafter the therapy will be shown allocating each patient to one offour mutually exclusive treatment outcomes: a) realiable deterioration;b) no change; c) reliable improvement within the dysfunctionalpopulation, and d) reliable improvement from the dysfunctional tothe normal population or recovery.PO2.167.CLINICAL AND PSYCHONEUROENDOCRINOLOGICALEFFECTS OF COGNITIVE THERAPY IN PATIENTS WITHGENERALIZED ANXIETY DISORDERG.E. Tafet, D.J. FederDepartment of Psychiatry and Neurosciences, MaimonidesUniversity, Buenos Aires, ArgentinaPsychosocial stress is known to induce an adaptive response mainlymediated by neural and neuro-endocrine components, involving therelease of catecholamines and the activation of the limbic–hypothalamic-pituitary-adrenal(HPA) system, with the consequent release ofcorticotropin releasing hormone (CRH), adrenocorticotropin hormone(ACTH), and cortisol. Chronic stress, as occurring in variousanxiety disorders, may lead to the persistent activation of the HPAaxis, resulting in sustained increase of cortisol levels. It has beenshown that patients with chronic anxiety disorders have been successfullytreated with cognitive therapy, alone or in combination withpharmacotherapy. We evaluated the efficacy of cognitive therapy inthe treatment of patients with generalized anxiety disorder, performingclinical assessment and testing biochemical indicators of HPAfunction, such as plasma cortisol levels. Significant changes at bothlevels were observed after completion of treatment. These observationssuggest that the effect of psychotherapy may be studied at bothpsychological and biological levels.PO2.168.OPEN LABEL, FIXED DOSE MIRTAZAPINETREATMENT OF SOCIAL PHOBIA: PRELIMINARYRESULTSD. De Berardis, F. Gambi, D. Campanella, G. Sepede, A. Carano,L. Pelusi, V. Matera, D. Di Matteo, F. Di Giacinto, G. Salini,M.R. Grimaldi, A. Pacilli, R.M. Salerno, F.M. FerroInstitute of Psychiatry, University of Chieti, ItalyTwenty-five adult outpatients with social phobia, according to DSM-IV criteria, were recruited and treated with a fixed dose of mirtazapine(30 mg/day) for 12 weeks. Measures were the Liebowitz SocialPhobia Scale (LSPS), the Interaction Anxiousness Scale (IAS), theAudience Anxiousness Scale (AAS), the Hamilton Anxiety RatingScale (HAM-A), the Beck Depression Inventory (BDI) and the ClinicalGlobal Impression Scale - Improvement (CGI-I). The efficacy wasprincipally assessed by the change in mean total LSPS score frombaseline to last assessment (50% or greater reduction in total LSPSscore) and by having ratings of 1 or 2 on the CGI-I. 22 patients (78%)completed the study and three (12%) dropped out due to side effects.16 out of 22 patients (72.7%) were classified as responders. An overallimprovement was seen at endpoint on all rating scales and, amongnon-responders, no one reported a worsening of symptoms duringtreatment. Generally mirtazapine was well tolerated and the most frequentlyreported side effects were sedation and weight gain. Theresults of this preliminary trial support the notion that mirtazapine iseffective in the treatment of social phobia. However, these findingsmust be viewed with caution and further investigation is needed.PO2.169.SUBLINGUAL ALPRAZOLAM EFFICACY INPRIMARY INSOMNIA AND IN SLEEP DISORDERSASSOCIATED WITH ANXIETY STATESN. Gargiulo 1 , M. Eiras 1 , S. Guerstein 2 , N. Caruso 31 Centro de Psiquiatría Clínica FADE, Mar del Plata; 2 HospitalMilitar Bahía Blanca; 3 Laboratorios Bagó, Buenos Aires, ArgentinaThe study aimed to assess the short-term efficacy and tolerability ofalprazolam, 0.5 mg sublingual tablets (SL-ALP), used as sleep aid inprimary insomnia and in sleep disorders associated with anxiety states.We carried out a comparative, multicentre, randomised, double blind,placebo controlled, crossover study. Sixty one patients (44 women,mean age 48±13 years), treated with SL-ALP or placebo for 8 days,with a four-day washout period between both treatments, were evaluated.Patients received the treatments in a random order. Treatmentwas initiated with 1 tablet at bedtime and the dose could be duplicatedas necessary from the fourth night of treatment. The efficacy wasassessed by Patient General Impression (PGI), Analogue Visual Scale(AVE) and Pittsburgh Sleep Quality Index (PSQI). According to PGI,91.9% of the patients improved with SL-ALP and 36.1% with placebo(p

PO2.170.DIAZEPAM LONG-TERM USERS: A STUDY INPRIMARY CARE CENTERS IN CAMPINAS, BRAZILC.S. Ribeiro, N.J. BotegaUniversity of Campinas, BrazilThe aim of this research was to investigate the long-term use of diazepam.We studied 41 outpatients from primary care services in Campinas(Brazil) who had been taking prescribed diazepam daily during 3 years.Our study was divided in two parts. First, we investigated the chronic useof medication, focusing on dosage and origin of prescription. In the secondpart of the study, we administered the Hospital Anxiety and DepressionScale (HAD) and the Schedules for Clinical Assessment in Neuropsychiatry(SCAN). Diazepam use was examined using a semistructuredinterview designed to cover the following areas: reasons for use,drug effects, perceptions of their doctor's attitude to the prescription,efforts to stop taking the tablets. Our results showed that long-term userstend to be white women, aged 50-69 years, with low educational andsociodemographic levels, with depressive illness inappropriately diagnosedand treated with benzodiazepines. By SCAN we found that 63.4%of subjects had depressive symptoms, 29.6% had benzodiazepinedependence, and 14.6% sleep disorders. Our conclusion points to theneed to establish guidelines for prescription of benzodiazepines andintervention programs based on orientation of patients and professionalsof the public health system.PO2.171.SUCCESSFUL TREATMENT OF A WOMAN WITHTOURETTE’S DISORDER WITH AMISULPRIDEK.N. Fountoulakis, A. Iacovides, G.S. Kaprinis3rd Department of Psychiatry, Aristotle University ofThessaloniki, GreeceWe report the case of a 40 year old woman suffering from Tourette’sdisorder. At the age of 5, she had for the first time involuntary headmovements, at the age of 8 involuntary leg movements and by the ageof 12-13 years vocal tics. During the previous 10 years the patient hadreceived mirtazapine, buspirone, valproate and sulpiride. Onlysulpiride had had a weak effect. The patient was assessed with theYale Global Tics Severity Scale. Her baseline motor score was 16, herphonic score 18 and her impairment score 30. She was put on amisulpride100 mg per day. Three weeks later her scores dropped to 9, 10and 20 respectively. Amisulpride was raised to 200 mg daily and afteranother three weeks her scores were 5, 6 and 10 respectively. A furthertitration to 400 mg/day was made but without further improvement.The patient decreased the dose to 100 mg/day without anydeterioration in her condition. For the next three months the patientcontinued treatment and her condition remained stable. Then shedecided to discontinue because of amenorrhea and within 20 days thesymptoms reappeared. Her scores climbed to 10, 11 and 30. Thepatient decided to restart amisulpride treatment and simultaneouslystarted visiting a gynecologist for the treatment of amenorrhea.PO2.172.CHILDHOOD HISTORY OF ANXIETY DISORDERSAMONG ADULTS WITH ANXIETY DISORDERSAND ITS CORRELATESY.H. Oh, K.S. Oh, S.M. Lee, K.M. Lee, H.K. Yoon, M.K. Kim,C.M. LimDepartment of Psychiatry, Kangbuk Samsung Hospital,Sungkyunkwan University, Seoul, South KoreaThis study examined the rates and correlates of a childhood history ofanxiety disorders in adults with anxiety disorder. The presence of achildhood history of anxiety disorders was assessed by a structuredinterview. The association with co-morbid disorders, anxiety severity,functional impairments and chronicity variables were examined. 110patients (52 social phobia and 58 panic patients) were recruited forthis study. Among them, 37.3% met criteria for anxiety disorders duringchildhood, but the rates of the childhood history of anxiety disorderswere significantly higher in social phobia than in panic disorderpatients (48.1% vs. 27.6%). The past history of childhood anxiety disorderswas associated with early age of onset, greater anxiety morbidities,lower global functions, greater severity of fear and avoidanceof social situations. These results indicate that the majority of adultanxiety disorders patients, especially those with social phobia, have ahistory of anxiety disorders in childhood, and that the presence ofchildhood anxiety disorder is linked with more severe pathologicalcharacteristics.PO2.173.CONSTITUTIONAL AND BIOLOGICAL CORRELATESOF ANXIOUS PERSONALITY DISORDERO.D. GolovinMental Health Research Institute, Tomsk, RussiaWe examined 135 patients with anxious personality disorder (ICD-10diagnostic criteria), 87 women and 48 men. The mean age of patientswas 39.4±1.0 years. The control group consisted of 300 mentally andphysically healthy men and women. The mean age of the controlgroup was 40.2±1.0 years. The methods of investigation were clinical,anthropometric, somatoscopic, immunological, neurophysiologic.The aspects associated with anxious personality disorder includedasthenic somatotype, anthropometric characteristics of somatic sexualretardation, increased rate of gynecomorphous features in the body,accumulation of regional morphological dysplasias. We found a relationshipin these patients between asthenic somatotype, somatic constitutionalpathology (weakness of connective tissue, abdominal ptosis,etc.) and steadily substantial psycho-vegetative syndrome.PO2.174.TREATMENT OF MIXED ANXIETY AND DEPRESSIVEREACTIONS IN PATIENTS WITH ANXIOUS ANDANANKASTIC PERSONALITY DISORDERN. Tchernyak, I. PshenichnihState Medical University of Irkutsk, Russian FederationWe studied 12 patients (5 females and 7 males; age 20-45 years) withanxious and anankastic personality disorder who developed a mixedanxiety and depressive reaction following a stressful life event.Tianeptine in therapeutic doses (37.5 mg/day) was used as the drug ofchoice, because of the specificity of its anxiolytic action, in theabsence of sedative and other side effects, and of any negative impacton social behaviour. The therapy was combined with clonazepam at2 mg/day. The choice of this drug was determined by the combination288 World Psychiatry 3:S1 - October 2004

of a tranquilising effect with the decrease in responsiveness to visceralstimuli through a stabilising effect on vegetative system. In patientswith a positive response to therapy, both affective and anxiety symptomsdecreased slowly, at the end of the second or beginning of thethird week of treatment.PO2.175.ANXIETY AND HEALTH IN THE ADOLESCENCE:IMPACT OF FAMILY RELATIONSHIPS?V. Algrain, N. Zdanowicz, C. ReynaertService de Psychosomatique, Université Catholique de Louvain,Yvoir, BelgiumThe present research aims at comparing family relationships and adolescents'beliefs about their own health in a sample of adolescentswith and without anxiety disorder. 672 "healthy" adolescents completedthe Multidimensional Health Locus of Control questionnaireand Olson scale questionnaire describing their family of origin. Theywere compared to a sample of 81 adolescents diagnosed with anxietydisorders. Family relationships are more cohesive and adaptable inthe healthy sample (p=0.007; p=0.017). Adolescents with anxiety disorderfeel less responsible for their own health (p=0.003), are moredependent from their relatives (p=0.0001) and believe more in chance(p=0.023). These data suggest that family relationships and healthlocus of control should be considered as targets for intervention inanxiety disorders.PO2.176.PSYCHOPHYSIOLOGICAL FEATURES OF PATIENTSWITH NEUROCIRCULATORY DYSTHONIAA.V. SamokhvalovPsychiatry Department, State Medical University, Kharkov,UkraineA complex anamnestic, psychopathological, psychological, vegetativeand psychophysiological examination of a group of young patients(16-25 years, both males and females) with neurocirculatory dystoniahas been performed, which allowed estimation of several psychophysiologicalfeatures (time of sensory-motor reaction, quality of attentionand visual memory, individual minute test, stabilometric test, vegetativemaintenance of higher nervous activity, etc.) and their correlationto the mental state of the patients and expressivity of symptoms of neurocirculatorydystonia. Statistical analysis of the data achieved in differenttests revealed correlations between the signs of neurocirculatorydystonia and social and psychological factors. It also showed significantrelations between the mental and psychophysiological state ofthe patients and their psychophysiological reaction to physical loads.Several clinical and psychophysiological patterns in patients with neurocirculatorydysthonia have been described, and several correspondingstrategies of treatment and prophylaxis of its further progressingand complications have been proposed.PO2.177.CONSTANCY OF PERCEPTION IN ANXIETY VS.DEPRESSIVE SYNDROMESY.S. Savenko, L.N. VinogradovaIndependent Psychiatric Association of Russia, Moscow, RussiaAmong anxiety-depressive syndromes, there are many cases wherethe predominance of anxiety or depression is not obvious, because ofa dissociation between the phenomenological quality of feeling andits behavioral expression. The dynamic clinical-experimental evaluationof 373 anxiety patients and 272 depressive patients demonstratedthat psychotic anxiety is associated with different forms of reducedconstancy of perception, while the melancholic syndrome is revealedby its hyperconstancy. A reliable method of their differentiation hasbeen worked out. The pseudo-scopic inversion of the inner side of aplastic doll’s face, in most patients with psychotic anxiety, failed aftermore than one minute observation through pseudoscope, while inmost cases of melancholic syndrome the inversion took place withina minute even without pseudoscope.PO2.178.A DIDACTIC SONG ABOUT ANXIETYA.B. Marques Filho, M.A. van Erven, A.A. Paiola, A.C.A. Soares,D.L. Tìmpano, R.P.G.N. CastroMedicine School and Bezerra de Menezes Hospital, São José doRio Preto, Sao Paulo, BrazilThe study aimed to verify if the main anxiety aspects, reported inverses, have a pedagogical function, teaching students and communitymembers about how a carrier of anxiety disorder feels his symptoms.We composed a popular song (lyrics and melody) denominated"Fears". Verses include descriptions which illustrate anxiety symptoms.Several psychopathological features of social phobia are exemplifiedin rhymes: dizziness, dyspnea, palpitation, paleness, shame,blank mind, stress, bradycardia, tachycardia, sensation of beingwatched, vertigo, fears of becoming mad or to die. Words of a tunecan be utilized as a significative and illustrative didactic resource inlessons and lectures; musical compositions describing conspicuousaspects in psychiatry should be stimulated and published.PO2.179.DISSOCIATION SYMPTOMATOLOGYIN ANXIETY DISORDERSO. Zikic, L. TrajanovicClinic for Mental Health Protection, Nis, Serbia and MontenegroApart from dissociation disorders, dissociation symptomatology canalso be observed in other psychiatric disorders, especially in schizophrenia,affective disorder and post-traumatic stress disorder. Moreover,a number of studies have indicated that dissociation symptomatologycan appear in general population as well. Dissociative symptomatologyis usually present in conditions of high arousal, which frequentlyaccompanies anxiety disorders. Our research was aimed atdetermining the presence of dissociation symptomatology in patientssuffering from anxiety disorders, and detecting any significant connectionbetween the two conditions. Experimental and control groupnumbered 25 members each. A structured questionnaire for obtainingsocio-demographic and medical history data was used. The DissociativeExperiences Scale, a dimensional questionnaire, was utilized forthe assessment of dissociation symptomatology. Anxiety was assessedby the Beck Anxiety Inventory. Results indicate that anxiety patientsmanifest significantly higher values of dissociation in comparison tothe healthy population (p=0.004). High anxiety level intervieweeshave higher average values of dissociation in comparison to othergroups. Female patients suffering from anxiety disorder manifesthigher levels of dissociation in comparison to male patients. Youngerpatients (up to 25 years of age) have statistically significant highervalues of dissociation in comparison to the healthy population(p=0.001). Dissociation score decreased with the prolongation of theepisode.289

PO2.180.DISSOCIATIVE IDENTITY DISORDER - IS IT BOUNDBY CULTURES.T. Jambunathan, S.G. Jesjeet, C.C. Low, J. JacobDepartment of Psychological Medicine, Faculty of Medicine,University Malaya, Kuala Lumpur, MalaysiaMultiple personality disorder, now known as dissociative identity disorder,has long been a controversial phenomenon. Patients withsymptoms suggestive of dissociation are often misdiagnosed as malingeringor even schizophrenia, the former as a result of clinicians overlookingthe fact that suggestibility itself plays a key role in the emergenceand perpetuation of this illness and the latter due to the lack ofknowledge of the whole dissociative disorder spectrum, which oftenresembles that of a psychotic disorder. The lack of experience andskills in this field, and also fear of humiliation by sceptics, may contributeto the underdiagnosis of dissociative identity disorder andother dissociative states. In Malaysia, various culture bound syndromesoften present with symptoms that mimic dissociative identitydisorder. This paper will attempt to understand dissociative identitydisorder from a local context using a case study as a reference point.In this case, therapy failed because the cultural perspective was overlooked.PO2.181.MUTUAL REGULATION OF NARRATIVEPERSPECTIVE IN THERAPEUTIC INTERACTION:THE CASE OF A DISSOCIATIVE IDENTITYDISORDERU. Zsolt 1 , B. Eszter 21 Department of Psychiatry and Psychotherapy, SemmelweisUniversity Faculty of General Medicine; 2 Eötvös LorándUniversity, Institute of Psychology, Budapest, HungaryIn this paper we examine the construction and functioning of narrativeself in the course of therapeutic interaction by analysing themutual regulation of narrative perspective (NP) taken by patient andtherapist. The concept of NP is used to define the narrator's positionwith respect to the story plane, the time and place of its actions,actors, and characters. The authors describe their own model of NPdefined in linguistic terms, operating with the structural properties oftexts, being able to capture the continuous shifting of NP, andaccounting for the interactants’ mutual determination of each other’sNPs, and shifts of NP. We distinguish three levels of perspective differingwith respect to insight, knowledge, and emotional involvement.By analysing excerpts from a therapeutic session with a patientsuffering from dissociative identity disorder we show that NP plays aformative role in the construction of self-narratives, since there is aclose causal relationship between the narrator’s perspective, and thekinds of memories that he has access to. Our analysis reveals that thesurfacing of different narrative selves - and the isolated self-states theyrepresent - is tied to NP, and hence, the formation and realization ofthe narrative self is the function of NP.PO2.182.DIFFERENTIATED REHABILITATIVEPROGRAMS FOR HYSTERIC STATESO.E. PerchatkinaMental Health Research Institute, Tomsk, RussiaWe studied 144 patients with hysteric states: 98 with hysteric personalitydisorder (F60.4) and 46 with disorders of the neurotic range(F44.4-44.7). We applied six differentiated rehabilitative programsbased on psychotherapeutic, psychopreventive and psychopharmacologicalcomponents. Two of them were applied in hysteric personalitydisorder and four were intended for hysteric disorders of neuroticspectrum. The analysis of the results indicates a higher efficacy ofthe therapy in dissociative disorders as compared with hysteric personalitydisorder. Catamnestic investigation of treated patients hasshown maintenance of achieved results and a stable clinical recoveryin 89.1% of cases of dissociative disorders and 65.1% of cases of hystericpersonality.PO2.183.GUIDED SELF-HELP COGNITIVE-BEHAVIORALAND WEIGHT-LOSS TREATMENTS FOR BINGEEATING DISORDERC.M. Grilo 1 , R.M. Masheb 1 , K.D. Brownell 2 , G.T. Wilson 21 Yale University School of Medicine; 2 Rutgers University, NewHaven, CT, USAThe aim of this study was to perform a randomized controlled trial totest the relative efficacy of cognitive-behavioral therapy (CBT) andbehavioral weight loss treatment (BWL) for binge eating disorder(BED). To control for the non-specific influences of attention, a thirdcontrol (CON) treatment condition was added. Given the promisingresults from initial studies using minimal therapist guidance, treatmentswere tested using a guided self-help approach. Ninety overweight(mean body mass index 35.5; mean age 46.3 years) patients (19males, 71 females) with a DSM-IV diagnosis of BED were randomlyassigned (5:5:2 ratio) to one of three treatments: CBT (n=37), BWL(n=38), or CON (n=15). The three 12-week treatment conditionswere administered individually following guided self-help protocolsthat included six brief meetings with research clinicians and daily selfmonitoringof eating, binge eating, and physical activity. The CBTtreatment condition followed Fairburn’s protocol and the BWL treatmentcondition followed Brownell’s protocol. Detailed assessmentswere performed at baseline, 4, 8, and 12 week time points. The primaryoutcome measure was remission from binge eating defined aszero binges for 28 days. Secondary measures included body massindex and dimensional measures of the features of eating disorders.Of the 90 patients, 70 (78 %) completed treatment; CBT (87%) andCON (87%) had significantly higher completion rates than BWL(67%). Intent-to-treat analyses revealed that CBT had significantlyhigher remission rates (50%) than either BWL (19%) or CON (13%).Weight loss was minimal and differed little across treatments.PO2.184.A COMPARISON OF THE EFFECTS OFOLANZAPINE AND RISPERIDONE VERSUSPLACEBO ON EATING BEHAVIORS AND GHRELINPLASMA LEVELS IN NORMAL HUMAN SUBJECTSJ.L. Roerig, J.E. Mitchell, M. de Zwaan, R.D. Crosby, B.A.Gosnell, K. PedersonDepartment of Neuroscience, University of North Dakotaand Neuropsychiatric Research Institute, Fargo, ND, USAThe addition of atypical antipsychotics to the armamentarium utilizedin the treatment of schizophrenia has substantially advancedour ability to combat this illness. However, in considering a patient’soverall health, the practitioner often is faced with the side effect ofweight gain. Recently, a gastric peptide, ghrelin, has been reported toinfluence eating and weight gain in animals and hunger and quantityof food eaten in humans. In light of these findings the effects of the290 World Psychiatry 3:S1 - October 2004

atypical antipsychotics on pre-prandial ghrelin plasma levels and thearea under the ghrelin plasma concentration-time curve (AUC) are ofinterest. This study is a randomized double blind, parallel group trialcomparing the effect of a two week treatment with olanzapine andrisperidone vs. placebo on ghrelin plasma levels and eating behaviorin 48 healthy human subjects. This project utilizes the current state ofthe art feeding lab procedures to better characterize the effect of thecompounds on eating behaviors including appetite, satiety, amount ofnutrient ingested and the resting energy expenditure. This project willhelp to determine the difference in biological markers and objectiveeating behavior parameters between the atypical antipsychotics olanzapineand risperidone compared to placebo.PO2.185.EVENT-RELATED POTENTIALS TOPOGRAPHY ANDCORTICAL SOURCE IMAGING IN SUBJECTS WITHDEFICIT AND NONDEFICIT SCHIZOPHRENIAE. Merlotti, U. Volpe, A. Mucci, P. Bucci, S. Galderisi, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalyDifferent electrophysiological abnormalities have been reported inpatients with deficit and nondeficit schizophrenia. In the presentstudy, event-related potentials (ERPs) recordings were obtained duringa three-tone oddball task in clinically stable patients with deficit(DS) and nondeficit schizophrenia (NDS) and matched healthy controlsubjects (HCS). DS and NDS patients were comparable for durationof illness and severity of disorganization and positive symptoms.The N100 component did not show amplitude differences amonggroups. A topographic abnormality (rightward shift of the negativearea) was observed in the DS group, as compared to both NDS andHCS. P300 amplitude was significantly reduced over the left posteriortemporal regions only in NDS patients vs. HCS; topographic P300abnormalities, including a posterior shift of the negative area and arightward shift of the positive area, were observed only in NDSpatients. Low-resolution brain electromagnetic tomography (LORE-TA) showed that, when compared to HCS, in DS patients, N100 currentsource density was reduced in the left cingulate while, in NDSsubjects, the reduction of the P300 current source density involvedtemporo-parietal regions of the left hemisphere. According to ourfindings, subjects with DS and those with NDS show a different patternof ERP abnormalities, which suggest different etiopathogeneticmechanisms.PO2.186.VOXEL BASED MORPHOMETRY IN ANOREXIANERVOSA. A PRELIMINARY CONTRIBUTIOND. Munno 1 , G. Zullo 1 , S. Sterpone 1 , P. Mortara 2 , A. Boghi 2 ,G.B. Bradac 3 , S. Sales 31 Section of Psychiatry, 2 Section of Neurology, 3 Section ofNeuroradiology, Department of Neuroscience, University of Turin,ItalyPatients with anorexia nervosa are often impaired in some neuropsychologicalfunctions, such as attention, concentration, visuo-spatialability, short-term memory and lower processing speed. Neuroimagingstudies have shown sulci widening, loss of brain parenchyma and ventricularenlargement; the reversible nature of such brain alterations isstill debated. We conducted a voxel-based-morphometry analysis ofthe brain magnetic resonance imaging (MRI) of 10 right-handedpatients suffering from anorexia nervosa since more than 5 years(mean 16.09±10.2; body mass index, BMI: 15.49±2.38) and 5 righthandedpatients with early anorexia nervosa (mean duration of illness1.2±0.44 years; BMI: 15.36±1.3) compared with 10 age matched righthandedwomen with normal BMI. Correlations between MRI findings,BMI, disease duration and neuropsychological performance(Wechsler Adult Intelligence Scale) were also calculated. No significantneuropsychological deficits were found in anorexia nervosapatients. Focal reduction of grey matter was found in occipital lobes,especially in the right one, precentral right, left parietal, right crus andright cerebellar hemisphere. These findings slightly correlated withBMI without reaching a significant value. No correlation was foundbetween grey matter atrophy and disease duration. No white matterloss was found. The lack of correlation between clinical and neuroimagingdata may be due to the limited number of patients. Nevertheless,the occipital grey matter loss, above all on the right side, maysuggest a dysfunction in the right visual areas which could be responsiblefor a wrong visual perception. Our research is progressing toidentify correlations between these morphological alterations andclinical picture.PO2.187.MELANOCORTIN-4 RECEPTOR (MC4R) GENEMUTATIONS IN BINGE EATING DISORDERA. Tortorella 1 , P. Monteleone 1 , E. Miraglia del Giudice 2 ,G. Cirillo 2 , L. Perrone 2 , E. Castaldo 1 , M. Maj 11 Department of Psychiatry and 2 Department of Pediatrics,University of Naples SUN, Naples, ItalyBinge-eating disorder (BED) is a provisional diagnosis delineated inthe DSM-IV, that involves recurrent episodes of binge eating withoutcompensatory behaviours. Therefore, people with BED gain weight upto become obese. A genetic predisposition to eating disorders is widelyrecognized. Recently, in a population of obese individuals, it has beenreported that BED was present in all the carriers of melanocortin-4receptor (MC4R) variants, suggesting a causal link between mutationsin the MC4R and BED, since MC4R is part of the endogenous systemregulating eating behaviour. It is known that about 20% of BED individualsare not obese. Therefore, an approach to assess a possible associationbetween MC4R mutations and BED could be to screen bothobese and non-obese individuals with BED for mutations in MC4R. Atotal of 57 women, aged 17-58 years, were recruited for the study; theirbody mass index (BMI) ranged from 20.00 to 53.00 Kg/m 2 . The frequencyof their binge eating was 3-21 episodes/week. DNA wasextracted from peripheral lymphocytes and the coding region of theMC4R gene was amplified by polymerase chain reaction andsequenced. We observed one mutation (G523A) and two non-functionalpolymorphisms (V103I – I251L) of the MC4R. The missensemutation G523A, resulting in the substitution of alanine with threonineat codon 175, was detected in a 40-year-old woman who was heterozygoticfor the mutation. The woman was overweight at the age of 37(BMI = 29.00 Kg/m 2 ), when she developed BED, that led to a frankobesity (BMI at the observation time was 32.85 Kg/m 2 ). Since the missensemutation G253A has been previously shown to reduce the MC4Rfunction, it is possible that it could represent a vulnerability factor forBED in this patient. These results, although preliminary, do not confirmthe hypothesis that mutation variants of the MC4R are frequentlyassociated with BED.291

PO2.188.PSYCHOPATHOLOGICAL ASPECTS AND FOODCHOICE IN EATING DISORDERSC. Segura García 1 , F. Sinopoli 2 , R. De Masi 2 , P. De Fazio 1 ,A. Amati 1 , F. Brambilla 31 Chair of Psychiatry and Clinical Unit, University of Catanzaro;2 Dietetics Unit, Materdomini Hospital, Catanzaro; 3 Departmentof Mental Health, Sacco Hospital, Milan, ItalyPatients with eating disorders (ED) tend to reduce or increase foodintake but they also present peculiar food choices which may worsentheir nutritional pathology as well as interfere with the neurotransmitter(NT) secretions, resulting in some specific psychopathological aspects ofthe disease. Our study aimed to explore whether a specific alteration infood choice might be detected in ED and whether this aspect could suggestany pathological link with the subtypes of ED psychopathology. In18 patients with anorexia nervosa (AN), 12 with bulimia nervosa (BN)and 10 with binge eating disorder (BED), we assessed the averageamount of caloric consumption, the percent of macronutrients and foodchoices. Psychopathological aspects were evaluated through the Temperamentand Character Inventory (TCI) and the Eating DisorderInventory-2 (EDI-2). Respectively for AN, BN and BED patients, meanKcal consumption (excluding binging) was 939±410, 2277±1864,1435±436; carbohydrate consumption (%) was 66.48±8.7, 61.28±4.04,61.87±2.45; fat consumption 13.76±5.68, 19.74±4.12, 17.85±1.99 andprotein consumption 19.76±4.83, 18.99±2.42, 20.29±3.03. TCI investigationrevealed significantly reduced novelty seeking and increased persistencein AN, whereas increased harm avoidance and reduced selfdirectednesswere found in all the three subgroups. EDI-2 mean valuesresulted impaired in the cumulative sample and showed large differencesbetween groups. The mean macronutrients and psychopathologicalaspects correlated as follows in the whole sample: carbohydratescorrelated negatively with novelty seeking and positively with feelinginadequate; fats correlated positively with novelty seeking and bulimia;proteins correlated positively with reward dependence and negativelywith insecurity, interpersonal distrust and feeling inadequate.PO2.189.ATTACHMENT STYLES AND ALEXITHYMIA INEATING DISORDER SUBJECTSD. Sorrentino, R. Di Benedetto, A. Tonni, F. Mancuso, A. Mucci,S. Galderisi, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalyInsecure attachment styles and alexithymia have been reported insubjects with eating disorders, but the relationships with the individualdisorders have been seldom investigated. This study was aimed toevaluate the attachment styles and alexithymia in subjects with eatingdisorders and to explore the relationships between these variablesand major diagnostic subgroups. 95 outpatients (52 with bulimia nervosa,BN; 17 with anorexia nervosa, AN; 26 with binge eating disorder,BED), and 100 healthy controls were recruited. Attachmentstyles were investigated by means of the Bartholomew Scale (BS), theAttachment Style Questionnaire (ASQ) and the Parental BondingInstrument. Alexithymia was investigated by means of the TorontoAlexithymia Scale -20 items (TAS-20). All patient subgroups, as comparedto controls, showed a poorer perceived quality of parental careand a higher frequency of adult insecure attachment styles. In particular,AN and BED patients reported more frequently a preoccupiedstyle, while BN patients a fearful one with respect to controls. Groupdifferences on the ASQ indicated lower confidence in all patient subgroupsand higher discomfort with closeness only in BN patients, incomparison with controls. Scores on TAS-20 demonstrated a greaterdifficulty in the identification and description of feelings in all patientsubgroups, and a greater difficulty in the internally oriented thinkingonly in BED patients, with respect to controls. According to ourresults, BN patients showed the most insecure adult attachment styleand subjects with BED the highest degree of alexithymia. These findingsmight have profound implications in planning psychotherapeuticintervention.PO2.190.ABNORMAL EATING BEHAVIOUR AND EATINGDISORDER ATTITUDE IN A CROSS-PUBERTALPOPULATIONP. Cotrufo, F. Cremato, S. Cella, G. Aiello, M.G. AielloDepartment of Psychology, University of Naples SUN,Naples, ItalyIn recent years some studies have been conducted on eating disordersin pre-pubertal population revealing an alarming diffusion of abnormaleating behaviours. Less information is available about the psychologicaland personality characteristics associated with thesebehaviours. According to some psychodynamic theories we wereinterested to evaluate the role of menarche and body transformationof puberty in the development of eating disorders. We conducted anepidemiological research on 1776 subjects, aged 11-13, attendingmiddle school. We administered an ad-hoc socio-demographic schedule,the Eating Disorder Inventory 2 (EDI-2) and a symptom checklistfor eating disorders according to DSM-IV criteria. The resultsconfirmed a diffused abnormal eating behaviour. 29.0% of the sampleis on diet, 38.1% conduct binge eating and the 5.7% had it twice aweek during the last three months, 23.1% lose control duringepisodes and 4.9% of the sample use laxatives, diuretics or diet pillsto lose weight. Comparing male (n=917) with female (n=859) subjectson each EDI-2 scale, we found significant differences on DT, B, BD,I, P, ID, IA scales and on body mass index. The post-pubertal femalesubsample (n=467) scored significant higher then pre-pubertal subsample(n=392) on DT, B, BD, ID scales, and the pre-pubertal scoredsignificantly higher on the maturity fear scale. These data suggest thateating disorders may be diffused even in the pre-adolescent population,which appears to be concerned about body weight and shape.PO2.191.ANOREXIA NERVOSA TREATED BY ANTIREFLUXSURGERY: A CASE REPORTD. Eraslan, Ö. ÖztürkDepartment of Psychiatry, Ege University Medical School,Izmir, TurkeyAnorexia nervosa is a chronic disorder that can cause esophagealsphincter failure and delayed gastric emptying. Even in the absence ofesophageal motility problems, patients with anorexia nervosa have ahigh incidence of gastrointestinal manifestations, such as vomiting,flatulence and abdominal pain, which can also be observed in gastroesophagealreflux disease (GERD). On the other hand, some achalasiapatients may show up with symptoms resembling anorexia nervosa.This overlap in symptomatology of anorexia nervosa and GERDmay cause problems in differential diagnosis and treatment decisions.We report on a 25 year old woman, who had been forced to anunwanted marriage. One year later, after the occurrence of depressivesymptoms, she started vomiting everyday, and lost weight until shewas 31 kg. She was hospitalized for GERD, and an endoscopy292 World Psychiatry 3:S1 - October 2004

showed she had cardioesophageal sphincter failure and esophagitis.After medical GERD therapy did not work, she was hospitalized in apsychiatry clinic, where she received a diagnosis of anorexia nervosa,and took antidepressants and psychotherapy for three months, withno improvement in symptoms. After consultations with gastroenterologistsand surgeons, she underwent a Nissen fundoplication forGERD, after which she started eating normally, with an improvementin her living conditions, and reached an acceptable weight. In conclusion,this patient improved dramatically, although there was nodoubt on the diagnosis of anorexia nervosa. The prevalence of eatingdisorders in the GERD population, and their response to therapy,deserve further attention.PO2.192.SUCCESSFUL TREATMENT OF ANOREXIA WITHA COMBINATION OF OLANZAPINE, FLUOXETINEAND MIRTAZAPINE AT HIGH DOSESK.N. Fountoulakis, A. Iacovides, V. Koumaris, G. Kaprinis3rd Department of Psychiatry, Aristotle University ofThessaloniki, GreeceAnorexia nervosa is one of the most difficult to treat psychiatric disorders,and (in contrast to bulimia) the role of pharmacotherapy is itstreatment is limited to the management of comorbid or secondarydisorders. We report the case of a 21 years old woman suffering fromanorexia nervosa (restricting type). When admitted to our departmentshe weighted 27 kg (height 160 cm). Her laboratory tests were normal.During the first two weeks of hospitalization she refused foodand insisted to exercise regularly. Since the case was considered a lifethreateningone, a nasogastric tube was placed for feeding purposes.Pharmaceutical treatment rose gradually during the next week andreached 20 mg/day of olanzapine, 60 mg/day of mirtazapine and 60mg/day of fluoxetine. The tube was removed after one week. Thepatient started eating gradually increasing quantities of food. Sheremained in the hospital for a further period of 2.5 months and duringthis period gained 19 kg. No specific psychotherapeutic interventionwas applied, so the improvement could be attributed mainly tomedication. At release the patient not only was eating three fair mealsdaily but this was causing her minimal annoyance.PO2.193.THERAPEUTIC IMPLICATIONS OF THEINDIVIDUAL, FAMILIAL AND CULTURAL CONTEXTOF EATING DISORDERS IN POLANDB. Józefik, M. PileckiDepartment of Child and Adolescent Psychiatry,Jagiellonian University, Krakow, PolandThe aim of the research was to study, in the Polish cultural context,the links between family patterns, social-cultural patterns regardingself-image and perception of one’s body in patients with eating disorders(ED). We used the Polish version of the Family Assessment Measure,the Family of Origin Scale, the Offer questionnaire and the CulturalFactors Questionnaire. Preliminary data show that perception offamily relationships in ED groups is more negative and incoherent incomparison with the control group.PO2.194.SELF-HELP GROUPS OF RELATIVES ANDASSOCIATIONS OF FAMILIES IN THEMANAGEMENT OF EATING DISORDERSA. Arata, V. Guiducci, F. PolicanteCenter for Treatment of Eating Disorders, Local Health Unit 3,Genoa, ItalySince 1996 we have been organizing psychoeducation groups for relativesof anorexic and bulimic young patients. These groups meetfortnightly for 6 months, led by a psychiatrist or psychologist of ourteam, with the aim of giving information and emotional support. Relativesparticipating in these groups expressed the wish to help otherparents to get out of their isolation and to learn coping strategies.Therefore, they founded in Genoa an association called “Relativesagainst eating disorders”, which collaborates with the professionalsof our center, who helped them to create self-help groups and aninformal consultation service for families and patients. In our presentationwe describe the function and results of these self-help groups.PO2.195.USE OF MINDFULNESS MEDITATIONTECHNIQUES IN TREATMENT OF ANOREXICFEMALE TEENAGERSA. Arata, D. MorandoCenter for Treatment of Eating Disorders, Local Health Unit 3,Genova, ItalyMindfulness training in eating disorders helps patients to find newvalues beyond body shape, based on interior research. Using JonKabat-Zinn’s work as conceptual background, we report our experiencesof psychotherapeutic groups for anorexic female teenagers (14to 19 years old), in which verbal activities are accompanied by workon body (relaxation techniques, meditation, breath exercises). Bodybecomes by this approach a means for self-knowledge and improvedself-regulation. For instance, this approach helps to identify physicalsensations as hunger and to distinguish it from feelings of internalemptiness and anxiety.PO2.196.ANOREXIA AND BULIMIA: EXPERIENTIALGROUPS FOR THE PHYSICAL SELF INTEGRATIONG. Volpato, M. CampanaMedicinDipendenze-onlus, Azzano S. Paolo, Bergamo, ItalySelf practice (SP) is a method developed during a biennial experiencewith anorexic and bulimic female patients. This paper is aimed atdescribing the crucial assumptions on which this approach to eatingdisorders is based. The fundamental assumptions are related to: theneed for the patient to feel her active role in the therapeutic process,in order for her to be the first one to discover or to interpret what hasbeen happening; the cohesion of the physical processes as preconditionto the ego cohesion; “the suffering needed to feel alive” as criticalproblem in these patients and the relevance of the experience concerning“the pleasure to be there” (meant as narcissistic libido). Ourexperience has led us to conclude that what is missing in the patientssuffering from narcissistic deficits is the ability to organise someaspects of their psychological structure through some physical, sensorialcontact and interpersonal experiences. Intellectualism and idealizationcan be interpreted as defence mechanisms needed to fillsome physical experiential gaps underlying a sound individuation.The denial of corporeity, through psycho-physical experiences sug-293

gested by SP, progressively turns into the acceptance of one’s bordersand the ability to compensate narcissistic deficits.PO2.197.ANOREXIA NERVOSA TREATMENT WITHOLANZAPINE: AN OPEN LABEL TRIALS. Sanzovo, G.L. BianchinEating Disorders Unit, Department of Mental Health,Montebelluna, Treviso, ItalyThe goal of this study was to determine whether olanzapine is effectivein producing weight gain and improving body image in patientswith anorexia nervosa. Twenty patients with restricting anorexia nervosawithout schizophrenia, schizoaffective disorder or bipolar disorderwere enrolled in an open label study. Ten patients (Group A) weretreated only with cognitive-behaviour therapy (CBT); ten patients(Group B) were treated with CBT and olanzapine. All the patientscompleted the six month study. Group A gained an average of twokilos; group B gained an average of six kilos (p>0.001). Group B wascharacterized by better body image and less anxiety after treatment.PO2.198.EFFECTS OF SERTRALINE PLUS COGNITIVEBEHAVIOURAL THERAPY IN BINGE EATINGDISORDERA. ArataCentre for Eating Disorders, Local Health Unit 3, Genoa, Italy14 female outpatients (age 22 to 60 years) with DSM-IV binge eatingdisorder, all belonging to the same cognitive behavioural therapy(CBT) group, were randomly assigned to receive sertraline or no medicationin a 3 month flexible dose (50-150 mg/day) trial. At the end ofthe study period, sertraline treated patients showed a greater rate ofreduction in the frequency of binges and in the body mass index anda greater improvement of mood, anxiety and social phobia. Thesedata suggest that sertraline enhances the effects of a CBT group inbinge eating disorder.PO2.199.PRESURGICAL PSYCHIATRIC ASSESSMENTIN OBESE PATIENTS CANDIDATE TO BARIATRICSURGERYA. Koppmann, D. Montt, K. Pappapietro, E. Diaz, A. CsendesSurgery Department, Clinical Hospital, University of Chile,Santiago, ChileThe study aims to describe the main psychiatric features of a group ofobese patients undergoing bariatric surgery, referred for presurgicalassessment. All consecutive candidates to bariatric surgery evaluatedbetween March and December 2003 were included in the study. Allpatients were examined with a semi-structured psychiatric interviewand three self-administered tests (Gormally’s Binge Eating DisorderScale, Moorehead-Ardelt’s Quality of Life Scale and Sukenfield’sBody Image Satisfaction Questionary). The study included 60 adultpatients, 88% female, age range 17 to 62 years, mean body mass index41 (range 36-50). In this series we found binge eating disorder in 30%of subjects. Other common psychiatric diagnoses were personalitydisorder, drug abuse, impulse-control disorder and affective disorder.Based on the results of psychiatric assessment, surgery was definitelynot recommended in 14% of patients.PO2.200.RISK TEST FOR EATING DISORDERS:VALIDATION IN AN OBESE POPULATIONP. Giosuè, R. Roncone, I. Cipollone, E. Storelli, M. CasacchiaUniversity of L’Aquila, ItalyEating disorders are disabling, unpredictable, and difficult to treat.Treatment has to focus directly on factors such as hopelessness anddepression in addition to standard procedures to ensure clients areable to engage in therapy. The present study was conducted in orderto evaluate the psychometric properties of the Italian version of RiskTest (RT), a 14-item questionnaire assessing the risk for eating disorders.The questionnaire was administered to 240 subjects: obese(n=40), medical (n=46) and non-clinical samples (n=154). The temporalstability of the RT was investigated in a sample of 30 non-clinicalsubjects and in a sub-sample of 12 long-term cases. The EatingDisorders Inventory (EDI) was administered to all subjects and thebody mass index (BMI) was calculated. The RT showed satisfactorypsychometric properties. Inter-rater reliability was satisfactory. Therewas good internal consistency and stability over time. Concurrentvalidity with the EDI dimensions was good. Factor analysis showedthat the distribution of RT scores can be accounted for by one factorable to explain 64% of total variance. The RT was well accepted bythe patients and needed very little supervision by the interviewer. Innon-psychiatric subjects, RT appears to be a good test to screeningeating disorders in the obese population.PO2.201.HOSTILITY DIRECTION IN EATING DISORDERS:A WARTEGG TEST STUDYS. Daini, C. Lai, F. Maiorino, E. Quinti, M. Pertosa, M. Gaglione,S. De RisioInstitute of Psychiatry and Psychology, Catholic University,Rome, ItalyAssertiveness and direction of hostility have been studied in eatingdisorder patients with conflicting results: some studies did not showsignificant differences between anorexics and bulimics, while othersfound outward directed hostility in anorexic patients. Because of theinterference of aggressiveness with therapeutic programs and of theinfluence of inward and outward hostility on psychopathologicaldevelopment, we studied hostility direction in anorexic and bulimicpatients. We assessed 10 anorexic (age 22±6) and 10 bulimic (age28±7) women by the Wartegg projective method. Clinical groups werecompared with a control group of 18 healthy subjects (age 25±6).ANOVA showed a significant difference between the control groupand clinical groups on formal quality (p

PO2.202.EVOLUTION FROM OBSESSIVE-COMPULSIVEDISORDER TO ANOREXIA NERVOSA IN AMALE PATIENTR. San Miguel Cuellar 1 , JA. Aguado-Mañas 1 , A. Miranda-Sivelo 21 Centro Hospitalario Benito Menni; 2 Psychiatric Service, HospitalUniversitario, Valladolid, SpainWe report the case of a 21 year old man, single. His mother is epilepticand had suffered from anxiety and depression episodes that neededtreatment. His father has an obsessive personality disorder and dysthymia.His brother has a phobic personality. The patient developed atthe age of 8 a somatization disorder, at the age of 9 a depressive disorder,at the age of 10 an obsessive-compulsive disorder, at the age of 17a restrictive anorexia and finally at the age of 20 a reverse anorexia.From the beginning there were evident anxious and depressive symptoms.We suggest that some cases of male reverse anorexia and restrictiveanorexia may be secondary to an affective disorder that determinesproblems with self-concept and subsequently with self-image.Treatment in these cases should be focused on the affective disorder.PO2.203.COMORBIDITY IN EATING DISORDERSG. Nieddu, P. Milia, A. Nivoli, L. Lorettu, L.F. Nivoli, G.C. NivoliDepartment of Psychiatry, University of Sassari, ItalyThis study was conducted at the Eating Disorders Center of theDepartment of Psychiatry of the University of Sassari. 80 patientsaffected by eating disorders according to the criteria of the DSM-IV-TRwere evaluated. The Structured Clinical Interview for DSM-IV Axis IDisorders (SCID-I) was used, as well as several scales for the assessmentof subclinical mood and personality disorders. The prevalence ofcomorbid conditions, and their impact on therapeutic choices andcourse and prognosis of the condition, are described.PO2.204.PREVALENCE OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN SCHOOLBOYSIN MASHHAD, IRANA. Talaee, E. AbdollahianMashhad University of Medical Sciences, Mashhad, IranWe assessed the prevalence of attention-deficit/hyperactivity disorder(ADHD) in Mashhad, the second biggest city in Iran, with more thantwo millions population. We listed all the schools in the city and chose12 schools (24 classes, 714 students) by stratified cluster sampling.After that, 72 children were selected randomly for a preliminary study.Their parents and teachers filled the 10 items Conners’ questionnairefor ADHD separately and a clinical interview based on DSM-IV criteriawas also performed. Then data were analyzed using the cut-off lineof 23 for total scores of parents and teachers. Then parents and teachersof selected 714 students of 24 classes filled the questionnaires. Studentswith the total scores higher than 23 were selected for interviewaccording to DSM-IV criteria, from which 102 students were diagnosedas having ADHD. Students with the total scores lower than 23who were suspect for ADHD according to teachers’ reports were alsointerviewed and 7 students were diagnosed as having ADHD (falsenegative). 109 students out of 714 schoolboys were thus diagnosed ashaving ADHD (15.27%). The prevalence rates for subgroups were:attention deficit 4.62%; hyperactive impulsive 5.32%; combined type5.32%. The sensitivity of Conners’ questionnaire for the cut-off line of23 was 93.6% and its specificity was 73.5%.PO2.205.THE INFLUENCE OF SYMPTOMS OFHYPERACTIVITY AND EMOTIONAL PROBLEMSON INATTENTION SYMPTOMSL. Sørensen, A. LundervoldDepartment of Biological and Medical Psychology,University of Bergen, NorwayThe study aimed to investigate how much symptoms of hyperactivityand emotional problems in children can explain symptoms of inattention.We expect to find that boys’ symptoms of hyperactivity will explainmore of their inattention problems compared to girls’ symptoms ofhyperactivity. Further, we hypothesize that this gender difference will beless when it comes to the emotional symptoms and how much theyinfluence the inattention problems. A parent and teacher questionnaireincluding DSM-IV defined attention-deficit/hyperactivity disorder(ADHD) symptoms and the Strengths and Difficulties Questionnaire(SDQ) were sent to 9430 7 to 9 year old Norwegian children. Reportsfrom 6641 parents on the Inattention subscale were obtained from thesample. Simple and multiple linear regression analyses were computedto investigate how much of the variance in the Inattention variable canbe explained by the hyperactivity and emotional symptoms. The hyperactivitysymptoms alone can explain 44.8% of the variance in the boys’inattention symptoms and 36.2% in the girls’ inattention symptoms. Theemotional symptoms can explain 19.3% of the variance when it comesto the boys’ inattention problems and 12.1% of the girls’ symptoms ofinattention. The hyperactivity and emotional symptoms togetherexplain 49.3% of the boys’ inattention symptoms, and 39.2% of the girls’inattention symptoms. In conclusion, in the parent reports both thesymptoms of hyperactivity and emotional problems explain more of theboys’ inattention problems than the girls’ inattention problems, and thisgender difference becomes larger when we consider the symptoms ofhyperactivity and emotional problems together.PO2.206.ASSESSMENT OF HEALTH STATE UTILITIESFOR ATTENTION-DEFICIT/HYPERACTIVITYDISORDER IN CHILDREN USING PARENT-BASEDSTANDARD GAMBLE SCORESK. Secnik 1 , S. Cottrell 2 , L. Matza 3 , E. Edgell 1 , M. Aristides 2 ,D. Tilden 2 , J. Burridge 2 , S. Mannix 31 Eli Lilly and Company, Indianapolis, IN, USA; 2 M-Tag Limited,London, UK; 3 MEDTAP International, Bethesda, MD, USAThe purpose of this research was to use standard gamble (SG) utilityvaluation methodology to assess attention-deficit/hyperactivity disorder(ADHD) health states in a sample of children diagnosed withADHD. The study was conducted in August 2003 in London, England.Parents of children diagnosed with ADHD completed the feelingthermometer (range 0-100) and SG utility interviews, in whichthey rated their child’s current health and 14 hypothetical healthstates (e.g., untreated ADHD, short- and long-acting stimulant treatment,and atomoxetine treatment). Participants were 83 parents ofchildren diagnosed with ADHD. Raw and adjusted SG ratings arepresented. The mean parent raw and adjusted SG rating of theirchild’s current health state was 0.72 and 0.91, respectively. Raw andadjusted SG ratings of hypothetical health states ranged from 0.63-0.90 and 0.88-0.96, respectively. Parents’ responses to the hypotheticalhealth states using the feeling thermometer were lower overall(26-87) when compared to the SG scores, with parents rating theirown child’s current health state at 57. Standard gamble ratings scorescan be obtained for children who have been diagnosed with ADHD295

y using their parents as proxies. Moreover, parents are able to distinguishand evaluate different hypothetical ADHD health states byassigning unique values to the scenarios presented to them.PO2.207.GENDER DIFFERENCES IN RESPONSE ANDOCCURRENCE OF SIDE EFFECTS WITHPSYCHOSTIMULANT TREATMENT OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDERW.J. Barbaresi, S.K. Katusic, R.C. Colligan, A.L. Weaver,D.A. Mrazek, S.J. JacobsenMayo Clinic College of Medicine, Rochester, MN, USAThis study examines gender differences in response and occurrence ofside effects with psychostimulant treatment of attention-deficit/hyperactivitydisorder (ADHD) in a population-based birth cohort. Subjectsincluded children from the 1976-1982 Rochester, MN birth cohort(n=5718; males=2956, females=2762). We reviewed medical and schoolrecords of each subject, employing research criteria to identify ADHDincident cases (n=379; boys=284, girls=95). Data regarding episodes ofpsychostimulant treatment, including dose, dates, response, and occurrenceof side effects were collected. There were 1069 episodes of psychostimulanttreatment (867 for boys, 202 for girls), among 283 treatedsubjects with ADHD. The proportion of episodes with a favorableresponse was 73.1% and did not differ by gender (74.5% for boys vs.66.8% for girls). Overall, 22.3% of patients experienced at least oneside effect, with no difference between boys (23.6%) and girls (17.5%).In conclusion, the likelihood of a favorable response and occurrence ofside effects with psychostimulant treatment of ADHD did not differ bygender. These results provide population-based evidence reinforcingthe importance and benefit of medical treatment of ADHD for bothboys and girls.PO2.208.THE IMPACT OF PSYCHOSTIMULANTTREATMENT ON SUBSTANCE ABUSE AMONGATTENTION-DEFICIT/HYPERACTIVITY DISORDERCASES WITH CONDUCT DISORDERS.K. Katusic, W.J. Barbaresi, R.C. Colligan, A.L. Weaver,D.A. Mrazek, S.J. JacobsenMayo Clinic College of Medicine, Rochester, MN, USAThis study aims to report the impact of treatment on substance abusein population-based attention-deficit/hyperactivity disorder (ADHD)cases with conduct disorder through long-term follow-up. ADHDcases (n=379) from 1976-1982 population-based birth cohort(n=5,718) were retrospectively followed from birth until last followup.Medical and school records were reviewed for documented substanceabuse, conduct disorder, and psychostimulant treatment. Conductdisorder diagnosis was documented in the records and verifiedby expert review. Type of psychostimulant, dosage, start/stop dateswere collected on treated ADHD cases (n=283). Among 379 ADHDcases, 32 (29 boys; 3 girls) had conduct disorder. There was a tendencyfor treatment to be protective. Among boys with ADHD and conductdisorder, 54% treated had substance abuse compared to 100%not treated (OR=0.11, 95% CI=0.01, 2.1). There was a lack of statisticalpower to compare abuse status between treated (n=2) and nottreated (n=1) ADHD girls with conduct disorder. This large, longitudinal,population-based study demonstrates that treatment is associatedwith decrease in substance abuse among boys with ADHD andconduct disorder. While these results cannot demonstrate cause andeffect, they suggest the potential for effectiveness of treatment.PO2.209.EFFICACY OF ATOMOXETINE IN PLACEBO-CONTROLLED STUDIES IN CHILDREN,ADOLESCENTS, AND ADULTS WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDERA. Zuddas 1 , A. Simpson 2 , C. Kratochvil 3 , J. Newcorn 4 , A. Allen 5 ,D. Faries 5 , D. Milton 5 , P. Feldman 5 , D. Michelson 5 , R. Pino 6 ,G. dell’Agnello 6 , J. Biederman 71 University of Cagliari, Italy; 2 Eli Lilly and Company Ltd.,Basingstoke, UK; 3 University of Nebraska Medical Center,Omaha, NB, USA; 4 Mount Sinai Medical Center, New York, NY,USA; 5 Lilly Research Laboratories, Eli Lilly and Company,Indianapolis, IN, USA; 6 Eli Lilly Italia, Florence, Italy;7 Massachusetts General Hospital, Belmont, MA, USAAtomoxetine is a highly specific inhibitor of the norepinephrinetransporter that has been developed as a nonstimulant treatment ofattention-deficit/hyperactivity disorder (ADHD). Eight large, acute,randomized, double-blind, placebo-controlled studies (4 in children,2 in children and adolescents, and 2 in adults) have been conductedinvolving atomoxetine in the treatment of ADHD. Three trials in childrenwere conducted with once-daily dosing (6–8 weeks), while theother 5 studies employed twice-daily dosing, all on a weight-adjustedbasis (8–9 weeks). Adults were dosed twice daily over 10 weeks withdose escalation within a fixed range. Protocol-specified primary outcomemeasures in 5 of the pediatric studies were parent-reportedassessments corresponding to DSM-IV symptom criteria, and 1involved teacher-reported assessments. Adult studies were selfreported.In all studies, atomoxetine was superior to placebo inreduction of mean symptom ratings for the primary outcome measure.The effect size for once-daily treatment was similar to that oftwice-daily treatment. No serious safety concerns were observed andtolerability was good, as evidenced by discontinuation rates of lessthan 5% for adverse events in the pediatric studies. Atomoxetineappears to be safe and efficacious for the treatment of ADHD in children,adolescents, and adults.PO2.210.LONG-TERM SAFETY OF ATOMOXETINEIN CHILDREN AND ADOLESCENTS WITHATTENTION-DEFICIT/HYPERACTIVITY DISORDERG. Masi 1 , M. Bangs 2 , D. Michelson 2 , H. Gao 2 , R. Pino 3 ,G. dell’Agnello 3 , P. Feldman 21 Division of Child Neuropsychiatry, University of Pisa and StellaMaris Foundation, Calambrone, Pisa, Italy; 2 Lilly ResearchLaboratories, Eli Lilly and Company, Indianapolis, IN, USA;3 Eli Lilly Italia, Florence, ItalyAtomoxetine (ATMX) is a non-stimulant, noradrenergic reuptakeinhibitor that has been approved in the United States for treatment ofattention-deficit/hyperactivity disorder. This analysis examined thetolerability and safety of ATMX during treatment lasting up to at least2 years. The long-term safety of ATMX was assessed using data fromall clinical trials to date: 15 in children and adolescents, and 3 inadults. A total of 3262 children and adolescents and 471 adults havebeen exposed to ATMX in these studies, with over 1200 patients treatedfor at least 1 year and over 400 for at least 2 years. Discontinuationsdue to adverse events (AEs) were uncommon (4.1%). AEs morecommonly associated with ATMX (gastrointestinal events, decreasedappetite, somnolence) were predictable from pharmacology, occurredmore frequently during initial treatment, and tended to resolve duringongoing treatment. Blood pressure during long-term (≥2 years) ATMX296 World Psychiatry 3:S1 - October 2004

treatment was stable. Controlling for age-appropriate increases,changes from baseline (end of acute treatment) were: systolic, +2.9mmHg; diastolic, +0.3 mmHg. ATMX did not significantly affect QTinterval. The initiation of treatment was associated with a modestdecrease in growth velocity that normalized over time. ATMX waswell tolerated during long-term use, with no evidence of unexpectedrisks or serious safety concerns.PO2.211.A REVIEW OF THE ABUSE LIABILITYOF ATOMOXETINE, A NON-STIMULANTPHARMACOTHERAPY FOR ADHDA.J. Allen 1 , F. Bymaster 1 , G. dell’Agnello 2 , R. Pino 2 ,D. Michelson 1 , C. Thomason 1 , M. Kallman 1 , D. Clarke 11 Lilly Research Laboratories, Eli Lilly and Company,Indianapolis, IN, USA; 2 Eli Lilly Italia, Florence, ItalyAtomoxetine was recently approved in the US as a treatment forattention-deficit/hyperactivity disorder (ADHD). Psychostimulantshave been the standard pharmacotherapies for the treatment ofADHD, but are associated with abuse potential. Receptor binding,preclinical behavioral, and human laboratory studies of the abuse liabilityof atomoxetine have been completed and are summarized.Binding affinities of atomoxetine and its metabolites were determinedfor monoamine transporters and other neurotransmitter-relatedreceptors, ion channels, and transporter binding sites. The potentialstimulant effects of atomoxetine were evaluated preclinically in amouse locomotor activity study. Drug discrimination studies in animalswere reviewed, and self-administration studies using monkeystrained to discriminate cocaine or methamphetamine or self-administercocaine were conducted. Additionally, a human laboratory studywas conducted to examine the subjective, physiological, and psychomotoreffects of atomoxetine, methylphenidate, and placebo. Atomoxetineis a potent inhibitor of the presynaptic norepinephrinetransporter with minimal affinity for dopamine transporters oractions at GABA-A receptors. It did not stimulate locomotor activityin mice. In drug discrimination studies, it produced a profile similarto that of drugs without abuse liability. Atomoxetine, like desipramineand in contrast to methylphenidate and amphetamine, did not maintainself-administration in monkeys and was not preferred over fooddelivery up to doses that decreased response rates, consistent withlimited reinforcing strength. Results from the human laboratory studysuggested that atomoxetine was not perceived as pleasurable and didnot have a significant potential for abuse. Data from receptor binding,preclinical behavioral, and human laboratory studies suggest that atomoxetinedoes not have abuse liability.PO2.212.EFFICACY OF TWICE-DAILY RITALIN ANDONCE-DAILY EQUASYM XL IN CHILDREN WITHATTENTION-DEFICIT/HYPERACTIVITY DISORDERD. Quinn 1 , R. Findling 2 , J. Smith 3 , S. Cameron 4 , H. DeCory 5 ,M. McDowell 61 University of Saskatchewan, Canada; 2 Case Western ReserveUniversity, Cleveland, OH, USA; 3 Celltech, Bothell, WA, USA;4 Celltech, Slough, UK; 5 Celltech Americas, Rochester, NY, USA;6 Child Development Network, South Brisbane, AustraliaThe study aimed to compare the efficacy of Equasym XL (EXL), aonce-daily formulation of d,l-methylphenidate (MPH), with Ritalingiven twice-daily in children with attention-deficit/hyperactivity disorder(ADHD) and to compare the safety and tolerability of these formulationswith placebo. 318 children aged 6 to 12 years on clinicallyeffective, stable doses of twice daily Ritalin or equivalent were randomizedinto a double-blind, three-arm, parallel-group, multi-centerstudy and received three weeks of either EXL (20, 40 or 60 mg oncedaily) or Ritalin (10, 20 or 30 mg twice daily) comparable to their prestudyMPH dosage or placebo. Patients attended a study site at theend of each treatment week. The primary outcome measure was thedifference in the inattention/overactivity component of the teacher’sIOWA Conners’ Rating Scale on day 21. Safety was monitored byadverse events, laboratory parameters, vital signs, weight, physicalexam and Side Effect Rating Scale. The lower 97.5% CI bound of thedifference between MPH groups was greater than -1.5 at all scheduledvisits, demonstrating that EXL treatment was non-inferior to Ritalintreatment. In addition, analysis of covariance indicated that bothMPH treatment groups were statistically superior to placebo at all visits(p

PO2.214.GROUP THERAPY WITH OUTDOOR ELEMENTSFOR ADOLESCENTS WITH SOCIAL DEFICITSD. Hoenigl 1 , K. Hasiba 1 , A. Neuhold 2 , G. Berger 3 ,U. Schrittwieserv 21 Department of Psychiatry, Medical University of Graz;2 Psychiatric Service of Mental Health, Hartberg; 3 University ofVienna, AustriaSeven adolescents (age range 12-16 years) with a history of clinicallyrelevant internalising disorders participated in a time-limited therapeuticproject. The main instruments were 10 group therapy sessionsand two weekends with outdoor therapy for the adolescent studymembers and five group sessions for their parents. At two times adiagnostic interview according to DSM-IV criteria was done and severalitems concerning to the sociability of the adolescents (e.g. numberof good friends, frequency of meeting with peers, number ofadmissions to psychiatric services and number of days missingschool) were assessed with one parent (father or mother) and theadolescent separately. A baseline assessment was made before startingtherapy and the second evaluation was made one year later, i.e. 6months after the end of the therapy group. At the first interview theseven adolescents had a total number of eighteen diagnoses accordingto DSM-IV. At the second assessment point the number of diagnosesdiminished to two. From the social parameters only the numberof days missing the school diminished significantly according to theWilkoxon rank-test. Our setting of a time-limited group therapy withoutdoor elements and the accompanying parent group was an effectivetreatment for adolescents with internalising disorders. Thisapproach should be evaluated in further studies.PO2.215.CHILDREN’S PSYCHOLOGICAL RESPONSETO PARENTAL COMMUNITY VIOLENCEVICTIMIZATION IN THE UNITED STATESC. Dulmus, K. Sowers, J. Blackburn, W. RoweUniversity of Tennessee, Hunter College, University of SouthFlorida, Knoxville, TN, USAThis study examined gender and age differences in children’s psychologicalresponse to parental victimization. Thirty children, 6 through 12years of age, whose parents had been a victim of community violence(i.e., gunshot or stabbing) and a control group of 30 children matched onvariables of race, age, gender, and neighborhood served as the sample forthis study. Parents completed a demographic sheet and the Child BehaviorChecklist (CBCL). Data was collected within 6 weeks of parental victimization.Analyses found children in the experimental group wereexperiencing symptoms in the borderline clinical range, while children inthe comparison group fell below this range. In regard to gender and agespecific differences, no significant difference in male and female youth’sinternalizing and externalizing behavior at age 6-8 in either the control orexperimental groups was found. However, beginning at age nine therewas a significant difference in behavior. Specifically, in the experimentalgroup, males externalized more than females and females internalizedmore than males. In the control group, there was no significant differencein the internalizing and externalizing behavior of the male and femaleyouth. Thus, the perceived trauma response may vary as a function of thechild’s gender and developmental level or age. These findings suggest thatgender specific response related to trauma exposure may begin as early asage 9. Such knowledge has implications for practice as gender specificassessment and intervention approaches must be utilized at younger agesthen previously presumed.PO2.216.ADULT ATTENTION-DEFICIT/HYPERACTIVITYDISORDER AND BORDERLINE PERSONALITYDISORDERD. La Torre, R. Cambria, M.R.A. Muscatello, L. Cortese,D. Campolo, A. Bruno, R. Zoccali, M. MeduriDepartment of Psychiatry, University of Messina, ItalyWhile attention-deficit/hyperactivity disorder (ADHD) has alwaysbeen considered as a childhood disorder, the existence of adult ADHDhas been largely validated in many recent studies. The adult variant ofthe disorder seems to be characterized by less hyperactivity and relativelymore inattention, presumably related to executive dysfunctions.Our hypothesis is that, beyond the well-known overlap with antisocialpersonality disorder and substance abuse, ADHD may evolve in borderlinepersonality disorder (BPD). The aim of the present study wasthus to detect, in a sample of borderline patients selected for a neuropsychologicalassessment of executive functions, childhoodantecedents of ADHD. 70 subjects (mean age 37.25±4.73 years) with aBPD diagnosis according to DSM-IV criteria underwent a neuropsychologicalassessment involving the Wisconsin Card Sorting Test, theStroop Colour Word and the Standard Progressive Matrices to assessexecutive functions. An accurate anamnestic psychiatric interviewwith both patients and relatives was conducted by an expert psychiatristto collect antecedents of ADHD in childhood and psychiatriccomorbidity. The results suggest that a subgroup of BPD subjects characterizedby impairment in executive functions and more severe symptomatologyare positive to anamnestic screening for ADHD in childhood.The symptomatology of adult ADHD may thus overlap with“dramatic” personality disorders characterized by impulsivity, affectiveinstability and executive dysfunctioning, such as BPD. The detectionof executive dysfunctions in BPD may have important implications forthe treatment of personality disordered subjects.PO2.217.ADULTS’ PERCEPTIONS OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER ANDPOSSIBLE EFFECTS ON PREVALENCE RATES INBOYS AND GIRLSK. Maniadaki, E. KakourosPsychological Center for Developmental and LearningDisabilities ARSI, Athens, GreeceWithin the domain of developmental psychopathology, increasinginterest has emerged regarding parental perceptions about childhooddisorders. This interest stems from the assumption that parental interpretationsof and reactions to children’s abnormal behaviour maymediate the outcome of this behaviour and influence treatment effectiveness.Within this framework, parents’ and teachers’ causal attributionsabout attention-deficit/hyperactivity disorder (ADHD) havebeen particularly studied. Nevertheless, the child’s sex has rarely beentaken into account and causal attributions were the only kind of cognitionsincluded in these studies. This paper presents a theoreticalmodel that encompasses several cognitions regarding ADHD, takesinto account the child’s sex and links these factors with referral attitudes,socialisation practices and sex differences in prevalence ratesof ADHD. This integrative model consists of three stages. At the firststage, factors that might influence parental perceptions about ADHDin boys and girls are examined. At the second stage, possible interactionsof these perceptions with differential parenting practicestowards boys and girls are presented. At the third stage, the mediatingrole of differential parenting practices towards boys and girls for the298 World Psychiatry 3:S1 - October 2004

sex differences in prevalence rates of ADHD is explained. Preliminaryresearch findings regarding the first stage of this model are reported.The aim of this model is to serve as a theoretical basis for futureresearch regarding the role of adult cognitions in the development ofchildhood psychopathology and of sex differences in the prevalencerates of several childhood disorders.PO2.218.CONDUCT DISORDER: A REVIEWOF EVIDENCE-BASED TREATMENTSO. SavenkovDepartment of Psychiatry, Queen’s University, Kingston, CanadaConduct disorder is one of the most frequent reasons for referral ofchildren and adolescents to psychiatric and mental health services.With a reported prevalence of 4% to 7% and a poor long-term prognosis,it is one of the most expensive disorders in terms of suffering anddysfunction of the person and cost to society. This paper will review thecurrent literature, reporting that there is now a good evidence for theeffectiveness of parent management training, multisystemic therapy,and cognitive problem-solving skills training. Limitations of well-investigatedpsychosocial treatments will also be discussed. Lastly, treatmentsand interventions that have not demonstrated effectiveness willbe reviewed. The limited role of psychopharmacological treatments willalso be examined.PO2.219.NEW APPROACH TO TREATMENTOF CHILDREN WITH ATTENTION DEFICITDISORDER AND HYPERACTIVITYA.N. Mihajlov, I.P. Briazgounov, M.D. Mitish, T.D. DegtyaryovaRussian Academy of Medical Science, Moscow, RussiaAttention deficit disorder and hyperactivity is a widespread diseasewhich is challenging various specialists: pediatricians, psychiatrists,neuropathologists, clinical psychologists. We developed a newapproach to the treatment of this condition based on the psychotherapeuticcorrection of the specific features of processing of sound,visual and kinetic stimuli observed in a sample of 50 children agedfrom 7 to 12 years, mostly male. The efficacy of the method is beingtested by a medico-psycho-pedagogical supervision.PO2.220.FLUVOXAMINE IN CHILDREN AND ADOLESCENTSWITH AUTISTIC SYMPTOMS, MENTALRETARDATION AND SELF-INJURIOUS BEHAVIORS. MileaAl. Obregia Hospital, Bucharest, RomaniaWe explored the efficacy and safety of fluvoxamine in children andadolescents with self-injurious behavior (SIB). Fourteen children andadolescents, 9 boys and 5 girls, with mental retardation and SIB, weretreated with 200-300 mg of fluvoxamine daily for a period of 2months. Ten cases fulfilled DSM-IV criteria for autism and four foratypical autism. Six cases exhibited self-restraint behavior. The evaluationwas carried out weekly. Very good improvement occurred in 4cases, good in 5 cases, mild in 2 and no improvement in 3 cases. Theimprovement of SIB was accompanied by a general improvement ofbehavior. No secondary or adverse reactions occurred. The bestresults were obtained in cases with self-restraint behavior: there were4 with very good and one with good improvement. If risperidone isassociated, the quality of improvement increases. This study is anopen trial of a small sample. This fact limits the significance of ourobservations. They allow us, however, to suggest that: fluvoxaminecan be used without risk and with good results for improvement ofSIB, a disorder that has had no satisfactory therapeutic solution sofar; the most significant improvement can be obtained in cases withself-restraint behavior, probably because they have a common mechanismwith obsessive-compulsive disorder; the clinical response isnot present in all cases and not in the same degree; efficacy, if any,begins in the second week, and increases progressively during the secondtill the fourth week of treatment.PO2.221.REGRESSION IN AUTISTIC DISORDERA. Belhadj , L. Mezghani, A. Bouden, M.B. HalayemDepartment of Child and Adolescent Psychiatry, Razi Hospital,La Manouba, TunisiaThe age at onset of autistic symptoms has been discussed in the literatureas a possible marker for a special subgroup. The purpose of thisstudy is to analyse how often an early regression in language, sociabilityand play is reported in a clinical sample and how it is related toother abnormalities found in these children. The study included 63children referred to a child psychiatry department between January1998 and September 2003 and diagnosed with autistic disorder byDSM-IV and Autism Diagnostic Interview-Revised (ADI-R) criteria.These 63 children included 48 boys and 15 girls. Their ages at the timeof the first visit ranged from 24 months to 15 years (mean 8 years). 8patients (12%) had a history of regression and 21 patients (33%) hada history of epilepsy. Children with regressive symptoms had morefrequently mental retardation and no language. They did not presentmore epileptic seizures or epileptiform EEG. Further studies areneeded to clarify the pathophysiologic basis of autistic regression inorder to devise more effective therapies.PO2.222.A PSYCHOMOTOR APPROACH TO SEVERE AUTISM:REPORT ON THREE COMPLETED CASESP. Gabusi, U. Incasa, S. ValerianiBernardi Rehabilitation Center, Bologna, ItalyThis work represents the follow-up of the treatment of five cases ofsevere autism associated with severe neurological and cognitive disorders.Three patients continued the rehabilitation programme forfive years. One patient followed a control cycle for a few months andone patient did not continue the treatment. The therapeutic protocolincluded individual sessions which were carried out once or twice aweek in a special rehabilitation swimming pool. The treatmentincluded a psychotherapeutic supervision and was divided in threesubsequent stages: search for reflex movement reactions associated toarousal or surprise; search for a simple relationship supported bypleasant and unpleasant stimuli; search for intentionality and imitativeability. It was possible to observe that the three patients who continuedthe treatment showed significant improvements mostly in thebehavioural area.299

PO2.223.AUTISM AND MENTAL RETARDATION:THE USEFULNESS OF PSYCHODIAGNOSTICEVALUATIONC. Ruggerini, V. Neviani, C. Adenzato, F. Villanti, G.P. GuaraldiDepartment of Neurosciences, University of Modena andReggio Emilia, Modena, ItalyWhen autism is part of a clinical picture of severe mental retardation,the phenotypic heterogeneity of the disorder is even more marked,leading to diagnostic assessments and therapeutic and rehabilitativeinterventions which are not always correct. In order to implement amanagement which is adequate to the characteristics of each individual,it is necessary to use a psychodiagnostic protocol including standardizedinstruments. We studied 13 adult subjects with a clinicaldiagnosis of autism and severe mental retardation. 11 were males andtwo females; the age range was between 18 and 50 years (mean30.69). All subjects were assessed using a psychodiagnostic protocolincluding the following scales: Brunet-Lézine or Leiter-R, Vineland,Messier, Diagnostic Assessment for the Severely Handicapped-II(DASH-II) and Adolescent and Adult Psychoeducational Profile(AAPEP). The diagnosis of autism was confirmed in 10 cases. In twocases autistic traits were found. In 7 cases there was an associatedmental disorder (mood or anxiety disorder, motor stereotypies) and inthree cases a problem behaviour. Psychodiagnostic evaluation allowsto identify mental disorders associated with autism and mental retardationand to implement a differential diagnosis between the latterand problem behaviours. Moreover, it allows to assess individualcharacteristics, thus leading to the implementation of personalizedtherapeutic and rehabilitative programs.PO2.224.RESIDENTIAL TREATMENT FOR AUTISTICPATIENTS IN ADULTHOOD: PRELIMINARY RESULTSFROM AN ITALIAN FARM-COMMUNITYS. Ucelli di Nemi, G. Carrà, G. Segagni Lusignani, F. BaraleSection of Psychiatry, Department of Applied Health andBehavioural Sciences, University of Pavia, ItalyResidential programs for individuals with developmental disabilitieshave been in existence for almost two centuries, but peculiar programsfor autism are relatively recent. As a result, the first residential treatmentprograms designed specifically for adults with autism were developedin the 1970s. These community-based treatment programs forindividuals with autism have been developed in urban, suburban, andrural settings. Most programs emphasize special education and behaviouraltechniques to optimise the residents’ development of new skillsand their ability to function independently in the community. The programsmay vary in the use of specific teaching strategies, the vocationalcurriculum, family involvement, size and staff training procedures. Theresearch on the effectiveness of residential treatment models for individualswith autism is limited. In 1975, following the experience ofSommerset Court in England, we implemented a new residential modelfor autistic patients, the farm-community, with a program of activitieswhich could be encompassed by a farming life-style in a rural environment.In 2002, joining with the Autism Laboratory of the University ofPavia, we started the first Italian farm-community. This programattempts to address the needs of autistic people for growth in every areaof life, using the rural, extended family-community as the model. Everythingis done by residents with the staff, and these activities constitutethe program and the means whereby skills for daily living are developed.The preliminary results of a 12-month follow-up are presented.PO2.225.PSYCHOSOCIAL AND TEMPERAMENTALFACTORS ASSOCIATED WITH SCHOOL REFUSAL.A STUDY FROM A DEVELOPING COUNTRYR. Hariharan, V. RaveendranHunter Mental Health Services, Newcastle, AustraliaSchool represents an entirely new world for the young child where heis suddenly expected to acquire complex activities according to specificrules. Most children attend school voluntarily. Some childrenfind this experience very distressing resulting in prolonged absencesfrom school. Various factors are implicated in school refusal, such ascharacteristics of the child, family and school. This study attempts tolook into these factors in an urban setting in a developing country. Allconsecutive children registered from July to December 2002 at theChild Guidance Clinic at the Institute of Child Health, Madras MedicalCollege and Research Institute, presenting with the chief complaintof school refusal, were the cases. Controls were age, sex andsocioeconomic status matched children attending school regularly.Malhotra’s Temperament Assessment Schedule to assess temperamentand Parent Interview Schedule to assess psychosocial factorsand a semi-structured interview schedule to assess sociodemographicfactors were administered. Statistical analysis was done using SPSS-10. Mean age of the sample was 10.3 years, with male/female ratiobeing 2:1. Of the nine temperamental dimensions, cases and controlsdiffered significantly on the dimension of intensity. The cases andcontrols differed significantly on many of the psychosocial factorslike chronic interpersonal stress related to school.PO2.226.SCHOOL REFUSAL AND AGGRESSIVE BEHAVIOURG. ButorinState Pedagogical University, Chelyabinsk, Russia76 aggressive pupils of primary school who refused school underwenta multidisciplinary examination. The work was conducted by clinical,psychological and neurophysiologic methods. Special attention waspaid to personal and social factors. An organic cerebral pathologywas found in 64.5% of cases, social and pedagogical delay with psychicdeprivation in 53.9%, personal peculiarities of character in44.7%, somatic weakness and school difficulties in 27.6%. As a rule,these factors were combined. The first negative evaluation of the childby a teacher was important for the appearance of crisis reactions.37.8% of pupils lived in a rejecting atmosphere; an indifferent attitudeby teachers was observed in 26.6% of cases; 35.6% of childrenhad been abused.PO2.227.SUICIDAL ATTEMPTS IN A PEDIATRIC POPULATIONIN CONCEPCION, CHILEM. Valdivia, M.I. Condeza, D. Ebner, M. Cifuentes, C. Llorente,S. Torres, B. Vicente, M. ZuñigaDepartment of Psychiatry, University of Concepcion, ChileWe describe the biodemographic characteristics of all the children thatwere admitted for a suicidal attempt to the Pediatric Unit of ConcepcionGeneral Hospital between October 1995 and September 2002,and the characteristics of their attempts. During this period, 103 childrenwere admitted; their mean age was 12.9 years (range 6-15), 85.4%were female, 42.7% lived with both parents, 54.4% reported somekind of domestic violence, and 58.3% had at least a relative with a psychiatricdisorder. Most of the suicide attempts took place in the chil-300 World Psychiatry 3:S1 - October 2004

dren’s home (76.7%). They were in October (beginning of Spring) in13% and in December (end of the school year) in 14% of the cases.Most of them were without previous planning (55.1%), and after a precipitantsituation (85.5%). Medicament overdose was the most commonlyused method and intensive care unit was required only in17.5% of the cases. The study of children who attempt suicide is of theoutmost importance in order to design early intervention and preventionprograms.PO2.228.PSYCHODERMATOLOGY IN CHILDREN:A STUDY AT PENDELIS HOSPITAL IN GREECEA. Michopoulos, A. Karagianni, S. Siapati, A. Nicolaou,A. Tsinou, B. BelesiotiPsychology Department, Pendelis Children Hospital, Athens,GreecePrevious research has shown that there is a close relationship betweensome dermatological symptoms and psychological problems. Personalityfactors (such as anxiety, anger, depressive mood) and stressful lifeevents that occur in children’s life (parent’s divorce, death, illness, etc.)can cause psychosomatic symptoms and especially psychodermatologicalproblems such as neurodermatitis, trichotillomania, onychomania,alopecia areata, etc. The aim of this study is to examine thevalidiy of this hypothesis. Psychological factors were evaluated by personalityand projective tests such as Achenbach for parents, Beck forchildren, patte-noire and family drawing tests. Stressful life eventswere evaluated during the interview with the parents and the child andthrough a specific questionnaire designed for this purpose. The studyinvolves 30 children whose psychological profiles are presented. Wefound that half of the children present personality factors such as anxiety,depression and aggressiveness. We also found that almost all thechildren had experienced a very stressful life event before the emergenceof the dermatological symptom.PO2.229.ZIPRASIDONE’S “BRIGHTENING” EFFECT INMENTAL RETARDATIONS. CohenPuget Sound Psychopharmacology Services, Seattle, WA, USAThe study aimed to evaluate ziprasidone’s effects on mood and behaviorin mentally retarded inpatients with histories of assault, selfinjury,or property destruction. This retrospective chart review comprised82 mentally retarded adults given ziprasidone because of maladaptivebehaviors or significant metabolic disturbances (≥7% weightgain, increased lipid or glucose levels) associated with other atypicalantipsychotics. The age range was 17–68 years. 48 (58.5%) patientshad severe-to-profound deficits, and 33 (40.2%) had concomitantseizure disorders. Duration of ziprasidone therapy was 1–32 months(mean 18.6 months); total daily dosing was 20–280 mg (mean 104.6mg). Besides improving maladaptive and compulsive behaviors, aswell as metabolic parameters, ziprasidone induced a “brightening” ofmood and affect in 29 (35.4%) patients. Brightening was expressed asgreater social engagement, expressiveness, and friendly demeanor.Some patients (n=14) whose behaviors improved experienced agitation,which generally responded to dosage increases or beta-blockade.Ziprasidone safely controls maladaptive behaviors in mentallyretarded adults and, importantly, improves mood and social engagement.“Brightening” may reflect improvements in primary presentingsymptoms, an effect on prosocial behaviors, or a mild antidepressanteffect from serotonin and norepinephrine reuptake inhibition.PO2.230.NON-PSYCHOTIC FORMS OF RESIDUAL-ORGANICPSYCHOSYNDROME IN CHILDRENL. BenkoUral State Medical Academy for Postgradual Education,Chelyabinsk, RussiaIn the present research, we attempt to identify neuropsychologicalsyndromes in children with residual encephalopathy. 80 childrenaged from 6 to 12 years (57 males and 23 females) underwent a psychopathological,neurophysiological, neurological and neuropsychologicalevaluation. We identified an asthenic-hyperdynamic variant,with restlessness, unpredictability of affect, motor reactions, maladaptationto social environment. Another group of children, withfatigue, passivity in behavior, inertia in social environment and cognitiveand intellectual problems, sometimes with somato-vegetativeimpairments, was defined as asthenic-hypodynamic variant. Theunderlying cerebral pathologies are described.PO2.231.NEURO-MENTAL PATHOLOGY IN CHILDRENIN THE SOUTH URAL AREAN. ButorinaState Pedagogical University, Chelyabinsk, RussiaThe result of a number of accidents (since 1957) in the South Uralarea has been the programme well known as East Urals RadioactiveTrace (EURT). Now it is possible to estimate the risk of distant manifestationof chronic radioactive effects on the children and adolescentsof this region. This work deals with neuro-mental pathology(NMP) among the children in primary schools of the area. Pediatricians,neuropathologists, psychologists, defectologists and psychiatriststook part in this investigation. The results we received show thatthe spread of NMP among the children's contingent of EURT is 4times higher than in official reports. We discovered that 66.8% of 132children had various learning difficulties linked with school problems.In 45% of cases an organic psychosyndrome was identified. Agroup of cases with moderate brain damage, paroxysms and changesin the electroencephalogram was revealed. These disorders were consideredas being on the border with epilepsy. Further multidisciplinaryinvestigations are necessary to clear up the outcome of thesestates.PO2.232.PERSONALITY TRAITS AND CRIMINAL BEHAVIOUR:AN EMPIRICAL STUDY ON 63 JUVENILEOFFENDERSR. Sperandeo 1 , P. Cotrufo 2 , F. Perris 1 , F. Palladino 1 , M. Cigliano 1 ,F. Catapano 11 Department of Psychiatry and 2 Department of Psychology,University of Naples SUN, Naples, ItalyThe aim of the study is the identification of personality traits whichcan describe the psychopathologic features of juvenile offenders. Theresearch was conducted in a juvenile penitentiary in Italy. We assessedthe recurrence of personality disorders (PD) in a sample of 63 individualsaged between 15 and 20 using the Structured Clinical Interviewfor the DSM-III-R Axis II (SCID-II). The diagnostic criteria underwentprincipal component analysis (PCA) in order to identify factorswhich could better describe the psychopathologic elements of the subjects.From the PCA 3 factors emerged related to borderline personalitydisorders, 5 to narcissistic personality disorders and 3 to paranoid301

personality disorders. The most frequent personality traits which betterdescribe the psychopathologic features of the individuals are:impulsive aggressiveness, lack of empathy, grandiose self-image, antisocialbehaviours and suspiciousness. Notably the most recurring factorsseem to describe individuals characterized by that pathologic conditiondefined malign narcissism by Kernberg. These individuals displayan antisocial behaviour, ego-syntonic sadism, impulsive aggressivenessand paranoid orientation and nevertheless can keep a senseof loyalty and a realistic view in the relationships. It is desirable thatfurther investigations focus on the individuation of dimensional criteriaeffective in describing the psychopathology and useful in planningpossible rehabilitative and therapeutic interventions for these individualscharacterized by a great clinical and diagnostic complexity.PO2.233.PSYCHOPATHOLOGICAL FEATURES ANDFREQUENCY OF PERSONALITY DISORDERSIN A SAMPLE OF IMPRISONED MINORSR. Sperandeo, D. Cantone, F. Palladino, N. Nascivera, E. Liberti,F. CatapanoDepartment of Psychiatry, University of Naples SUN,Naples, ItalyIn Italy, in the last 10 years, an increase in adolescents’ antisocialbehaviours and a change in the typology of crimes committed by adolescentshas been found. The need to evaluate the psychopathologicalaspects of adolescent criminals derives from that. Our study aims toevaluate the frequency of personality disorders (PD) in imprisonedminors and to detect specific psychopathological elements characterizingthe sample. It was conducted on 63 prisoners, with an averageage of 18 years, who received an average sentence of 597 days. Thepsychopathological evaluation was carried out by administering theStructured Clinical Interview for the DSM-III-R Axis II (SCID-II)and the State-Trait Anger Expression Inventory (STAXI). Moreover,data were collected on the typology and the modality of the criminalaction, on subject’s socio-cultural level and on the sentences. Themost frequently diagnosed personality disorders were paranoid(51%), antisocial (46%), borderline (43%) and narcissistic (36.5%).A strong comorbidity was present among the various PD. No significantcorrelations were found between the specific diagnoses and thescore on STAXI scales and the typology of committed crimes. Thehigh frequency found for more serious PD seems to show a role ofaxis II psychopathology in the genesis of adolescents’ criminal behaviours.The lack of correlation between personality diagnoses, typologyof crimes and styles of anger management seems to reflect the inefficiencyof DSM criteria for PD. This study shows the need for a clinicalmanagement of the imprisonment period and the organization ofrehabilitative modalities which take into account the psychopathologicalcharacteristics of these subjects.PO2.234.PSYCHIATRIC CHANGES IN PATIENTS WITHHYPERTHYROIDISMZ. Caparevic 1 , V. Diligenski 2 , N. Kostic 11 Department of Endocrinology and 2 Psychiatric Clinic, Dr.Dragisa Misovic-Dedinje Clinical-Hospital Centre, University ofBelgrade, Serbia and MontenegroThe aim of our study was to evaluate the psychiatric status in patientswith hyperthyroidism. We examined 126 patients with hyperthyroidismin stable remission by using a semistructured diagnosticinterview, the Minnesota Multiphasic Personality Inventory (MMPI)and the Hamilton Scales for Depression (HAMD) and Anxiety(HAMA). The mean T4 levels were 113.12±9.8 nmol/L, the meanTSH levels were 1.99±0.8 mU/L. 86% patients had anxiety, and 28%met DSM-IV-TR criteria for partial or complete panic disorder withor without agoraphobia. The most frequent symptoms were shortnessof breath (64%), trembling or shaking (38%), sweating (44%), fear ofdoing something uncontrolled (24%), excessive guilt (12%), andfatigue or loss of energy (86%). Depression with HAMD score morethan 17 was found in 42% of patients. The MMPI showed an elevationon Ha, D, and Pt scales. Psychotic decompensation was presentin 6% of patients.PO2.235.5-YEAR OUTCOME OF PHYSICIANS WITHSUBSTANCE USE DISORDERSM.S. Gold 1 , R. Pomm 2 , K. Frost-Pineda 11 Department of Psychiatry, College of Medicine, University ofFlorida, Gainesville, FL; 2 Physician Resource Recovery Network,Florida, USASubstance use disorders in physicians are a significant problem. Tounderstand whether treatment for addiction works, we reviewed 5-year data on all State of Florida physicians that were identified andreferred to the Impaired Practitioners Program for the State of Florida(PRN) by the Board of Medicine in 1995-1996. All were treated foraddictions at facilities throughout Florida and the US. Demographicinformation, drug history, psychiatric evaluation, and outcome measureswere gathered by chart review. 5-year outcomes were assessed byfacilitator reports, physician/psychiatrist evaluations, AlcoholicsAnonymous (AA) and Narcotics Anonymous (NA) attendance, returnto work and quantitative result of regular supervised urine testing. Thesample consisted of 68 physicians (59 males, 9 females), ages 25-63(mean 40.2±7.0). 32.4% of the sample had a history of intravenousdrug use, 11.8% had used crack and 7.4% had used both. Completedata for 5 years after inpatient treatment was analyzed and successfultreatment was defined by negative urine testing, positive facilitatorassessments, positive psychiatric assessment, 12-step meeting attendanceand full return to work. Coercion and voluntary treatment wereequally effective. Even among physicians who used crack, injecteddrugs, or both, more than 88% had negative drug tests, positive physicianassessment and returned to work. Prognosis is not dependent onlocation of treatment, type of drug treatment, particular drug of abuseor route of administration. Factors such as age of first use, duration ofuse, age of addiction, pre-addiction level of functioning, psychosocialskills, job coercion, drug monitoring, motivation, mandatory aftercareor co-morbid disease may have greater prognostic significance.PO2.236.A PILOT DRUG USE PREVENTION PROGRAMFOR HIGH SCHOOL STUDENTSL. Iliopoulou, V. Koutras, E. Fidi , S. Thomos, K. KomninouCounseling Center for Combating Drug Abuse, Ioannina, GreeceThe Counseling Center for Combating Drug Abuse of Ioannina hasplanned and implemented a pilot drug prevention program called“Black – White, the Book of Life” for high school students. The programwas carried out during the school year 2001–2002 and the studentscame from the third grade of high school of the prefecture ofIoannina. The program was implemented by two specialists from theCounseling Center, who met the students of each class and workedwith them in a group setting using cognitive, experiential and behaviouraltechniques. The meetings were incorporated in the annual302 World Psychiatry 3:S1 - October 2004

school curriculum and applied to all the students of each class. Themain directions of the program were the following: a) the reinforcementof individual and social skills, so that the children would be ableto develop a positive self-image, to improve communication and tofind the most functional process to cope with problems and difficulties;b) the active students’ participation in creative activities with collectivemind in order to help them develop positive attitudes in theirlives; c) the development of students’ responsibility and capability inorder to be able to make their own independent and assertive decisionsand express personal and collective opinions in the adults’world. The evaluation of the program showed that the vast majority ofthe students who attended the program considered it to be interestingboth with regard to its content and its procedure. The program helpedthem to develop personal and social skills very helpful in shapingtheir own attitude regarding drug use.PO2.237.A STABLE MEANINGFUL BELIEF ISREQUIRED FOR ADDICTION RECOVERYW.G. CampbellAddiction Centre/Philosophy of Psychiatry Group, Department ofPsychiatry, Faculty of Medicine, University of Calgary, CanadaIn order for addictive behavior to cease, the individuals’ subjectivebelief must be that addictive behavior will result in negative consequences.For stable recovery, this integrated meaningful mental statemust not be changed by other mental inputs or environmental factors.I propose that the recently conceptualized dynamic core model ofbrain function, hypothesized by Edelman and Tononi, allows anexplanation of the addicts’ varying perceptions of being-in-the-world.This model suggests that reasons for action are based on beliefs ormeaningful relationships similar to Jaspers’ phenomenology. In theaddict, maladaptive actions are suggested to be a consequence ofpathology at the level of the dynamic core, which itself is dependenton structure, development, learning, and past history or memory (sedimentation).It is proposed that a dynamic core defect explains theaddicts’ apparent intermittent belief that continued addictive behavioror action would not produce negative results. The reason for the volitionaldysfunctional action associated with addiction is because ofmaladaptive value-based lack of access to various memories or beliefsat the level of the dynamic core. Successful addiction treatment andrecovery must necessarily address the mental process that results inthe lack of formation and access to the beliefs, propositions or meaningfulmental states representing the concept that repeated addictivebehavior will result in negative consequences. This requires that thisdispositional state or belief, that addictive action will result in negativeconsequences, be continually present, accessible and stable.PO2.238.CO-OCCURRENCE OF ANXIETY DISORDERS ANDALCOHOLISMH. Kolbeinsson 1 , H. Oskarsson 2 , J.G. Stefansson 1 , E. Líndal 1 ,T. Thorgeirsson 3 , J. Gulcher 3 , K. Stefansson 31 Landspitali-University Hospital; 2 Therapeia; 3 deCode Genetics,Reykjavik, IcelandThis study aimed to investigate the co-morbidity of alcoholism(dependence and abuse) among subjects diagnosed with anxiety disorders.The study was based on the screening for anxiety and depressionin a population sample, followed by diagnostic work-up withthe computerized version of the Composite International DiagnosticInterview (CIDI). Of 2649 individuals who completed the CIDI,1234 (47%) were diagnosed with one or more anxiety disorders; 221with alcohol abuse (F10.1) and 383 with alcohol dependence(F10.2). Of 496 subjects diagnosed with alcoholism, one-third(p

pituitary-adrenocortical (HPA) axis in alcohol-dependent subjectstreated with naltrexone. Pharmacotherapy with naltrexone was accompaniedby elevated plasma concentrations of cortisol, which correlatednegatively with the level of alcohol craving. For discussion of this nexuswe would like to add additional data on cortisol plasma levels duringplacebo-controlled treatment with naltrexone and acamprosate. Atbaseline, two weeks after onset of withdrawal, plasma cortisol was elevatedin the total sample. In the placebo group, cortisol normalized byweek 12, as reported earlier by studies on HPA axis activation duringearly abstinence. However, in patients treated with both naltrexone andcombined medication, plasma cortisol remained elevated until terminationof treatment. In subjects treated with acamprosate a trendtowards elevated cortisol was also detectable. Additionally, baselineconcentration of both cortisol and adrenocorticotropin hormone(ACTH) predicted early relapse to renewed drinking. It might be speculatedwhether the efficacy of pharmacological anti-craving is related -at least in part - to the ability to activate the HPA axis.PO2.241.SCREENING OF ALCOHOL CONSUMPTIONAND BRIEF INTERVENTION AMONG DRUGUSERS IN TREATMENTN. Feldman, A. Chatton, P. Gache, M. Croquette KrokarDepartment of Psychiatry, University Hospitals of Geneva,SwitzerlandThe aims of this research is double: a) screening of alcohol consumptionamong drug users in treatment measured with AUDIT (AlcoholUse Disorders Identification Test), a standardized questionnairedeveloped by the World Health Organization; b) evaluation of theeffectiveness of brief intervention for hazardous and harmful drinkingamong drug users with a randomised controlled trial. The screeningwas carried out in 215 adult outpatients from the drug addiction unitof the Department of Psychiatry, University Hospitals of Geneva. Thequestionnaire was administered as an interview by different professionals(psychiatrists, nurses, psychologists and social workers)between November 2003 and June 2004. Patients with an AUDITscore of 7 or more were randomised in two groups: a) brief intervention(BI) during the regular program of treatment, applied by professionalstrained by a workshop; b) only regular program (C). Monitoringwith AUDIT was used to evaluate scores after 3 and 6 months inthe two groups. The prevalence of alcohol problems among drugusers in treatment is higher (39%). Three months later, the AUDITscore decreased significantly in the BI and C groups, mainly in hazardousdrinking.PO2.242.GENDER, CULTURE AND PATTERNSOF ALCOHOL USE IN BRAZIL. THE GENACIS STUDYF. Kerr-Corrêa 1 , A.F. Sanches 1 , L.A. Trinca 2 , I. Dalben 2 ,M.C.P. Lima 11 Department of Neurology and Psychiatry; 2 Department ofBiostatistics; 3 Department of Public Health, UNESP, BotucatuMedical School, Botucatu, Sao Paulo, BrazilThis is a preliminary analysis of the Brazilian data of the GENACIS(Gender, Alcohol International Study), a multinational study aimedat comparing patterns of alcohol use/abuse between men andwomen. Results from the first 525 interview showed that men,younger and single, drink more, while abstinence is more frequent inwomen (76.4% vs. 40.7%). Heavier drinkers (at least 6 drinks perday, one drink=12 g ethanol), were mostly married/living-togetherwith people who also drank heavily; they found it easier to talk aboutfeelings, and found sexual activities more pleasurable when drinking(p

tively. Discrimination between alcohol-dependent individuals andsocial drinkers, as measured by the areas under the ROC curves, wassignificantly better for %CDT than for GGT and MCV (p=0.006 andp=0.0001, respectively). Thus, CDT seems to be the most reliable laboratorymarker for chronic alcohol consumption, and it may providea useful contribution to the objective detection of alcohol-dependentindividuals.PO2.245.FUNCTIONAL POLYMORPHISMS OF THEALCOHOL-METABOLISM GENES ANDASSOCIATIONS WITH THE RISK OF ALCOHOLISMIN THE KOREAN POPULATIONI.-G. Choi 1 , H.-G. Son 1 , B.K. Son 1 , B.-H. Yang 2 , S.H. Kim 2 ,B.-S. Kee 3 , J.-S. Lee 4 , Y.-G. Chai 5 , H.D. Shin 61 Hallym University College of Medicine, Seoul; 2 HanyangUniversity College of Medicine, Seoul; 3 Chung-Ang UniversityCollege of Medicine, Seoul; 4 Kwandong University College ofMedicine, Goyang; 5 Hanyang University College of Sciences,Ansan; 6 SNP Genetics Inc., Seoul, KoreaAlcoholism is a multifactorial, polygenic disorder involving complexgene-gene and gene-environment interactions. Alcohol metabolismcould significantly be influenced by genetic polymorphisms in alcohol-metabolismgenes, which are believed to affect drinking behaviorand development of alcoholism. In order to identify the associationbetween the polymorphisms of genes encoding alcohol metabolizingenzymes and alcoholism, the sixteen genetic polymorphisms in alcoholdehydrogenase 2 (ADH2), alcohol dehydrogenase 3 (ADH3) andaldehyde dehydrogenase 2 (ALDH2) were studied in 106 male Koreanalcoholics and 116 non-alcoholic controls. Five common haplotypes(Freq. >0.05) were constructed by single neuclotide polymorphisms(SNPs) in ADH2 and ADH3, which were on chromosome4q22, 15.5kb apart each other. By statistical analysis, strong associationswere found between ADH2, ADH3 and ALDH3 polymorphisms(SNPs and haplotypes) and alcoholism, as anticipated(p=0.00000007-0.05). Further statistical attempts to analyze thegenetic effects of two linked ADH genes were performed. The magnitudeof risk of alcoholism and significance of associations were likelydecreased along with the distances from ADH2-R48H, which causedamino acid change from arginine to histidine. In conclusion, thegenetic association of ADH3 polymorphisms could be suggested astracking effects of nearby ADH2-R48H. The information derivedfrom this study could be valuable to estimate the risk of alcoholismand facilitate another investigation in other ethnic groups.PO2.246.TREATMENT OF INTRAVENOUS BUPRENORPHINEDEPENDENCE: A RANDOMIZED CLINICAL TRIALJ. Ahmadi, H. Farrashbandi, M. Ahmadi, N. AhmadiUniversity of Medical Sciences, Shiraz, IranThe study aimed to characterize intravenous buprenorphine-dependentpatients with respect to socio-demographic and other backgroundfeatures, and to assess the effect of a 40 mg/day oral dose ofmethadone in the maintenance treatment of intravenous buprenorphinedependence in comparison with a 4 mg/day sublingual dose ofbuprenorphine over a 12-week treatment period. As a secondaryobjective, the results were determined concurrently for subjects treatedwith a 0.4 mg/day oral dose of clonidine. One hundred and eightintravenous buprenorphine-dependent patients who met the DSM-IV criteria for opioid dependence and were seeking treatment wererandomly allocated to three groups, receiving respectively 40 mg oralmethadone tablet, or 4 mg sublingual buprenorphine tablet, or 0.4 mgoral clonidine tablet, and were treated in an outpatient clinic in theyear 2002. The mean age was 29.4 years (range 19-46). The majority(76.8%) was between 20 and 34 years of age. The educational level ofmost of them (82.4%) was between 6 and 12 years of study. Themajority (86.1%) had a history of opium or heroin dependency beforethey were introduced to intravenous buprenorphine. The main sourceof buprenorphine for misusers was street sale (93.5%). The meanduration of buprenorphine dependence was 1.8 years and the meandose per day was 4.6 ampoules (1 ampoule contains 0.3 mg ofbuprenorphine in 1 ml). Overall, 55 (50.9%) of the patients completedthe 12-week study. Completion rates by groups were 83.3% for themethadone group, 58.3% for the buprenorphine group and 11.1% forthe clonidine group (p=0.0001). Retention in the methadone groupwas significantly better than the buprenorphine group (p=0.020) andthe clonidine group (p=0.0001). Retention in the buprenorphinegroup was significantly better than the clonidine group (p=0.0001).The results support the efficacy and safety of oral methadone and sublingualbuprenorphine tablets for injection buprenorphine-dependentpatients.PO2.247.EFFECTS OF ADDITIONAL DOSES OFBUPRENORPHINE IN OPIOID DEPENDENTSUBJECTS ON BUPRENORPHINE MAINTENANCEA. Singhal 1 , B.M. Tripathi 2 , P. Hemraj 1 , R. Jena 11 Department of Psychiatry, All India Institute of MedicalSciences, New Delhi, India; 2 Manchester Royal Infirmary,Manchester, UKBuprenorphine maintenance is an effective treatment for opioiddependence and is used in many countries. The subjects maintainedon this drug often abuse it. Effects of additional doses of buprenorphine,on and above maintenance dose, on subjective experiencesand psychomotor performance were assessed in 19 male subjectswho were maintained on buprenorphine 4 mg sublingually daily forat least 1 month. An additional dose of buprenorphine 2 mg sublinguallywas given at 2 hourly interval up to a maximum of 10 mg.Subjective effects and psychomotor performance were assessed 2hours after each dose. If a subject became drowsy or was unable toparticipate in assessments, the experiment was terminated. Instrumentsused were Digit Symbol Substitution Test, Digit Span,Delayed Recall and Trail Making for psychomotor performance, andMorphine Benzedrine Group Scale, Pentobarbital ChlorpromazineAlcohol Group Scale, Visual Analogue Scale and Modified SingleDose Opiate Questionnaire for subjective effects of the drug. Nosubject consumed substances other than prescribed medication asconfirmed by urine examination. Performance of subjects on DigitSymbol Substitution Test and Trail Making Test improved consistentlywith each assessment. Digit Span Test and Delayed Recallwere not significantly affected. Subjective effects, dysphoria andsleepiness increased and euphoria and drug liking decreased withadditional doses of buprenorphine, which was maximum at thehighest cumulative dose. Improvement in psychomotor performancestands out in contrast to most of the earlier studies. Thisimprovement in psychomotor function may be the effect ofbuprenorphine itself, inadequate buprenorphine maintenance dose,learning, or a combination of these.305

PO2.248.INHALANT USE AMONG CHILDREN ANDADOLESCENTS: PSYCHOSOCIAL ANDELECTROPHYSIOLOGICAL CORRELATESK. Todadze, M. Zakaraia, D. Mikeladze, G. LejavaResearch Institute on Drug Addiction, Tbilisi, GeorgiaThe number of children and adolescents using inhalants hasincreased in Georgia in recent years. The aim of this study was toexplore the psychosocial and electrophysiological correlates ofinhalant use among children and adolescents in Tbilisi. 62 subjectswith age from 10 to 15 were studied; among them 44 were inhalantusers. The personal and family history, drug use motivations, personality,cognitive characteristics and EEG were investigated. The importantcontribution of several factors was shown in the development ofsolvent abuse and dependence: high level of anxiety, extreme economicdeprivation and homelessness; antisocial behavior (begging,prostitution, theft); association with inhalant-using peers; parentalantisocial behavior, drug and alcohol use. The frequency and durationof inhalant use was highly correlated with cognitive, behavioral,personality and EEG changes.PO2.249.TREATMENT OF CIGARETTE SMOKING BYCLONIDINE, NICOTINE GUM AND NALTREXONEY. Kalafi, J. Ahmadi, M. Mohagheghzadeh, T. Hidari, N. AhmadiUniversity of Medical Sciences, Shiraz, IranThe study aimed to test the efficacy and safety of clonidine, nicotinegum, and naltrexone, in the treatment of cigarette smoking. It was arandomized trial. We recruited 171 subjects who met DSM-IV criteriafor nicotine dependence and smoked 10 cigarettes or more each day.The interventions consisted of twelve weeks of nicotine gum, clonidineor naltrexone. The nicotine gum dose was 2 mg every 1 to 2hours for the first 6 weeks, 2 mg every 2 to 4 hours for the next 3weeks, and 2 mg every 4 to 8 hours for the remaining 3 weeks. Theclonidine dose was 0.4 mg and the naltrexone dose was 50 mg perday. Continuous abstinent rates were recorded weekly up to 12 weeksfrom the quit date. The mean age of the nicotine-dependent patientswas 37.7±10.1 years (range 17 to 64). The mean duration of smokingwas 12.4 years and the mean number of smoked cigarettes per daywas 19.9. The abstinence rates by treatment groups were 43.9% forthe nicotine gum group, 24.6% for the clonidine group and 7.0% forthe naltrexone group (p=0.0001). Abstinence rate in the nicotine gumgroup was significantly better than in the clonidine group (p=0.03)and the naltrexone group (p=0.0001). Abstinence rate in the clonidinegroup was significantly better than the naltrexone group(p=0.01). These results support the efficacy and safety of nicotine gumand clonidine for smoking relapse prevention for Iranian nicotinedependentpatients, but call into question the utility of naltrexonetreatment for smoking relapse prevention.PO2.250.TREATMENT SUCCESS RATE AMONGOPIOID DEPENDENTS IN SHIRAZ, IRANY. Kalafi, J. Ahmadi, F. MotamedUniversity of Medical Sciences, Shiraz, IranThe goal of this study was to assess the characteristics and treatmentsuccess rate (outcome) among Iranian opioid addicts. The data weregathered from 437 opioid addicts (using DSM-IV criteria) seekingtreatment and referred to the Shiraz Self-Identified Addict Center affiliatedto the Fars Welfare Organisation in 1998. Their mean age was35.6 years, and 72.8% were married. Of these subjects 34.1% listedsecondary school, 25.9% primary school, and 23.6% high school astheir level of education. Of these addicts 26.1% were unemployed,24.5% workers and 22.4% drivers. About 49.4% reported opium,31.8% heroin, 12.4% cooked dross and 6.4% reported other opioidsas the substance currently used. Of the 437 addicts, the majority (54%)did not complete detoxification phase, 35% had experienced abstinenceat least for 3 months and 11% relapsed before 3 months of abstinencebeing completed. The relation was statistically significantbetween outcome and type and dose of used opioid. During the lastyears, some demographic characteristics of the Iranian addicts havechanged. Cultural attitudes toward drug use are quite likely to affecttypes and amount of use and also outcome of treatment. These findingscan be considered when planning preventive and therapeutic programs.PO2.251.CONSULTATION PROGRAMS: A STRATEGY OFPRIMARY PREVENTION OF DRUG ABUSEFOCUSING ON FAMILY RELATIONSHIPSL. Iliopoulou, V. Koutras, K. Komninou, S. Thomos, E. FidiCounseling Centre for Combating Drug Abuse, Ioannina, GreeceThe Counseling Centre for Combating Drug Abuse of Ioannina is currentlyapplying consultation programs for high school students withinthe scope of primary prevention programs. The aim of these programsis to help students to cope with their psychosocial problems asthey occur. One of the most frequent and important problems forwhich students express request for help regards family relationships.The students seeking help come not only from families with problemsin their structure but in their majority from families which appear tobe united. But these “united” families actually have serious problemsin communication (negative criticism, blames, lack of praise, doublemessages), in relationships (difficult and distant relations regardingthe father, lack of affection and competition regarding the mother), inaspects of control (strictness, which regards more the girls, inconsistency),as well as problems with alcoholism in parents. The aim of ourintervention is to support the child and reinforce his/her skills inorder to be able to cope with family problems. We expect that throughthe personal change some improvement be achieved in the familyenvironment. The evaluation shows that regarding family problemsthe students who apply to the programs, in their vast majority, areprovided considerable help. These students are also receiving importanthelp regarding other psychosocial problems, such as anxiety, difficultiesin peer-relationships and academy failure.PO2.252.A MODIFICATION OF THE RAPID OPIATEDETOXIFICATION METHODS. AlcazInstitute of Addictive Diseases, Belgrade, Serbia and MontenegroThe paper describes a modification of the rapid opiate detoxification.A total of 45 patients, aged 18-45, addicted from one to 10 years, weretreated. They were all heroin addicts. Premedication included administeringclonidine and anxiolytics, while naltrexone was used to precipitatethe abstinence syndrome. Modification consisted in applyingtramadol at the appearance of the first signs of abstinence syndrome.Tramadol significantly reduced the severity and duration of the precipitatedabstinence syndrome. Nausea, vomiting, restlessness as wellas a confused and delirious state were manifest, lasting an average of306 World Psychiatry 3:S1 - October 2004

four hours. Symptomatic therapy was used to treat these symptoms:anxiolytics (lorazepam, midazolam), nonsteroidal antirheumatics,metoclopramide, dicyclomine, clonidine and phenergane. Subsequently,the patients were practically rid of the symptoms, apart fromweakness and slight leg pain. The next dose of naltrexone (secondday of detoxification) did not lead to precipitation of the abstinencesyndrome. The patients were practically detoxified and ready for discharge.They experienced nearly full amnesia of the detoxificationperiod. The detoxification process was 100 percent successful.PO2.253.PSYCHIATRIC COMORBIDITY IN CHILDRENWITH SUBSTANCE ABUSEI. ŠkodácekDepartment of Child Psychiatry, University of Comenius,Bratislava, Slovak RepublicWe studied 97 children with various types of substance abuse. Theprevalence of attention-deficit/hyperactivity disorder (ADHD) was12.2% (higher than the usually reported prevalence of 3-9%). ADHDwas the third most frequent psychiatric comorbid condition, afterconduct disorder and mental retardation. 43% of the children hadsuffered from emotional deprivation, 18.6 from physical abuse. 15.2%of the children reported they hated their family environment; 49.4%of the children had a negative attitude to their tutor.PO2.254.PARALLELS AND DIFFERENCES IN THETREATMENT OF ALCOHOLISM BETWEENITALY AND GERMANY: CLINICAL, SOCIALAND INTERCULTURAL ASPECTS OF QUALITYASSURANCEI. Hinnenthal 1 , M. Cibin 2 , G.C. Ardissone 11 Service for Drug Abuse, Imperia; 2 Service for Drug Abuse,Dolo/Mirano, ItalyItaly is a traditionally family oriented, catholic country with aMediterranean lifestyle of drinking every day a moderate dose ofwine. For alcoholic patients, the latency before getting to treatment islong and when the patient gets into treatment his physical conditionsare usually very bad. The working situation deteriorates later. In Germany,it is socially tolerated to drink mainly beer in public situations,even getting drunk. However, manifest addiction is socially not toleratedat all: an addicted patient will lose much quicker his work andfamily. The latency to get into treatment is shorter, and physicalaspects are less dramatic. The consequences of these facts on therapyand development of addiction services are discussed.PO2.255.LAY PREFERENCES CONCERNING TREATMENT OFALCOHOL DEPENDENCE IN SÃO PAULO, BRAZILE.T.P. Peluso, S.L. BlayDepartment of Psychiatry, UNIFESP, São Paulo, BrazilThis study aimed to evaluate community preferences concerning thetreatment of alcohol dependence. A household survey was carriedout with a representative sample of residents of São Paulo city, aged18-65 years. A vignette depicting a person suffering from alcoholdependence was presented to 500 respondents. They were given a listof ten sources of help and a list of seventeen intervention options andasked to rate them as helpful or harmful. Next, they were asked toselect a first choice of help and the intervention option they consideredthe most helpful. The sources of help most often rated as helpfulwere self-help groups (96%), counselor/psychologist (95%) and closefamily (87%). Medical professionals were considered less often helpful.When asked to select the first choice of help, the public choseself-help groups (31%), close family (29%) and a counselor/psychologist(12%). The interventions most often rated as helpful were counseling(96%), “to keep the mind busy” (96%) and to improve eatinghabits (94%). Medical treatments like taking medicines and hospitalizationwere considered more harmful than helpful. When asked toselect the intervention considered the most helpful, the public chosecounseling (36%), to practice physical exercises (15%) and “to keepthe mind busy” (14%). In conclusion, lay support systems and interventionswere more often recommended than professional ones totreat alcohol dependence in São Paulo, Brazil.PO2.256.THE THERAPEUTIC ROLE OF THE COMMUNITYIN ALCOHOLISMF. Priftis, L. Iliopoulou, S. Kyprianos, A. FotiadouDepartment of Psychiatry, G. Hadzikosta General Hospital,Ioannina, GreeceThe role of community support is considered extremely important forthe help of the alcoholic patient in primary, secondary and especiallytertiary prevention. We studied 860 persons who came to our hospitalin the years 2000-2002 (580 men and 280 women). 25% of the menand 5% of the women had alcohol-related problems. 40% of allpatients had good social support (supporting family and non-drinkingfriends). 70% of patients in the group with good social supportand 20% of those in the group with poor social support had a 2-yearabstinence after treatment. The need for various interventions for secondarypreventions (centres with trained personnel and with liaisonwith other health services; special groups in the community) and tertiaryprevention (interventions in families, support group for families,organizations of patients) of alcoholism is emphasized.PO2.257.PREVALENCE OF PSYCHOLOGICAL TRAUMAAND POST-TRAUMATIC STRESS DISORDERIN A METHADONE MAINTENANCE CLINICG. AcuñaJosé Horwitz Institute of Psychiatry, Santiago, ChileThe association between psychological trauma, post-traumatic stressdisorder (PTSD) and substance use disorders (SUD) has been welldocumented across different community samples and treatment-seekingpopulations. The presence of this PTSD-SUD comorbidity mayhinder treatment outcomes. Different pathways may account for thisdual diagnosis. The most plausible one is the self-medication hypothesis.This was a cross-sectional study. A self-report questionnaire wasused to measure the prevalence of trauma and PTSD amongst a populationof 102 opiate dependent people receiving opiate substitution ina methadone clinic placed in South London. Point prevalence ofPTSD was 54.9%. Women with PTSD were seven times more likely toinject than the rest of female subjects. Women appeared to be a particularlyvulnerable group for sex-related traumas and higher severity andfrequency of PTSD symptoms. This study showed that PTSD is a frequentcomorbidity among methadone users. It also evidenced thatPTSD is associated with drug taking behaviour. Due to its high frequency,PTSD should be assessed routinely in methadone users. Finally,this study gives some support for the self-medication hypothesis.307

PO2.258.COMORBIDITY OF PSYCHOSIS AND SUBSTANCEMISUSE IN THE IRISH PRISON POPULATIONS. Monks, K. Curtin, B. Wright, D. Duffy, S. Linehan, H. KennedyNational Forensic Psychiatry Service, Central Mental Hospital,Dublin, IrelandThe study aimed to estimate the prevalence of comorbid psychotic illnessand substance misuse in the Irish prison population. A survey ofIrish prisons was conducted in three phases: phase 1 sampled 15% ofthe sentenced population in 16 centres in the jurisdiction (n=438);phase 2 sampled a cross section of the remand population in 6 centres(n=235); phase 3 (in progress) is an incident survey of remand andsentenced prisoners in Dublin seen within 48 hours of committal(n=408 at time of writing). The Schedule for Affective Disorder andSchizophrenia - Lifetime Version (SADS-L) was used to generateICD-10 diagnoses of mental disorder. The severity of dependencequestionnaire and individual substance use histories were used toquantify substance use disorders. The lifetime prevalence of psychosiswas high across the entire sample: phase one 4.5%, phase two 11.1%,phase three 6.4%. For those with a lifetime diagnosis of psychosis(n=72), the rates of comorbid lifetime substance misuse was high(79.2%). Rates of substance misuse were higher in inmates with psychosisin phase 1 (90% vs. 84%) and phase 3 (90% vs. 84%) thanthose with no history of psychosis. The reverse was true for phase 2psychotic inmates (77% vs. 82%). High rates of comorbidity raiseissues over diagnosis of psychosis in prisons. The lower rate in theremand population may represent a different pathway to psychiatriccare for these individuals.PO2.259.TOBACCO SMOKING: A PREVALENCE STUDYIN ELDERLY PEOPLE IN THE COMMUNITYV. Marinho, S.L. Blay, S.B. Andreoli, F.L. GastalDepartment of Psychiatry, UNIFESP, São Paulo, BrazilThe study aimed to evaluate the prevalence of smoking in elderlypeople living in urban areas of Rio Grande do Sul, Brazil. In a crosssectionaldesign, a representative sample of 6963 subjects, aged 60years and over, was examined. All subjects were personally interviewed.A questionnaire administered during home visits inquiredabout current tobacco use and sociodemographic characteristics.The prevalence of tobacco use was 28.9% among men and 13.5%among women. Several variables were strongly related to tobaccouse: less educated men, non-white, lower income and divorced orwidowed. Non-whites and non-evangelic were 2.1 fold more likelyto be a smoker than the other subjects (95% CI 1.2-3.7). In conclusion,the use of tobacco in the studied population is more frequentin men than in women in a proportion of 2:1. The findings presentedhere indicate the potential of some sociodemographic variablesto increase the risk of tobacco use.PO2.260.TREATMENT OF HEROIN DEPENDENCEJ. Ahmadi, H. Farrashbandi, M. Babaee, M. Mohagheghzadeh,J. Porter, G. DehbozorgiDepartment of Psychiatry, Hafez Hospital, Shiraz, IranWe tested the efficacy of naltrexone, methadone and buprenorphineover a treatment period of 12 weeks. Subjects were randomized toreceive the three drugs in a comparative study. We recruited 93 heroin-dependentmales who met the DSM-IV criteria for heroin dependenceand were seeking treatment. Subjects received methadone (31patients), or buprenorphine (31 patients), or naltrexone (31 patients)in 2001 and 2002. There was no significant difference in mean age inthe three groups. The majority (58%) was between 25 and 34 years ofage. The educational level of most of them (68.8%) was between 6and 12 years of study. The mean dose of heroin use per day was 1.9 g,and the mean duration of current heroin use was 2.8 years. Daysretained in treatment were measured. Completion rates were 93.5%for the methadone group, 67.7% for the buprenorphine group, and41.9% for the naltrexone group (p=0.0001). Retention in the 60 mgmethadone group was significantly better than in the 6 mg buprenorphinegroup (p=0.01) and in the 50 mg naltrexone group (p=0.0001).In the buprenorphine group, it was significantly better than in the naltrexonegroup (p=0.04).PO2.261.PLASMA DOPAMINE LEVELS IN HEROIN ADDICTSA. Spasovska-Trajanovska, L. IgnjatovaPsychiatric Hospital, Skopje, Republic of MacedoniaDopamine (DA) is commonly considered the most important neurotransmitterinvolved in reward systems, whose role in heroin abuse hasbeen repeatedly reported. The aim of this study was to compare plasmaDA levels between heroin addicts and healthy controls. We included30 male heroin abusers (who reported illicit heroin use for morethan 3 years) and 30 male students of the Faculty of Medicine withouta history of drug abuse. All subjects were in good health from the physicalviewpoint. Plasma DA was determined by high-performance liquidchromatography with electrochemical detection (HPLC-ECD).Plasma DA levels were 110.5±10.4 pg/ml among heroin addicts and30.2±4.6 pg/ml among controls, a highly significant difference.PO2.262.ANTIBODIES TO BRAIN-SPECIFIC S-100PROTEIN IN PATIENTS WITH ALCOHOLISMTREATED WITH PROPROTENT.P. Vetlugina 1 , S.A. Ivanova 1 , N.A. Bokhan 1 , S.A. Sergeyeva 2 ,O.I. Epstein 21 Mental Health Research Institute, Tomsk; 2 Materia MedicaHolding, Moscow, RussiaThe aim of the investigation was to study the influence of proproten,a preparation containing antibodies to brain-specific S-100 protein inultralow doses, on the dynamics of natural antibodies to S-100 proteinin patients receiving therapy for post-abstinent disorders. 55patients with alcoholism were examined. Patients were divided intotwo groups: the first (n=30) received traditional therapy, the second(n=25) received monotherapy with proproten. Therapy of post-abstinentstate was conducted after stopping the acute manifestations ofthe withdrawal syndrome. Antibodies to brain-specific S-100 proteinin blood serum were assessed before and after the therapy by immunoenzymaticanalysis. Before the beginning of the therapy, the level ofnatural antibodies to S-100 was 1.28±0.09 conventional units. Weobserved an increase to 1.68±0.20 conventional units (p

PO2.263.INFLUENCE OF ANAR ON HOMEOSTATICSYSTEMS OF PATIENTS WITH OPIOID ABUSE INTHE PROCESS OF THERAPYS.A. Ivanova 1 , T.P. Vetlugina 1 , N.A. Bokhan 1 , E.V. Guseva 1 ,O.A. Lobachyova 1 , S.A. Sergeyeva 2 , O.I. Epstein 21 Mental Health Research Institute, Tomsk; 2 Materia MedicaHolding, Moscow, RussiaThe investigation of new effective and safe medicines for treatment ofpatients with drug abuse is currently topical. We studied the effects ofanar, a preparation containing antibodies to morphine in ultralowdoses, on indices of the immune, neuromediator and hormonal systemsin patients with opioid abuse. Therapy with anar was conductedby patients with opioid abuse after stopping the acute manifestationsof the withdrawal syndrome. Patients were divided into those with afast reduction of post-abstinent disorders (up to 10 days) (19 persons)and those with a protracted reduction (9 persons). Immunobiologicaltests were performed at the beginning and at the end of the therapy.We found a decrease of lymphocytes carrying receptors for serotoninand an increase of the number of cytotoxic killer/suppressors inpatients with a fast reduction of post-abstinent disorders in theprocess of the therapy. The dynamics of cortisol concentration wasdifferent: a decrease of serum cortisol levels was observed in thegroup with fast reduction of post-abstinent disorders and an increasein the group with protracted reduction. In conclusion, the use of anarin the therapy of opioid abuse exerts a positive impact on indices ofbasic homeostatic systems of the organism.PO3.OLD AGE, CONSULTATION-LIAISON AND FORENSICPSYCHIATRY; PSYCHIATRIC SERVICES;PSYCHOTHERAPIESPO3.1.NEUROPSYCHOLOGICAL MEASURES TODISTINGUISH MILD COGNITIVE IMPAIRMENTFROM NORMAL AGINGP. Antuono 1 , J. Jones 1 , S.J. Li 2 , M. Franczak 1 , T. Hammeke 11 Department of Neurology, 2 Department of Biophysics, MedicalCollege of Wisconsin, Milwaukee, WI, USAMild cognitive impairment (MCI), a transitional state between normalaging and early dementia, is becoming increasingly recognized asa risk factor for Alzheimer’s disease (AD). This study aimed todescribe the baseline characteristics of patients with MCI and normalcontrols recruited for participation in a longitudinal study evaluatinga functional MRI index as a preclinical marker for AD. 50 patientswith amnestic MCI and 46 cognitively normal elderly controls wereevaluated. All subjects were ≥ 65 years old, had a normal neurologicalexamination, and a Mini-Mental State Examination (MMSE) score ≥24. MCI subjects had a Clinical Dementia Rating (CDR) of 0.5, andcontrols had a CDR of 0. No significant differences in reading level,constructional praxis, or executive function (Trails A, Trails B) werenoted between MCI subjects and controls. Normal controls performedslightly but significantly better than MCI subjects on SymbolDigit Modalities (p=0.028), Digit Span Backwards (p=0.002), andBoston Naming (p=0.009). MCI subjects performed significant worsethan controls on all tests of learning and recall. The Rey Auditory VerbalLearning Test (RAVLT) was particularly sensitive to differences inmemory performance, with MCI subjects performing worse on totallearning (p

cessful in all centrum semiovale and occipital regions in AD and controlsubjects. Acquiring proton spectra from temporal lobes wasunsuccessful due to the voxel localization problems connected withbrain atrophy in this region. In conclusion, in DLB patients 1H-MRSexamination is feasible but there are difficulties in scanning patientsdue to tremor and uncooperativeness. In DLB and AD subjects thereare difficulties in acquiring proton spectra from temporal lobes in thelater stages of the illness due to uncooperativeness and the degree ofbrain atrophy. 1H-MRS is feasible in DLB patients early in the courseof dementia.PO3.4.POSSIBLE ROLE OF SEROTONIN TRANSPORTERGENE IN ALZHEIMER'S DISEASE AND OTHERDEMENTIAS: A PILOT STUDYC. Lorenzi 1,2 , A. Serretti 1 , P. Artioli 1 , A. Pirovano 1 ,D. De Ronchi 2 , M. Catalano 1 , E. Smeraldi 11 Department of Psychiatry, Vita-Salute University, San RaffaeleInstitute, Milan; 2 Department of Psychiatry, University ofBologna, ItalyAlzheimer's disease (AD) is a major cause of disability in the elderly.Genetics could play an important role in AD and in otherdementias. In addition to mutations in amyloid precursor, presenilin-1,presenilin-2 and apolipoprotein E, also serotonergic systemseems to be implicated in AD and other dementias. The brain serotonintransporter (SERT), besides being the principal site of actionof selective serotonin reuptake inhibitors (SSRI), could to beinvolved in neurodegenerative mental diseases. Several studiestried to validate an association between the 44-bp insertion/deletion(long/short) polymorphism within the promoter of SERT gene(SERTPR) and AD, independently from apolipoprotein E genotype,but the result was not univocal. Therefore, we performed apilot study to test the association between SERT polymorphismand AD or vascular dementia. We compared a sample of 34patients with dementia (female/male 24/10; age 66.56±4.83), 14with AD and 20 with vascular dementia, to 64 healthy controls,matched for sex and age (female/male 31/23; age 78.33±8.03). Nosignificant difference between the SERTPR polymorphism distributionswas found, comparing demented patients and healthy controls,even analysing the two diagnostic subgroups separately. Wedetected a higher frequency of the short/short genotype among elderlypatients and controls (F=32.40; df=2; p

PO3.7.EPIDEMIOLOGY OF LATE-LIFE MENTALDISORDERS IN COMMUNITY SUBJECTS: THE ROLEOF SOCIAL AND DEMOGRAPHIC FACTORSS.L. Blay, S.B. Andreoli, F.L. GastalDepartment of Psychiatry, UNIFESP, São Paulo, BrazilThe aim of this study was to assess the prevalence of mental distressin the elderly living in the community and the role of socio-demographicfactors. In a cross sectional design, a representative sample of7000 subjects aged at least 60 years was examined. All subjects werepersonally interviewed. A validated reduced version of the Short PsychiatricEvaluation Schedule, among other questionnaires, was usedto detect mental distress. Adjusted prevalence estimates were calculatedaccording to the coefficients obtained in the validity study. Theestimated prevalence of mental distress was 18%. A logistic regressionindicated that women, non-white, less educated, unmarried, livingin the rural areas were significantly more likely to have mental distress.Odds ratio ranged from 1.3 (95% CI 1.1-1.4) for ethnicity (non-Caucasians) to 1.9 (95% CI 1.7-2.1) for education (less educated).Unexpectedly, low income and higher age had no relation to psychiatricmorbidity. The data indicate the potential for gender, ethnicity,marital status, education and rural areas to substantially increase therisk of mental morbidity in older subjects living in the community.PO3.8.LAY BELIEFS ABOUT THE CAUSESAND PROGNOSIS OF DEMENTIAS.L. Blay, E.T.P. PelusoDepartment of Psychiatry, UNIFESP, São Paulo, BrazilThe aim of this study was to assess the public’s beliefs about the causesand prognosis of dementia. A representative city sample of individualsaged 18 to 65 years was interviewed in Sao Paulo, Brazil. A vignettedepicting a case of dementia was presented to 500 respondents, whowere asked to rate a 18-item list of causal agents and to choose the mostimportant item related to the cause of the disorder and to evaluate itsprognosis. When the 18 items were proposed, the five leading causes,according to the respondents, were ‘drug abuse’ (93%); ‘head injury’(90%); ‘isolation’ (89%); ‘disorder of the brain’ (89%); ‘important lifeevent’ (89%). The two most important causes of dementia werethought to be ‘isolation’ (29%) and ‘drug abuse’ (19%). 94.6% of thepublic considered that dementia had partial or total remission whenproperly treated. The beliefs of general public about the causes andprognosis of dementia differ from those accepted by psychiatricexperts. This discrepancy may lead to a lack of willingness to searchhelp from mental health professionals.PO3.9.PARANOIA AND GERIATRIC PSYCHIATRYR. Krsteska, V. VelkovPsychiatric Hospital, Skopje, Republic of MacedoniaEstimates of the incidence and prevalence of delusional disorder inthe contemporary literature support the clinical impression that thiscondition is less common than mood disorders or schizophrenia.However, it is not rare. Psychiatrists who work in the field of psychogeriatricsmay be more likely to encounter patients with delusionaldisorder. In our department of psychogeriatrics, in the last 4 years,we have diagnosed 15 cases of delusional disorder. All these patientswere over 65 years; 14 of them were male. All hospitalizations werecompulsory. In most cases, cognitive impairment co-occurred. Aftermany years of dysfunctional marital and family relationships, the newsituation of cognitive impairment and the inability to take care ofthemselves produced intolerance by their wives, who insisted for hospitalization.Our conclusion was that hospitalization of patients withdelusional disorder in old age is related to cognitive impairment morethan clinical phenomenology. Patients were treated with risperidone,at the average dose of 2 mg/day. Although the clinical pictureimproved in most cases, there was an impressive resistance by thefamily to accept the patient at home.PO3.10.MANAGEMENT OF AGITATION IN ELDERLYPATIENTSD.C. Domocos, A.M. DomocosAna Aslan National Institute of Gerontology and Geriatrics,Bucharest, RomaniaAgitation encompasses a range of behaviors, from verbally nonaggressiveoutbursts to physical assaults. Agitation is commonly associatedwith dementia, but, often, what appears to be agitated behaviormay be the patient's way of expressing needs he cannot communicateverbally. Agitation may generate feelings of frustration, fear and helplessnessin both the patients and caregivers. In addressing agitation inthe elderly, it is first of all essential to carry out a careful diagnosticevaluation for medical conditions, psychiatric illness, and social orenvironmental disturbances that can underlie behavioral disturbances.The treatment of behavioral symptoms is complex and difficult.Both non-pharmacological and pharmacological interventionmay be required. The goals of the treatment are: improving the qualityof life, reducing the stress and suffering as well as increasing thecomfort and safety of patients and caregivers.PO3.11.EXCESSIVE DAYTIME SOMNOLENCEAND HYPNOTIC USE IN THE ELDERLYJ.C. Souza 1 , L.A. Magna 2 , T.H. Paula 11 Catholic Dom Bosco University, Campo Grande; 2 StateUniversity of Campinas, BrazilA group of 148 elderly residents of a continued-care institution wasinterviewed by means of a structured questionnaire and the EpworthSleepiness Scale (ESS), from December 11, 2000 to February 2, 2001.Excessive day-time somnolence (EDS) (ESS ≥ 11) was present in 24%of the sample. EDS was not associated with age, time spent in the residence,gender and education. EDS was also not associated with hypnotictherapeutic use and alternative habits to sleep better. Marriedpeople showed a higher frequency of EDS (p

considered an effective tool, was now viewed as ineffective, harmfuland an assault on the patient’s dignity. Currently chemical restraintsshould always take precedence over physical restraints. Objectives ofthis study were to explore the perception on the use of physicalrestraints in elderly medical inpatients, among nurses and the patientsthemselves. Results revealed the commonest reasons given by nursesfor restraints were to prevent falls (74%) and altered mental states(44%). The commonest alternative measures to physical restraintsgiven were companions (51%) and environmental manipulation(46%). However, only 2% mentioned sedation. Results revealed thatsignificantly more nurses who were below 35 years and had less than10 years experience rated physical restraints as a “very important” protectiveand preventive tool, as compared to other nurses. From thepatients’ perspective, negative feelings such as anger, sadness, beingafraid and worry were reported. Only 55% indicated that they hadbeen informed on the reason for restraint. It is suggested that properguidelines be implemented and continuous education to nurses onrestraints be made a norm.PO3.13.PSYCHIATRY OF THE ELDERLY: THE EXPERIENCEOF A NEW SPECIALISTIC SERVICEM. Dalmotto, E. PirfoDepartment of Mental Health, Local Health Unit, Turin, ItalyThe need to make community psychiatric services more accessible tothe elderly population brought us to establish in 1999 a geriatric psychiatricservice including links between general practitioners, themental health department and specialists in geriatrics. The activity ofthe service in the semesters of the years 2000, 2001 and 2002 wascompared with that in the first semester of 1999. The number of outpatientsseen at the service increased from 84 in the first semester of1999 to 294 in the second semester of 2002. During the same period,the percentage of patients over 65 referred to the service for the firstvisit decreased from 6% to 1.2%. The number of elderly patients onlong-term care at the department of mental health decreased duringthe same period from 14 to 2. A comparison of the diagnoses of the364 outpatients seen at the geriatric psychiatric service with those ofthe 2140 outpatients seen at the mental health department shows avery different distribution of the various mental disorders.PO3.14.OVERT AGGRESSION IN GERIATRIC INPATIENTSF. Margari 1 , R. Matarazzo 1 , M. Sicolo 1 , T. Malesevic 1 ,M.G. Petruzzelli 1 , L.A.M. Spinelli 1 , F. Mastroianni 2 ,R. Semeraro 3 , F. D’Andia 31 Department of Neurological and Psychiatric Sciences, Universityof Bari; 2 Villa Giovanni Residential Centre for Elderly, Bari;3 S. Raffaele Nursing Home, Taranto, ItalyThe study aimed to assess the prevalence of aggressive behaviour inhospitalised geriatric patients. The patients who participated in thestudy came from two different geriatric units, one for acute and theother for long-term hospitalization. The sample included 159 patients(19 men and 140 women). 48% of patients had a diagnosis of dementia,64% another psychiatric diagnosis, and 88% had an organic disorder.23% of the patients showed aggressive behaviour (ModifiedOvert Aggression Scale > 0). 28% of the patients manifested autoaggressiveand 80% hetero-aggressive behaviour. Aggressivenessmanifested itself in verbal form in 64%, towards objects in 16%,towards people in 68% of cases.PO3.15.SUPPORTIVE ASSISTANCE AND ASSISTANCEFROM FAMILY MEMBERS: EVALUATIONAMONG PATIENTS WITH ALZHEIMER’S DISEASEADMITTED TO A DAY CENTERA. Trequattrini 1 , L. Guidi 2 , L. Spadoni 1 , M. Mezzetti 1 , F. Ciappi 11 Mental Health Department, ASL 1 Umbria, Perugia; 2 HealthOutcomes Research, Eli Lilly Italia, Sesto Fiorentino, Florence,ItalyWe investigated the burden on caregivers and the cost of resource utilizationamong patients with Alzheimer’s disease admitted to a day center.21 patients with Alzheimer’s disease, assessed by the National Instituteof Neurological and Communicative Disorders and Stroke/Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) criteria, took part in the study. During 8 months they wereassessed using the Mini Mental State Examination (MMSE), Activitiesof Daily Living (ADL) and Instrumental Activities of Daily Living(IADL). Day center attendance was found to be associated with animprovement in the clinical picture and a reduction in the family caregivinghours.PO3.16.INCIDENCE OF DEMENTIA IN THE PROVINCEOF BRINDISI, ITALYG. Pierri, M. ViolaDepartment of Neurological and Psychiatric Sciences,University of Bari, ItalyThe aim of the study was to appraise the incidence of dementia in thepopulation of an Italian province (Brindisi, in the South of Italy) inthe period 1998-2000. The study has been conducted on the basis ofthe new diagnoses made at the various facilities of the relevant localhealth unit, using DSM-IV criteria. The incidence of dementia in thepopulation over 65 years has been of 0.65% in 1998, of 0.75% in 1999and of 0.79% in 2000.PO3.17.ARE THE PATIENT PREFERENCES FORCOMMUNICATION RELATED WITH PERSONALITYVARIABLES? A MULTICENTRIC STUDY INCANCER PATIENTSN. Sánchez 1 , A. Sirgo 2 , C. León 3 , M.F. Hollenstein 4 ,T.M. Lacorte-Pi 5 , C. López 1 , M. Salamero 11 Clinical Institute of Psychiatry and Psychology, Hospital Clinic,Barcelona; 2 Psycho-oncology Unit, Oncology Department,University Hospital Sant Joan, Reus; 3 Clinical HaematologyDepartment, University Hospital Sant Pau, Barcelona; 4 PsychooncologyUnit, Catalan Institut of Oncology, Barcelona; 5 IMORFundation, Barcelona, SpainThis study assessed the preferences for communication in a Spanishsample of cancer patients, and evaluated the relationship betweenpreferences for communication and socio-demographic, tumor relatedand personality variables. A sample of 71 Spanish cancer patientscompleted a set of questionnaires: the Spanish adapted version of theMeasure of Patient´s Preferences for Communication, which includesthree variables - content (what and how much information is given),facilitation (setting and context variables) and support (emotionalsupport during the interaction), the Extraversion and Neuroticismscales from the short form of the Eysenck Personality Questionnaire-312 World Psychiatry 3:S1 - October 2004

Revised (EPQ-RS), the Quality of Life Questionnaire (QLQ-3.0) andthe Hospital Anxiety and Depression Scale. EPQ extraversion factorshows a significant correlation with higher needs for information(p=0.001) and emotional support (p=0.014) in the doctor-patientcommunication setting. Women show higher scores in content variables(p=0.001), support variables (p=0.004) and facilitation variables(p

examined the association between depression and survival after SCT.In a prospective inpatient study, 220 patients aged 16 to 65 yearsreceived SCT for hematologic cancer. Patients underwent a psychiatricassessment at hospital admission and weekly during hospitalizationuntil discharge or death, yielding a total of 1062 psychiatric interviewsperformed. Major and minor depression were diagnosedaccording to DSM-IV. Stratified Cox proportional hazard modelswere used to assess the independent effect of major and minordepression on 1,3 and 5-year survival, adjusting for confounding clinicalfactors. The overall mortality was 30.9% at 1 year, 46.4% at 3years, and 53.2% at 5 years. After adjusting for other prognostic factors,patients with major depression had an approximately two-foldgreater risk of dying than nondepressed patients at 1 year (hazardratio, 2.19; p=0.028) and at 3 years (hazard ratio, 1.91; p=0.026).Major depression did not significantly increase the 5-year mortality.Minor depression had no effect on any mortality outcome. Thus,major depression is linked to a significantly reduced chance of 1 and3-year survival among cancer patients after SCT. These results highlightthe importance of adequate diagnosis and treatment of depression.Further research is needed to determine if treatment of depressioncan decrease mortality.PO3.22.PSYCHIATRIC MORBIDITY AND ITS IMPACTON LENGTH OF STAY IN HOSPITAL AMONGHEMATOLOGIC CANCER PATIENTSRECEIVING STEM-CELL TRANSPLANTATIONJ. Blanch, J. Prieto, J. Atala, E. Carreras, M. Rovira, E. Cirera,C. GastóDepartment of Psychiatry, Clinical Institute of Psychiatry andPsychology; Stem-Cell Transplantation Unit, University ofBarcelona and Hospital Clínic de Barcelona, SpainThis study aims to determine the prevalence of psychiatric disordersduring hospitalization for hematopoietic stem-cell transplantation(SCT) and to estimate their impact on length of stay in hospital(LOS). In a prospective inpatient study, 220 patients aged 16 to 65years received SCT for hematologic cancer. Patients underwent a psychiatricassessment at hospital admission and weekly during hospitalizationuntil discharge or death, yielding a total of 1062 psychiatricinterviews performed. Diagnosis was made according to the DSM-IV.Univariate and multivariate linear regression analyses were used toidentify variables associated with LOS. The overall prevalence of psychiatricdisorders was 44.1%; an adjustment disorder was diagnosedin 22.7% of patients, a mood disorder in 14.1%, an anxiety disorderin 8.2%, and delirium in 7.3%. After adjusting for admission and inhospitalrisk factors, diagnosis of any mood, anxiety, or adjustmentdisorder (p=0.022), chronic myelogenous leukemia (p=0.003),Karnofsky performance score < 90 at admission (p=0.025), and higherregimen-related toxicity (p

PO3.25.CONTINUING RISK BEHAVIOURS INHIV POSITIVE DRUG USERSS.G. Jesjeet, Z. NorzuraidaUniversity Malaya Medical Centre, Kuala Lumpur, MalaysiaTwo major health and social concerns in Malaysia are the spread ofthe human immunodeficiency virus (HIV) and drug abuse. They areclosely related, as the main modality of HIV spread in Malaysia ishigh risk injecting behaviour among intravenous drug users (IVDUs).The purpose of this study was to assess the rate of high risk behavioursamong IVDUs and to determine if there is any difference inthese behaviours in those aware of their positive HIV status as comparedto those aware of their negative status or those whose status isunknown. 162 IVDUs were interviewed regarding high risk injectingand sexual practices. Results showed that 73.3% of IVDUs that wereaware of their HIV positive status were still practicing high riskbehaviours, as compared to 34.5% in the rest. In conclusion, thepractice of high risk behaviours is rampant among IVDUs and knowledgeof a positive HIV status does not appear to affect these behaviours.More stringent interventions and programs need to be implementedto curb the spread of HIV in our country.PO3.26.PSYCHIATRIC EFFECTS OF CONVENTIONALINTERFERON VERSUS PEGILATED INTERFERONIN CHRONIC HEPATITIS PATIENTS AFTER TWOAND SIX MONTHS OF THERAPYS. Zanone Poma 1 , G. Ferri 1 , M. Ortolan 1 , E. De Toni 2 ,C. Pavan 1 , L. Chemello 2 , L. Cavalletto 2 , E. Berardinello 2 ,P. Amodio 2 , G.I. Perini 11 Section of Psychiatry, Department of Neuroscience; 2 Departmentof Clinical and Experimental Medicine, University of Padua, ItalyInterferon treatment of hepatitis is often hampered by neuropsychiatricside effects that can lead to therapy discontinuation. Theseeffects have been extensively studied with conventional interferon.More recently new interferons have been developed with a biochemicalprocess called pegilation (conjugation to a molecule of polietilenglicole).This allows better bio-availability and less toxicity. Fewdata are available about psychiatric effects of pegilated interferons.The aim of our study is to identify the presence of symptoms ofdepression and/or anxiety in patients with chronic hepatitis underIFN treatment comparing two types of therapy. Twenty-six patientstreated with conventional interferon and 20 patients treated withpegilated interferon were evaluated by means of interviewer-administered(17-item Hamilton Scales for Depression and Anxiety) and selfreportpsychometric (Beck Depression Inventory) scales at baselineand after two and six months of treatment. Samples were homogeneousfor age, sex and baseline scores on psychometric scales. Bothpatients under conventional interferon and pegilated interferonexhibited a significant raise in all psychometric scales after 2 and 6months: no significant differences have been found comparing thetwo samples (ANOVA for repeated measures). Our data confirm thepresence of psychiatric effects (both depressive and anxiety symptoms)during interferon therapy. These effects seem to be given withthe same intensity also by pegilated interferon.PO3.27.EFFECTIVENESS OF PEROSPIRONE IN THETREATMENT OF PSYCHOGENIC VOMITING:A PRELIMINARY PILOT STUDYM. Yamashita, I. YanaiDepartment of Psychiatry, Hiroshima General Hospital,Hiroshima, JapanPsychogenic vomiting is difficult to treat. To date, D2-antagonists,antidepressants, antipsychotics and other agents have been used, butthere is no unconditionally effective agent without significant sideeffects. Perospirone is a new atypical antipsychotic agent developedin Japan that became available in 2001. Its primary mode of action isantagonism of both 5-HT2A and dopamine D2 receptors, with fewside effects such as extrapyramidal symptoms (EPS). From the perspectiveof its pharmacological profile, perospirone might be a promisingcandidate drug in the treatment of psychogenic vomiting. Wereport four consecutive patients with psychogenic vomiting treatedwith perospirone. All four patients showed significant improvementwhen evaluated with the Clinical Global Impression scale (CGI-S).There were no adverse reactions such as EPS. The limitations of thisstudy include the small sample size and lack of comparison withother agents. However, perospirone may be a promising candidatedrug to treat psychogenic vomiting.PO3.28.PSYCHIATRIC DISORDERS FOLLOWING HEADTRAUMAS: EVALUATION ONE YEAR LATERA. Bellomo 1,2 , A. De Giorgi 2 , A. Petito 1 , G. Di Sciascio 3 ,A. Bertolino 3 , M. Nardini 31 Department of Medical and Work Sciences, University of Foggia;2 Department of Medical Health, Local Health Unit 3, Foggia;3 Department of Neurological and Psychiatric Sciences, Universityof Bari, ItalyThe aim of this study was to explore the nature of mental disordersfollowing head traumas. 76 subjects who had received a psychiatricdiagnosis one year after a head trauma were subjected to neuropsychiatricexamination and to structured psychiatric interview based onthe criteria of the DSM-IV (SCID-IV), and to evaluation with theBrief Psychiatric Rating Scale (BPRS), the Wechsler Adult IntelligenceScale (WAIS), and the Disability Scale (DISS). The group wassubdivided into two subgroups based on evidence of a demonstrablebrain lesion. Post-traumatic stress disorder (PTSD) (31%) was themost frequent diagnosis, followed by modification of personality dueto a medical general condition (26%); anxiety disorders (5%) andpsychotic disorders (1%). Subjects without brain injury showedlower BPRS scores than those with brain injury. The results of thisstudy confirm that head traumas may be associated with psychiatricdisorders, especially with PTSD. There is a clear difficulty to formulatea diagnosis for those clinical phenotypes (like the post-concussiondisorder) not included in a nosographic system.PO3.29.ARTERIAL HYPERTENSION:A MULTIDIMENSIONAL APPROACHM.A.J. Mac Fadden, E. Paes, A.P. ZaniState University of Campinas, São Paulo, BrazilThis study proposes a reflection on the interaction of the multiplepsychological, social, biological and cultural aspects of arterial hypertensionwithin a theoretical context, with examples illustrating treat-315

ment programs executed at UNICAMP, Campinas and PAM, Teresopolis.An analysis of the various factors and peculiarities of arterialhypertension indicates the need for planning and executing treatmentthrough the collaboration of professionals from different areas ofknowledge, so that intervention takes place in relation to the multiplefacets of this disease. This study also shows the need for including thefamily in an educational program aiming to change concepts anddaily habits, because the family nucleus is a generator of the biopsychodynamicsof hypertension. In view of the multifactorial nature ofthis disease, an approach that includes these aspects is a model to beabsorbed into professional practices that are dedicated to the wellbeingof the patient.PO3.30.PSYCHOLOGICAL SUPPORT FOR PATIENTS WITHCHRONIC OBSTRUCTIVE LUNG DISEASESR. Vassoler, M.A.J. Mac FaddenState University of Campinas, São Paulo, BrazilThe purpose of this study was to evaluate the efficacy of the psychologicalsupport provided to patients with chronic obstructive lung diseasesat the Lung Rehabilitation Ambulatory Center at UNICAMP.Twelve patients were interviewed and their affective and emotionalcondition was assessed. The patients were provided with psychologicalsupport once a week for 18 months. This group support helpedthe patients elaborate their fantasies and provided them with realisticexpectations in relation to the disease. During therapy, there was amarked reduction in the anguish and anxiety caused by the disease.The therapeutic support also helped these individuals to face theirlosses and to adapt to a new way of life. Clinically, the group had alower incidence of infections and, consequently, a lower number ofhospitalizations. These findings indicate that psychological supporthelped the elaboration of the patients' internal contents and alsohelped them improve the quality of their physical and mental life.PO3.31.SCREENING FOR DEPRESSION ANDALEXITHYMIA IN A SAMPLE OF HEMODIALYZEDPATIENTS: PRELIMINARY RESULTSD. Campanella 1 , D. De Berardis 1 , F. Gambi 1 , W. Bisello 2 ,G. Sepede 1 , A. Carano 1 , L. Pelusi 1 , R. La Rovere 1 , L. Penna 1 ,A. Cicconetti 1 , G. Salini 1 , C. Cotellessa 1 , R.B. Salerno 1 ,F.M. Ferro 11 Institute of Psychiatry; 2 Nephrology Clinic, University of Chieti,ItalySeveral studies have investigated the relationship between dialysisand depression, but the reported incidence of depression varies widely,in part because of the different criteria used to diagnose depression.Alexithymia has been relatively less studied. Our purpose was toscreen depression in a sample of dyalized patients and evaluatewhether alexithymic features were related to more severe depressivesymptoms and disability. We evaluated 40 hemodialyzed patients (agerange: 35-68 years) by the Beck Depression Inventory (BDI), theHamilton Depression Rating Scale (HAM-D), the Toronto AlexithymiaScale (TAS-20) and the Sheehan Disability Scale (SDS). 17patients (42.5%) scored ≥ 11 on the BDI and fifteen of these 17patients (88.2%) received a clinical diagnosis of depression. Elevenpatients (25.7%) were alexithymic (score ≥ 61 on TAS-20) and alexithymicsshowed higher scores on BDI, HAM-D and SDS than nonalexithymics.PO3.32.MENTAL DISORDERS IN LIQUIDATORS OF THECONSEQUENCES OF CHERNOBYL ACCIDENTV.A. RudnitskyMental Health Research Institute, Tomsk, RussiaThis paper focuses on mental health problems among participants inthe liquidation of the consequences of the Chernobyl accident. Impactof a low dose of radiations leads to disturbances in the immune systemas well as to functional and morphological alterations in the centralnervous system. In addition, liquidators in Chernobyl had experienceswhich are typical for the victims of traumatising events such as militaryactions or catastrophes. These experiences led to the decompensationof already present mental disturbances, determining their clinicalmanifestation or worsening their course. Moreover, a significant contributionwas made by the quality of social adjustment. We conducteda clinical-psychopathological, experimental-psychological examinationof 575 liquidators. A variety of disorders with an organic basiswere observed, from simple asthenic reactions up to the various manifestationsof the psychoorganic syndrome. Mental disorders in thesepatients had a protracted, chronic course and were resistant to therapy.Practically all patients had multiple accompanying somatic diseasesand diverse immunological disorders.PO3.33.MENTAL DISORDERS IN CHILDREN ANDADOLESCENTS PRENATALLY IRRADIATED ASA RESULT OF THE CHERNOBYL ACCIDENTA.K. Napreyenko 1 , T.K. Loganovskaja 21 A.A. Bogomoletz National Medical University; 2 Scientific Centrefor Radiation Medicine, AMS of Ukraine, Kiev, UkraineMental health in children and adolescents exposed to acute prenatalirradiation as a result of the Chernobyl accident has been assessed.The frequency of mental disorders and personality disorders due tobrain injury or dysfunction, F06, F07; disorders of psychologicaldevelopment, F80–F89; paroxysmal states (headache syndromes,G44; migraine, G43; epileptiform syndromes, G40); somatoformautonomous dysfunction, F45.3; behavioral and emotional disordersof childhood, F90–F99 were increased among these children. Thediagnosis of the mental disorders according to multiaxial classificationsystems is more appropriate. The recommended treatment andrehabilitation will be optimizing psychosocial adaptation and mentalas well as physical development of the children.PO3.34.THE USE OF ALPHA-2 AGONISTS AS SEDATIVEAND THE REDUCTION OF POSTOPERATIVEDELIRIUM IN CARDIAC SURGERY PATIENTSJ. Maldonado, A. Wysong, P. van der Starre, T. Block, B. ReitzUniversity Medical Center, Stanford, CA, USAAs many as 80% of cardiac surgery patients experience postoperativedelirium, a condition which leads to increased morbidity and mortalityas well as a prolonged hospital stay. There are compelling clinicaland financial reasons to reduce the incidence of postoperative delirium.Dexmedetomidine, a selective alpha-2 adrenergic receptor agonist,may be an excellent alternative to the use of conventional sedativesfor lowering the incidence of delirium. In a prospective randomizedtrial, ninety patients undergoing elective cardiac surgery were randomlyassigned to one of three postoperative sedation protocols:dexmedetomidine (loading dose 0.4 µg/kg, infusion 0.2-0.7 µg/kg/hr),316 World Psychiatry 3:S1 - October 2004

propofol (25-50 µg/kg/min), or fentanyl and midazolam (50-150 µg/hrand 0.5-2 mg/hr respectively). All participants underwent neuropsychiatrictesting prior to surgery and received standardized generalanesthesia. Patients were monitored for the development of postoperativedelirium and neurocognitive deficits. The incidence of deliriumfor patients on dexmedetomidine was 3%, for those on propofol 50%,and for patients receiving fentanyl and midazolam 50%. Although notstatistically significant, there was a trend toward shorter intensive careunit and total hospital stays for patients who received dexmedetomidine.This may be attributed to the specific and unique pharmacologicalprofile of dexmedetomidine, including its norepinephrine specificity,lack of anticholinergic potential, promotion of a physiologic sleepwakecycle, and neuroprotective effects.PO3.35.EXPERIENCE ON TREATMENTOF DELIRIUM TREMENSM. Dalsaev, R. DalsaevaRepublican Drug Addict Clinic, Chechen State University,Grozny, Russia FederationWe report on our experience with 100 patients hospitalized in 2002and 2003 who presented delirium tremens. 56 of these patients wereadmitted after three or more days since the beginning of deliriumtremens, whereas in the others delirium tremens developed the daybefore, or during the first days after hospitalization. We used in allpatients an infusion therapy consisting of haemodesum or 5% solutionof glucose (200-400 ml) together with thiamine up to 100 mg duringthe day, diazepam 10 mg and phenobarbital up to 0.4 g. Diazepamwas injected intravenously at the dose of 10 mg and intramuscularlyup to 50 mg per day, and haloperidol 10 mg and dimedrolum 1-2mg/die intramuscularly. In 51 cases magnesium sulfate 25% wasinjected by 5 ml intramuscularly. The average duration of deliriumtremens was 3 days. A lethal outcome occurred in one case. In onecase the transition of delirium into Korsakov's psychosis and Wernicke'sencephalopathy was noted.PO3.36.EMOTIONAL STATE AMONG PATIENTSSUFFERING FROM ACNE VULGARISS. Tosic-Golubovic, S. Miljkovic, V. Sibinovic, H. Djordjevic,D. GugletaPsychiatric Clinic, Gornja Toponica, Serbia and MontenegroGiven the psychological importance of skin in the perception of bodyimage, emotional reactions to skin disease are natural, predictable, andeven appropriate. It is not surprising, therefore, that secondary or reactivepsychological and psychiatric problems, including depression, aresometimes encountered. The aim of our study was to determine andcompare the levels of depression and anxiety between patients sufferingfrom acne vulgaris and control subjects from the general population.The experimental group showed significantly higher scores for depressionand anxiety on Hamilton scales, and neuroticism on the EysenckPersonality Inventory. Levels of anxiety and depression were four timeshigher than those reported in general population. In acne vulgaris,emotional distress, including depression, anxiety, frustration, can exacerbatethe skin disease, and the worsened skin condition then exacerbatethe emotional state. A vicious circle is created.PO3.37.STRESSFUL LIFE EVENTS ANDPERSONALITY DISORDERS AS POTENTIALTRIGGERS OF PEMPHIGUSF. Rossano 1 , E. Ruocco 2 , M. Masella 1 , M. Cigliano 1 , A. Baroni 2 ,F. Catapano 11 Department of Psychiatry and 2 Section of Dermatovenereology,University of Naples SUN, Naples, ItalyThe onset and course of pemphigus depend on a variable interactionbetween predisposing and inducing factors. Genetic predisposition isknown to be associated with human leukocyte antigens (DR4,14 andDQ1,3). The genetic background alone is not by itself sufficient to initiatethe autoimmune response; the intervention of inducing or triggeringfactors seems to be crucial to set off the full-blown disease. Numerousand heterogeneous factors able to induce pemphigus in genetically predisposedsubjects are: drugs (thiols, phenols, cytokines), physical agents(burns, UV and ionizing rays), viruses (herpesviridae, myxoviridae),malignancies (cancers, lymphomas), pregnancy and hormones (progesterone),contact allergens (pesticides), diet factors (allyl compounds,tanninus), emotional stress. It has been claimed that intensive and prolongedemotional stress should be avoided by pemphigus patients. Theaim of the study is to investigate this hypothesis. We explored stressfullife events and personality disorders in 15 (6 men and 9 women) consecutivesubjects with pemphigus. Baseline information was collectedon demographic characteristics, family history, presence of psychopathology,psychoaffective impact of stressful life events occurring tothem within one year prior to onset of their pemphigus and the presenceof Axis I and II diagnosis. In our study the group of patients with pemphiguswas matched with a control group for age and sex. All pemphiguspatients having a negative anamnesis for psychiatric pathologies hadexperienced a stressful life event during the year preceding the onset ofpemphigus; 80% of these events were negative and 46.7% were verytraumatic. In the control group the frequency of traumatic events was13% (p

their association with CMD, their attribution patterns, and types ofCMD presentation (somatic or psychological). It was found thatunexplained somatic symptoms were the ones most strongly and stablyassociated with CMD (OR=2.32, 95% CI 1.10-4.86). On the otherhand, they did not represent genuine somatization since they werehighly associated with psychological complaints (OR=6.07, 95% CI2.96-12.42). There was one patient with somatic presentation foreach one with a psychological one, but 90% of these patients recognizedan emotional origin for their somatic symptoms. While unexplainedsomatic symptoms are the most common forms of CMD presentationin the FHP units, they may represent a cultural pattern ratherthan true somatization.PO3.39.INTERACTIVE VOICE RESPONSE AS ATHERAPEUTIC TOOL TO REDUCE CHRONICPAIN AND DECREASE MEDICATION USEM.R. Naylor, J.E. Helzer, B. Brigidi, A.L. Smith, S. NaudUniversity of Vermont, Burlington, VT, USAThe study aimed to test whether interactive voice response (IVR) canbe used to prevent relapse into pain behavior. After completing 11weeks of group cognitive behavioral therapy (CBT), ten subjects withchronic pain participated in four months of therapeutic IVR (TIVR);a comparison group of eight subjects received standard care only. TheTIVR is a computerized telephone system designed to reinforce paincoping skills learned in group CBT and provide messages for relaxation,sleep induction, and emotional support that can be accessed bypatients on demand. Within subjects analysis (ANOVA) showed maximumpositive change for nearly all outcome measures at the postTIVR point. Statistically significant improvements included Short-Form 36 (SF-36) Mental Health Composite Score (p

PO3.43.DIFFERENTIAL DIAGNOSIS OF MUNCHAUSEN’SSYNDROME: A CASE REPORTS. Caperna 1 , R. Castra 2 , C. Callegari 1 , S. Vender 11 Chair of Psychiatry, University of Insubria, Varese; 2 Departmentof Neuropsychiatric Sciences of Developmental Age, University ofRome, ItalyWe report on a case posing a problem of differential diagnosis amongvarious diagnostic categories, including Munchausen’s syndrome andparanoid personality disorder. A woman in her fifties had presentedfor twenty years hypochondriacal complaints. She had undergoneperiodic checks-up to confirm her fears, trying, successfully sometimes,to manipulate doctors, in order to obtain medical or even surgicaltreatments. She had had many operations through a few years,whose usefulness was often questionable. At the same time, she hadbeen accusing her husband that he was poisoning her, and repeatedlyrequested clinical ascertainments to support her conviction. Thebehavioural and psychopathological elements emerging from thiscase will be discussed.PO3.44.QUALITY OF LIFE AMONG ADOLESCENTS WITHFACIAL SCARRING FOLLOWING BURN INJURYC. Thomas, W. Meyer, F. CamposUniversity of Texas Medical Branch, Galveston, TX, USAReconstructive surgery efforts for children with facial burn injuryfocuses on improving function and appearance in order to enhancequality of life. Previous research on children with craniofacial conditionshas concentrated on provider-driven measures rather thanassessing the patient's view of the impact on their life. Physicalappearance is an important concern for adolescents, especially thosewith scars from burn injury. This study presents findings on depressivesymptoms among adolescents with facial disfigurement fromburn injury. The Youth Quality of Life Instrument – Research Version(YQOL-R) and other scales were administered to 66 adolescent burnsurvivors with significant facial scarring in order to assess their qualityof life. The adolescent participants ranged in age from 11 to 17 1 /2years and were more than two years post burn injury. Adolescentswith significant psychiatric illness unrelated to their burn injury wereexcluded from the study. The questionnaire provided important informationregarding the adolescent's view of themselves and overallcompetence with respect to their facial condition. The YQOL-R provideduseful insight in assessing the relative impact of acquired craniofacialconditions from burn injury in adolescents. Further study isneeded to test the comparability of the YQOL-R for adolescents withacquired craniofacial conditions from burn injury and those withcongenital craniofacial conditions for whom it was developed. TheYQOL-R may provide useful information to adolescent burn survivors,their parents and surgeons in determining the indication forand impact of surgical interventions for craniofacial conditions.PO3.45.PATTERNS OF REACTION TO THEDIAGNOSIS OF CANCERV.Y. SemkeMental Health Research Institute, Tomsk, RussiaOn the basis of detailed assessment of patients at the OncologyResearch Institute, we observed four variants of reaction to the diagnosisof cancer: a) the anosognostic variant (I have nothing, physiciansmade a mistake about me); b) the anxious variant (looking for mysticjustifications of the disease, not believing in physicians, searching forthe help of healers); c) the congruent-constructive variant (actively participatingin rehabilitative processes, properly perceiving treatment,finding ways of social adaptation); d) the depressive variant (withdrawal,phobias and fears). In the first three variants, an active psychotherapeuticintervention is conducted; in the fourth, we use treatment withantidepressants. The severity of the reaction is not related to the severityof the disease, but to the subject’s personality.PO3.46.INFLUENCE OF LOCALISATION OF BRAINIMPAIRMENT ON THE INNER PICTURE OF THEILLNESS IN POST-STROKE PATIENTSA.Y. Levina, N.G. KatayevaSiberian State Medical University, Tomsk, RussiaThe study aimed to study the influence of localisation of brain impairmenton the development of the inner picture of the illness (IPI). Weassessed the IPI in 96 post-stroke patients. One group consisted ofpatients with depressive disorders, the other of patients withoutdepression. In 50% of patients, the localisation of the brain impairmentcould be verified by magnetic resonance tomography. Inpatients with right hemisphere impairment, neurasthenic and paranoictypes predominate. In 40% of patients with depressive disorders,the euphoric type of IPI is observed, which is likely to be associatedwith anosognosia. In patients with impairment of the left hemispherewithout depression, ergopathic and sensitive types of IPI predominate.Only in this latter localisation, the hypochondriacal type of IPIwas noticed.PO3.47.FRONTAL EPILEPSY WITH SCHIZOPHRENIC ANDMANIC APPEARANCEE. Tzavellas, O. TzavellasUniversity of Athens, GreeceFrontal epilepsy is often not diagnosed correctly. Patients are hospitalizeddue to behavioural disturbances and are often misdiagnosedas schizophrenic or bipolar. We report on a sample of epilepticpatients admitted to our clinic with a diagnosis of paranoid schizophreniaor bipolar disorder. The reason for their admission was theinability to adjust to the environment, due to their “wrong and dangerousbehavior”. The diagnostic error was often reinforced by anelectroencephalogram without pathological features. We provide alist of criteria for the differential diagnosis between frontal epilepsyand primary psychosis.PO3.48.RISK FACTORS FOR THE DEVELOPMENT OFPSYCHIATRIC DISORDERS IN THE MENOPAUSEA. Fotiadou, F. Priftis, S. Kyprianos, L. IliopoulouDepartment of Psychiatry, G. Hadzikosta General Hospital,Ioannina, GreeceThe study aimed to examine the psychiatric disorders that areobserved in women during the menopause. We studied 84 women(mean age 48.7 years) that had been hospitalized for various reasonsin other departments and had been referred to the consultation-liaisonpsychiatric department in the years 2000-2002. 52 of them weremarried, 17 divorced, 9 not married and 5 widows. 68 were mothers.They were evaluated by the Hamilton Scales for Depression and Anx-319

iety and by a semistructured psychiatric interview. 65 (77.4%) of thewomen had hot flashes. In 27 (32.1%) we found anxiety or somatoformdisorders, and in 9 (10.7%) depression. The information collectedby the semistructured interview suggests that the developmentof psychiatric disorders during menopause is related to premorbidpersonality traits, the previous history of psychiatric disorders, theburden of somatic diseases and problems with adaptation to the newcircumstances.PO3.49.PSYCHOSOCIAL CHARACTERISTICS OFWOMEN ASKING FOR VOLUNTARY ABORTIONF. Priftis, S. Kyprianos, L. Iliopoulou, A. FotiadouDepartment of Psychiatry, G. Hadzikosta General Hospital,Ioannina, GreeceThe aim of this study was to examine psychosocial characteristics ofwomen asking for voluntary abortion. We studied 36 women with amean age of 24.6 years who came to the gynecological department ofour hospital asking for voluntary abortion. Their sociocultural backgroundwas explored by an ad-hoc inventory. They also received asemi-structured psychiatric interview and were administered theHamilton Scales for Depression and Anxiety. 24 (66.6%) of thesewomen were young and non-married. 23 (63.8%) of them came withouttheir partner. In 3 cases (8.3%) there were medical reasons for theabortion. 9 (25%) women considered their pregnancy accidental andunwanted. 15 (41.6%) of the women manifested afterwards anxiety ordepressive symptoms and feelings of guilty and self-reproach. Thefamily planning and the services that are developing in this directionare very helpful, in particular in families with young parents and lowincome. Adolescents must have free access to information about contraception.The decision about an abortion must be weighed verywell, in order to minimize the possibility of psychiatric symptomatolgyin the woman.PO3.50.LIFE EVENTS, PERSONALITY PROFILESAND PSYCHIATRIC DISORDERS AMONGPATIENTS SUFFERING FROM INFLAMMATORYBOWEL DISEASES. Tosic-Golubovic, S. Miljkovic, S. Raicevic-Sibinovic,N. Golubovic, H. DjordjevicPsychiatric Clinic, Gornja Toponica, Serbia and MontenegroPatients with inflammatory bowel disease (IBD), independent ofmetabolic abnormalities, tend to have significant psychologicalimpairment and disturbed social functioning. The aim of our studywas to determine differences in frequency of depressive and anxiousdisorders, personality profiles, life events between subjects sufferingfrom IBD and control subjects from the general population. Theassessments were made during remission periods of IBD patientsusing the Hamilton scales for depression and anxiety, the MinnesotaMultiphasic Personality Inventory, the Eysenck Personality Inventory,and the Paykel Life Events Inventory. The IBD group showedmoderately elevated levels of depression, anxiety, hypochondriasisand hysteria, and of neuroticism on the Eysenck Inventory, but thedifferences were not significant. There was no correlation betweenthe frequency of stressful life events in the 6 months prior to interviewand the severity of IBD. Although IBD is not a functional disorder,there are certainly psychological sequelae in living with this chronicdebilitating disease.PO3.51.SUICIDE RISK FACTORS AND VULNERABILITYIN MAJOR PSYCHIATRIC DISORDERSI. Modai 1,2 , J. Kuperman 1 , I. Goldberg 3 , M. Goldish 3 , S. Mendel 31 Shaar Menashe Mental Health Center, Hadera; 2 BruceRappaport Faculty of Medicine, Technion, Haifa; 3 RebbecaMeirhoff Technical School, University of Tel Aviv, IsraelThe impact of suicide risk factors (SRF) on suicide vulnerability isunclear. The Fuzzy Adaptive Learning Control Network (FALCON)was trained with 552 computerized suicide risk scales (CSRS-III) comprisedof 21 SRF and validated with 60 CSRS-III. Medically serious suicideattempts were used as target variable. Impacts were expressed byvariance of change in outputs of the trained neural network to allinputs. Its average for each variable reflected the direction of influence.Results demonstrated that methods of the last suicide attempt are themost significant variables. In major depressive disorder (MDD) andschizoaffective disorder (schA), as opposed to bipolar disorder (BD),gender (males>females and females>males, respectively) is rated second.Age has major impact in schizophrenia (SCH), intermediateimpact in BD and obsessive-compulsive disorder (OBS), and lowimpact in personality disorders (PD). Hallucinations are significantamong drug abused PD, even more than in SCH and schA. However,paranoid delusions are significant in SCH and schA, but absence ofdelusions is significant in PD and in OBS. The Global Assessment ofFunctioning (GAF) score is of great significance in OBS, MDD, schAand “others”. All kinds of stress have intermediate to low impact inSCH, MDD and “other” patients, and absence of stress has intermediateimpact in all other diagnostic groups. Separation from therapist isinsignificant in all diagnostic groups. Different variables have differentimpacts in different diagnostic groups.PO3.52.THE SODIUM CHANNEL, VOLTAGE GATED, TYPEVIII, ALPHA POLYPEPTIDE GENE: A RELATIONSHIPTO SUICIDE ATTEMPTD. Wasserman 1 , J. Wasserman 1 , V. Rozanov 2 , T. Geijer 11 National and Stockholm County Council Centre for SuicideResearch and Prevention of Mental Ill-health (NASP),Stockholm, Sweden; 2 Human Ecological HealthOrganization/Odessa National Mechnikov University, Odessa,UkraineFamily and twin studies show that genetic variation influences suicidalbehavior, but do not indicate specific genes. We screened 250genetic markers using the transmission disequilibrium test (TDT).Preliminary analysis of 79 triplets (suicide attempters and their parents)indicated (p=0.008) that genetic variation in the SCN8A (sodiumchannel, voltage gated, type VIII, alpha polypeptide) gene comigrateswith suicide attempt. Subsequent TDT analysis in an anothersample (190 triplets) confirmed that genetic variation in this genecomigrated with suicide attempt (p=0.005). Our data suggest thatgenetic variation in the SCN8A gene contributes to risk for suicideattempt, possibly through altered neural conduction.PO3.53.THE SUICIDAL ATTEMPT IN JAPANT. Yamate, T. Maruta, M. Sato, M. Nakane, M. IimoriDepartment of Psychiatry, Tokyo Medical University, Tokyo, JapanRecently the rate of attempted suicides is increasing enormously inJapan. The number of committed suicides according to the Japanese320 World Psychiatry 3:S1 - October 2004

police survey of 2003 was 32,143. However, our current psychosocialand biological knowledge about suicidal behavior is still limited.Community cohort studies and meta-analyses of randomized trialshave shown a relation between low serum cholesterol concentrationsand risk of death by violence (homicide, suicide, accident). The aimof this study was to investigate the characteristics of patients whowere admitted to the emergency room of the Tokyo Medical UniversityHospital and the relationship between suicidal behavior and cholesterol.In 2004, we interviewed 82 patients who attempted suicide(mean age: 35.7±14.3 years). The most common diagnosis by DSM-IV was borderline personality disorder (47.5%), followed by schizophrenia(18.3%) and depression (13.4%). The most common methodof suicide was ingestion of drugs (59.7%), the second jumping(17.1%) and the third stabbing and cutting (13.5%). Furthermore wewill discuss the relationship between serum cholesterol level and suicidalacts and the current views of suicidal attempts in the emergencyroom of the Tokyo Medical University Hospital from 1999 to 2004.PO3.54.FACTORS ASSOCIATED WITH RISKFOR SUICIDAL DEATH IN KOREAN ADULTSM.D. Kim 1 , S.W. Hwang 2 , S.C. Hong 31 Department of Psychiatry, 2 Department of Family Medicine,3 Department of Preventive Medicine, College of Medicine, ChejuNational University, Cheju, KoreaRecently, the rate of suicidal death has increased in Korea adults.However, few studies have examined the risk factors for suicide. Thisstudy investigated the risk factors for suicidal death in Korean adults.The study was based on the cause of death statistics between 1999and 2001 in Korea, as published by the Korea National StatisticalOffice. Cases were persons who died from suicide and controls werepersons who died from a natural cause between 20 and 64 years ofage. We examined the risk for suicide according to age, sex, occupation,marital status, education, area of residency, and social class.Multiple logistic regression analysis was used to examine the associationsbetween risk factors and suicidal death in males and females.The frequency and odds ratio of suicide among males were higher inyoung than elderly, students than managers, divorced than cohabitant,resident in country than metropolitan areas, social class III andIV than I and II. In females, the frequency and odds ratio of suicidewere higher in young than elderly, and in divorced, resident in countryareas, social class III and IV. In multiple logistic regression, suicidaldeath is associated with social class, marital status, and area ofresidence in male and is associated with social class, divorced andwidowed, and area of residence in females.PO3.55.ELDERLY SUICIDE PREVENTION PROGRAMSIN HONG KONGH. ChiuDepartment of Psychiatry, Chinese University of Hong Kong,Tai Po, Hong KongElderly suicide is a serious problem in Hong Kong. The suicide rate ofpeople aged 65 or above is about 30 per 100,000 and is 2 to 3 timeshigher than in the general population. This paper will describe the elderlysuicide prevention programs in Hong Kong. In particular, thereare two major programs. A 3-year pilot project on elderly suicide preventionconsists of three components: 1) a life-clinic based in oneregion of Hong Kong that provides urgent consultations for suicidalelderly; 2) an Asian-Pacific Regional Conference on Elderly SuicidePrevention; and 3) a series of territory-wide community educationprograms on healthy ageing and promoting mental health. Anothermajor program is a territory-wide elderly suicide prevention programusing a 2-tier model. The first tier consists of hot-line services, frontlineworkers, voluntary services and general practitioners. If elderlywith suicide risk are detected, they will be referred to the second tier,which are fast-track psychiatric clinics, and the elderly will by visitedby community psychiatric nurses. A multidisciplinary team will participatein the care of the elderly. Training for general practitioners is alsoa major part of the program.PO3.56.SUICIDE ATTEMPT WITH DRUGS:ANALYSIS OF CLINICAL AND EPIDEMIOLOGICALVARIABLESG. Cerveri 1 , M.C. Mauri 2 , S. Manfrè 3 , C. Mencacci 11 Department of Mental Health, Fatebenefratelli Hospital;2 Psychiatric Clinic, Ospedale Maggiore; 3 Anti-Poison Center,Niguarda Hospital, Milan, ItalyThe aim of this study was to assess the demographic and clinical characteristicsof the patients treated at the Anti-Poison Center of NiguardaHospital in Milan for attempted suicide by self-poisoning. 201 subjects,aged 18 years or more, treated for attempted suicide in 1999 and2000, were included in the study. Females were overrepresented(64%). 33% of subjects presented a previous suicide attempt. 25%met criteria for psychoactive substance use disorder, 25% for mooddisorder, 15% for personality disorder and 9% for schizophrenia.25% of subjects were suffering from severe organic disease. Only 34%did not meet criteria for any psychiatric disorder. The drugs most frequentlyinvolved in self-poisoning suicide attempts were benzodiazepinesand antipsychotics.PO3.57.PSYCHODYNAMIC PSYCHOTHERAPY INPATIENTS WITH SELF-DESTRUCTIVE BEHAVIORD. Malidelis, E. Panagoulias, P. Papadopoulos, G. Venizelou,K. DailianisMental Health Center of Peristeri, Athens, GreeceThis study examines the effectiveness of a psychodynamic psychotherapyfor patients with self-destructive behavior (accidents,injuries, excessive expenses of money, engagement in quarrels) andpersonality disorder. The psychotherapeutic method used for thetreatment of these patients is Transference-Focused Psychotherapy(TFP), which emphasizes the direct interpretation of a negative transference.The study included 20 patients who had a borderline personalityorganization according to Kernberg. None of them suffered frommajor depression and all of them had completed a two-year therapy.One year after the treatment, none of these patients showed selfdestructivebehavior.PO3.58.SUICIDE ATTEMPTS AND PERSONALITYDISORDERSF. Priftis, S. Kyprianos, L. Iliopoulou, A. FotiadouDepartment of Psychiatry, Hatzikosta General Hospital,Ioannina, GreeceThe aim of this study was to examine suicide attempts in relation toconcomitant personality disorders. We studied 58 individuals, 36females and 22 males, with mean age of 46 years, brought to the emer-321

gency department of our hospital in the biennium 2000-2002, after asuicide attempt. All of them had had a psychiatric examination on thesame day or afterwards (depending of their condition) and were followedup. The examination included a semi-structured psychiatricinterview and the Minnesota Multiphasic Personality Inventory(MMPI). The majority of subjects who had attempted suicide byingesting small amounts of drugs were young women with features ofnarcissistic or dependent personality. More violent attempts werecommitted by males with antisocial personality disorder. Alcohol andsubstance abuse was prevalent, far more in males. In some seriousattempters we found compulsive personality features. The relationbetween suicide attempts and personality disorders is obvious. Thedifferences in the seriousness of the attempt are closely related to thetype of personality disorder, sex, age and social support system.PO3.59.DIFFERENT CLINICAL APPROACHESTO SUICIDE PREVENTION BASED UPONPERSONALITY STRUCTUREG. Grava 1 , P. Scudellari 1 , G. Berti Ceroni 21 Department of Psychiatry, University of Bologna; 2 VillaBaruzziana Clinic, Bologna, ItalyIn a private clinic, 22 patients who had made a suicide attempt in thelast month underwent a multifaced examination, consisting of a neuropsychiatricevaluation including a multiaxial diagnosis followingthe DSM-IV; a psychological evaluation including two projectivetests (Rorschach and Object Relation Technique), and a clinical interviewfocused on the pathway to suicide. Three different groupsemerged: A) depressive patients (n=6) usually suffering from a longstandingsevere life difficulty and consequent hopelessness; B)patients with severe personality disorders (n=8) reacting in anextreme way to life events and with a history of previous suicideattempts; C) patients with comorbidity of Axis I disorders and adeeply disturbed personality structure (n=8) in whom hopelessnesswas expressed as a negative life-balance, and previous suicideattempts were frequent, but not so common as in group B. The strategyfor preventing suicide attempts in the three groups should be different.Patients, therapist and relatives need to realize that in group Cearly and appropriate drug intervention must be accepted, in group Ban active support must be provided both by the therapist and thesocial network, every time that the patient steps into impulsivity anddespair, while in group A the intervention should be focused on thenegative loop of thinking.PO3.60.ASSOCIATION BETWEEN ATTEMPTED SUICIDEAND PSYCHOLOGICAL OR SEXUAL ABUSEJ.R. Lippi, A. Roselli-Cruz, A.M. Carvalho, R. Las Casas,S. MarquesMedical School, Federal University of Minas Gerais State,Belo Horizonte, BrazilUsing a case-control methodology, we examined a sample of 644 people,with 68% of women and 32% of men, with ages between 10 and70 years, that were admitted to the Emergency Hospital of Belo Horizonte,Minas Gerais State, Brazil. The sample was divided in twogroups: those who were admitted for a suicide attempt and thoseadmitted for any reason, except suicide attempt (control group). Ahistory of psychological violence was found in 79% of suicideattempters and in 48% of controls. A history of sexual abuse wasdetected in 33% of suicide attempters vs. 13% of controls. Both differencesare statistically significant. The most significant correlationwas that between a suicide attempt at any age and sexual abuse duringthe childhood or adolescence.PO3.61.ADOLESCENT SELF-MUTILATORY BEHAVIOR:AN UPDATEN. Roberts 1 , F. Iftene 21 Division of Child and Adolescent Psychiatry, Queen’s University,Kingston, Canada; 2 Department of Child and AdolescentPsychiatry, University of Cluj, RomaniaSelf-mutilatory behavior (SMB) is defined as a direct and deliberatedestruction or alteration of body tissues without conscious suicidalintent. The most frequent type of SMB in adolescents is "cutting/slashing".The prevalence of this behaviour in the general population isreported to be 4%, but it is much higher in clinic and inpatient populations.Adolescence is the most commonly reported age of onset. Theassociation with major psychiatric diagnoses is frequent. SMB cutsacross all cultural and socio-economic levels. However, more femalesengage in this behaviour than males. We will discuss a number of theories,including the contagion theory, the psychodynamic explanation,the neurobiologic postulates and the role of serotonin. Then we willdiscuss current treatments, with special attention to selective serotoninreuptake inhibitors.PO3.62.INVESTIGATION OF MEDICAL STUDENTS’OPINIONS ON EUTHANASIA IN ATHENSB.J. Havaki-Kontaxaki, V.P. Kontaxakis, F. Siannis, K.G. Paplos,G.N. ChristodoulouDepartment of Psychiatry, University of Athens, Greece,and Institute of Public Health, Cambridge, UKA study was carried out to investigate medical students’ attitudestowards euthanasia (EUT) and physician-assisted suicide (PAS) inthe Athens University Medical School. We used a 26 items questionnaire,collecting data about demographics, personal experience withterminally ill patients, and opinions on whether EUT and PAS shouldbe permitted. A consecutive series of final year medical students participatedin the study. 251 students completed the questionnaire (55%male). Students were subdivided in two main categories, according towhether they believed that EUT or PAS are not acceptable or shouldbe permitted under circumstances. Initial univariate analysis showedthat students who answered that EUT and PAS should be permittedunder circumstances were more likely to answer “yes” to the question“Do you believe that there should be procedural safeguards regardingthe legalization of EUT or PAS?” (p

PO3.63.LACK OF PSYCHOLOGICAL SPACE IS ASSOCIATEDWITH A POSITIVE VIEW ON SECLUSIONJ. Stolker 1 , H. Nijman 21 Altrecht Institute for Mental Health Care, Den Dolder; 2 ForensicPsychiatric Hospital De Kijvelanden, Poortugaal, The NetherlandsIt is likely that a lack of psychological space, having no privacy or notbeing able to get sufficient rest, may be more important in triggeringaggression than a lack of physical space. We wanted to investigate theassociation between the availability of one- or more-person roomsand patients’ opinions on seclusion. Data were prospectively collectedfrom March 1999 to October 2000 from a consecutive sample of 78secluded patients of 18 years or over. They were hospitalised on a 20-beds closed ward of a Dutch psychiatric centre providing acute shorttermpsychiatric care. Patients were interviewed shortly after finishingseclusion and were asked to rate nine possible views of seclusion.Fifty-four patients (69%) provided informed consent. Most of thesepatients were suffering form psychotic disorders (67%). For allpatients we found an average score of 3.1 on positive items and 2.4 onnegative items. This significant difference (p=0.001) of 0.7 means thatpatients have more positive than negative feelings on seclusion.Patients staying on a more-persons room had a significantly morepositive view on seclusion compared to patients on a one-personroom. In conclusion, staying on a more-persons room was associatedwith positive feelings on seclusion, whereas patients from one-personrooms were more negative. It is worrying that a lack of psychologicalspace may make seclusion more ‘acceptable’ to patients.PO3.64.OUTPATIENT COMMITMENT LAW IN NEW YORKD. Garza 1 , G. Collins 2 , J. Idowu 3 , G. Murphy 41 Elmhurst Hospital Center; 2 Bellevue Medical Center; 3 WoodhullMedical Center; 4 Visiting Nurse Service, New York, NY, USAThe Assisted Outpatient Treatment (AOT) program implements a lawthat was passed in the State of New York to address dangerousness andrepeated hospitalizations among certain psychiatric patients who werenon-adherent to their outpatient treatment. "Kendra's Law" waspassed in 1999 to legally compel individuals to their outpatient treatmentunder risk of involuntary removal from the community if noncomplianceand clinical deterioration occur under such a court order.The law compels AOT programs to investigate, develop and monitortreatment plans for individuals meeting eligibility criteria, petition thecourt for orders and renewals of orders, and provide testimony duringhearings. Clients' stability and compliance with treatment plans specifiedby the court order are monitored closely. Providing the least restrictivecombination of services that will ensure safety in the communitymaximizes clients' stability and compliance. Voluntary agreements tobe monitored by AOT, outside of the purview of the courts, are offeredto some clients. Clients have free legal representation throughout theseprocedures to ensure maximal protection of their civil rights. Theauthors present the framework of these programs, the clinical experienceunder the new law, some legal challenges that have occurred andhow patients are affected by this strong approach. This developingmodel of care and its impact on clients with various diagnostic profileswill be explored. The ability of this law to ensure that clients sufferingfrom more disabling forms of mental illness have access to a safe andsupportive existence in communities will also be examined.PO3.65.PSYCHIATRIC MORBIDITY IN THE IRISH PRISONPOPULATION: AN INCIDENT SURVEY AND ITSIMPLICATIONS IN ILLNESS MANAGEMENT IN THEREMANDED AND SENTENCED POPULATIONK. Curtin, B. Wright, S. Monks, D. Duffy, H. KennedyNational Forensic Psychiatry Service, Central Mental Hospital,Dublin, IrelandThis study aimed to ascertain the prevalence of mental illness andsubstance misuse among men committed into the Irish prison servicewithin forty-eight hours of committal. The research ethics committeegranted approval, and informed written consent was given by all participants.We interviewed prisoners in the main remand and sentencedprisons in Dublin within forty-eight hours of their committal.Those who refused to be interviewed did not cause any detectablebias. We used the Schedule for Affective Disorders and Schizophrenia– Lifetime Version (SADS-L), and a semi-structured standardisedinterview for further demographic and personal details. At themoment we have interviewed approximately 450 persons, and theseearly results are calculated from 357 cases. They suggest that lifetimeprevalence rates of psychosis (8.1%) and major depression (10.1%)are high. We have noted a difference in severe mental illness (SMI)between the sentenced and remand committals, the latter havinghigher rates of psychosis (9.5% vs 3.5%). 2.6% of the remand committalswere felt to require urgent psychiatric admission at the time ofinterview, compared with none of the sentenced committals. Of theremand committals 36% had a past history of substance abuse, and32.2% had a history of substance dependence. The remand committalswill form a more transient population than the sentenced. Manyof them, depending on court disposals, are soon to return to the community.In a certain proportion of cases they are fit to plead, but arestill significantly psychiatrically unwell. The greater prevalence ofSMI in remand committals, as well as high rates of substance andalcohol morbidity, homelessness, unemployment, and recidivismdelineates a need for close liaison between the forensic, local community,and homeless psychiatric services, and adequate resources tomeet this need. This, of course, is a lesser problem in sentenced committals,where there is usually more time to treat illness (dependenton sentence length) and substance morbidity, if health services areadequately resourced. There is also more time for patients to obtainadvice and supports to stabilise their future social circumstances viathe prison probation and welfare services.PO3.66.PSYCHIATRIC MORBIDITY IN THE IRISHPRISON POPULATION: REMANDED MENS. Linehan, D. Duffy, B. Wright, K. Curtin, H. KennedyNational Forensic Psychiatry Service, Central Mental Hospital,Dundrum, Dublin, IrelandWe aimed to determine the prevalence of mental illness and substancemisuse among remanded prisoners. We interviewed 127 of the400 prisoners from Cloverhill Prison, using a random stratified samplingmethod. We also interviewed 103 of the 123 prisoners onremand in the other centres. The Schedule for Schizophrenia andAffective Disorders, Lifetime Version (SADS-L) was administered todetect lifetime and 6-month prevalence of major mental illness. Diagnosiswas made according to ICD-10 research diagnostic criteria. Thesix-month prevalence of psychosis was 7.6% (95% CI 5.7-10.2) andthe lifetime prevalence was 12.4% (95% CI 9.9-15.5). 83.5% of thepsychotic prisoners had a lifetime history of drug or alcohol problems323

(95% CI 72.9-90.6). This did not differ significantly from the non-psychoticgroup (73.7%, 95% CI 69.7-77.2). The high levels of morbiditydetected indicate a substantial unmet need for mental health servicesand for addiction treatment services.PO3.67.PSYCHIATRIC MORBIDITY IN IRISH WOMENPRISONERSD. Duffy, S. Linehan, H. KennedyIrish National Forensic Service, Central Mental Hospital,Dublin, IrelandThe study aimed to estimate the prevalence of psychiatric morbidity,substance abuse problems and related health and social problemsamong women prisoners in the Irish prison population. Female prisonersrepresent approximately 3% of the Irish prison population. InJune 2001 there were a total of 93 female prisoners in custody in Ireland.We interviewed 98 female prisoners (21 remanded and 77 sentenced).The Schedule for Schizophrenia and Affective Disorders,Lifetime Version (SADS-L) was used to measure prevalence of majormental illness. Substance misuse was measured using the SADS foralcohol and the Severity of Dependence Scale for other intoxicants.The twelve-month prevalence of psychosis (ICD-10 F11.5-F34) was3.1%, for major depression 27.6% and for anxiety disorders 15.3%.The twelve-month prevalence of deliberate self-harm was 12.7%.Deliberate self-harm was found to be significantly associated with ahistory of substance misuse problems. The prevalence of harmful useor dependency on alcohol or drugs (ICD-10 Research Diagnostic Criteria)in the year prior to committal was 62.5%. Self reported rates ofinfection with hepatitis C and human immunodeficiency virus (HIV)were 35.4% and 8.2% respectively. Rates of intravenous drug use andinfectious disease were higher in these female prisoners than in theirIrish male counterparts. We also found evidence of a cycle of deprivationand institutionalisation.PO3.68.DELIBERATE SELF-HARM IN THE IRISH MALEPRISON POPULATIOND. Duffy, S. Linehan, K. Curtin, B. Wright, S. Monks, H. KennedyCentral Mental Hospital, Dublin, IrelandThe study aimed to estimate the prevalence of deliberate self-harm(DSH) amongst Irish male prisoners and to identify associated riskfactors and co-morbidity levels. We interviewed 438 sentenced prisoners,235 remand prisoners and 288 new prison committals. The Schedulefor Schizophrenia and Affective Disorders, Lifetime Version(SADS-L) was used to detect lifetime and 6-month prevalence ofmajor mental illness. Substance misuse was measured using the SADSfor alcohol and the Severity of Dependence Scale for other intoxicants.DSH details were documented as part of a semi-structured standardisedinterview. 26.4% (n=254) of the total sample (n=961) had aprevious history of DSH. The lifetime prevalence of DSH was 28.3%(n=124) for sentenced prisoners, 31.6% (n=74) for remand and 19.7%(n=56) for new committals. The 6-month prevalence of DSH was1.8% (n=8) for sentenced prisoners, 7.3% (n=16) for remand and3.6% (n=10) for new committals. Lifetime history of DSH was significantlyassociated with a lifetime history of psychosis (p

group of patients with severe mental disorders (F20-F29, F31 and F6,according to ICD-10) who have been involved in judicial processesand are currently receiving treatment from various mental healthgroups in districts of the Andaluz Health Service, with the purpose ofdetermining whether, during their arrest, trial and jail confinement,their mental disorder had been taken into account, and if they hadreceived special attention in the elaboration of psychiatric assessmentand administration of specialized treatment.PO3.71.ASSESSMENT OF THE CAUSESOF VIOLENCE IN FAMILIES IN TEHRANS. Pournaghash-TehraniDepartment of Psychology, University of Tehran, IranDomestic violence is considered as one of the most prevalent problemsin families around the world, and often goes unreported. Thisphenomenon includes both violence against the child and thespouse. In general, the result of most of the studies done in this areaindicate that the underlying causes of this phenomenon includesocio-cultural, family, and personal factors. In other words, thesestudies have identified the causes of domestic violence at three differentlevels of the society, that are macrolevel (socio-cultural),mesolevel (family relationship) and microlevel (individual) factors,the interaction of which leads to the occurrence of family violence.Given the importance of domestic violence and its impact on thefamily (physical and psychological), the present study attempted toidentify the main factors which cause the occurrence of domesticviolence in families in Tehran. The results showed that, in the eventof domestic violence, men are more likely to resort to physical methodswhereas women resort to psychological methods. Also, ourresults showed that factors such as witnessing parental argumentsand physical fights during childhood (in both men and women), orbeing the victim of domestic violence, were determining factors inpredicting whether the individuals, in order to resolve their disagreementswith their spouses later on, would resort to violence or not. Insummary, our results indicated that, in order to explain domestic violence,one needs to take into account the interplay of all factors inthe three aforementioned levels, which is an indication of the complexityof this undesirable phenomenon.PO3.72.THE INDEX OFFENCE - A GAMEOF CHINESE WHISPERS?G.S. Gosall, P. Lim, K. Kilbride, S. MannEdenfield Medium Secure Unit, Manchester, UKPatients in secure psychiatric units are often detained in hospital forlong periods. Over time memories of the circumstances surroundingadmissions fade and facts become distorted, especially when informationis passed from one party to another. We carried out a survey todetermine how well health professionals involved in the care ofpatients in a medium secure unit recalled details of index offences.Detailed information about the index offences was obtained for inpatientsat a medium secure unit. Mental health professionals involvedin the management of these inpatients were asked about several differentaspects of the index offences of these patients. Responses wereevaluated against the facts of each case, rated for depth of detail andaccuracy of recall. Recall of the details of index offences was generallypoor. There was a wide variation in the marks achieved by differentmembers of staff. The index offences of some patients were betterknown than others but this was not related to either length of admissionor recency of admission. Performance on different questions varied.In conclusion, the overall recall of the details of index offenceswas poor. Many of the interviewees commented "I should know this"and were surprised at the difficulty they experienced talking abouttheir patients. We expect that similar results will be found in otherclinical settings. The outcome of this survey has important implicationsfor the care of these patients and the safety of both staff andpublic, as decisions about care are regularly taken on a multidisciplinarybasis with the presumption that everyone involved is aware ofnature and severity of the index offence.PO3.73.PROTECTIVE AND VULNERABILITY FACTORS TODANGEROUS BEHAVIORS IN ADOLESCENTSM.T. ChumyCuenca City, EcuadorTo collect data on the frequency of protective and vulnerability factorsin a group of adolescents in the community is important to guidethe development of interventions aimed to prevent dangerous behaviors.We carried out, in the city of Basin (Ecuador), a descriptive epidemiologicalstudy, selecting randomly from a population of 1500youths, students of two secondary schools, 100 subjects of the meanage of 15 years. We used the questionnaire for protective factors andvulnerability developed by the Canadian Association of Law Teachers.Three categories were explored: resilience/emotional, capacity ofcitizenship and social structures. Protective factors were not representedwith a high frequency in the sample: 49% of the subjects wasfound to have an adequate self-esteem, 18% had adequate communicationabilities and 20% had abilities to handle routine conflicts. Vulnerabilityfactors were much more frequent, with 43% of the youthshaving feelings of despair, 48% conflicts in sexuality, 58% contactswith drug abusers and 50% a condition of poverty.PO3.74.THE VICTIMS OF THE STALKER:PSYCHOLOGICAL DAMAGEA. Nivoli, L. Lorettu, P. Milia, G. Nieddu, L.F. Nivoli, G.C. NivoliPsychiatric Clinic, University of Sassari, ItalyThis study describes several aspects of the psychological damage of thevictims of stalkers: the feeling to have suffered a physic-emotional violence;the feeling of loss of control of one’s life; the feeling of social isolation;the feeling of being unable to change the situation; the feelingsof guilt; the somatization of anxiety; the abuse of substances. Theseelements allow, from a clinical viewpoint, to identify the needs of thevictim and to delineate the therapeutic plan and, from a forensic viewpoint,to evaluate objectively the damage suffered by the victims.PO3.75.THERAPEUTIC ERRORS IN THE RELATIONSHIPBETWEEN THE PSYCHIATRIST AND THE STALKERL. Lorettu, P. Milia, G. Nieddu, A. Nivoli, L.F. Nivoli, G.C. NivoliDepartment of Psychiatry, University of Sassari, ItalyThis study describes some errors committed in clinical practice in themanagement of stalkers: the therapists blinded by the complex of the"savior"; the abused therapists; the therapists who do not know howto manage the irrealistic demands of the patients; the therapistsmanipulated by the stalker; the therapists who are not aware of thesyndrome of the "false victimization". Knowledge of the dynamicsbetween the therapist and the stalker can avoid several harmful con-325

sequences, including the exacerbation of the situation or the therapistbecoming himself a victim of the stalker.PO3.76.SUBTHRESHOLD SYMPTOMATOLOGY OF MOODDISORDERS SPECTRUM IN A SAMPLE OFANTISOCIAL SUBJECTSG. Pandolfo, M.R.A. Muscatello, A. Bruno, R. Cambria,G. D’Amico, S. Isgrò, L. Cavallaro, M. Guzzo, D. La Torre,M. Meduri, R. ZoccaliDepartment of Psychiatry, University of Messina, ItalyThe spectrum model identifies and recognizes the partial, atypical andmild clinical features of a full-blown disorder; all this often neglectedsymptomatology, when enduring, may be distressing and may influencetreatment selection and response. The aim of the present studyhas been to evaluate spectrum symptomatology referred to panic agoraphobic,mood, social anxiety, obsessive-compulsive and eating disordersspectrum symptoms in a sample of subjects with antisocial personalitydisorder. From a total sample of 129 male subjects convictedin the prison of Messina, 24 subjects with antisocial personality disorder(subgroup A) and 21 nonclinical subjects without axis I and II disorders(subgroup B) were selected. Both groups were assessed with theGeneral 5-Spectrum Measure (GSM-V), which evaluates the lifetimepresence of spectrum symptomatology. In the subgroup A, we found ahigh frequency of social anxiety symptoms (33.3%), followed by panicagoraphobic symptoms (25%), obsessive-compulsive (16.7%) and eatingsymptoms (4.2%), while mood spectrum symptoms resultedabsent. No significant differences were evidenced between the twosubgroups in spectrum symptoms except for mood symptoms. Themost interesting finding is the complete absence of mood spectrumsymptoms in antisocials. This seems relevant to the recent hypothesisof an inverse relationship between psychopathy and depression, as thetwo conditions would represent mutually exclusive constructs.PO3.77.OLANZAPINE VS. HALOPERIDOL FOR THEMANAGEMENT OF AGGRESSIVE BEHAVIORIN A FORENSIC PSYCHIATRIC HOSPITALA. Ferraro 1 , S. de Feo 2 , M.F. Patti 11 Forensic Psychiatric Hospital, Aversa, Caserta; 2 ForensicPsychiatric Hospital, Naples, ItalyWe tested the impact of clozapine vs. haloperidol on measures ofaggressiveness in a sample of 60 subjects admitted to the forensicpsychiatric hospitals of Aversa, Naples, and Barcellona, Italy. Thepatients were randomly assigned either to clozapine (30 mg/day) orto haloperidol (12 mg/day). The Dress-Durkee Hostility Inventoryand the Aggressive Questionnaire were administered before andafter treatment. On both scales, there was a statistically significantsuperiority of olanzapine in reducing the total scores.PO3.78.DEVELOPMENT OF AN INTEGRATED CAREPATHWAY FOR THE ASSESSMENT OFMENTALLY DISORDERED OFFENDERSP. Larmour, C. MacConnell, M. McManusBlair Unit, Royal Cornhill Hospital, Aberdeen, UKThe Grampian forensic psychiatry service provides assessment andtreatment for mentally disordered offenders and other individualswith complex mental health and social needs. Patients are admittedfrom the criminal courts, prison service and Scotland’s maximumsecure facility. The aim of introducing the integrated care pathway(ICP) was to provide an agreed structure to the assessment processthat members of staff could use. This aims to identify needs forpatients ongoing care and to inform psychiatric recommendations tothe court. The project involved all disciplines working within theservice. A consensus agreement by each discipline involved in thecare pathway was achieved for the individual elements of the multidisciplinaryassessment process and the design and layout of the ICPdocument. A first draft was circulated outside the core project teamfor wider comment and training provided on the use of the document.Finally, a time plan was agreed for implementation of the pathway.The document was completed and implemented and is nowused by all multi-disciplinary staff within the clinical team. Theprocess of setting up an ICP can be lengthy and time consuming, asall members of the team have to be involved. However, once established,the staff can be confident that their patients follow an agreedevidence based protocol of care.PO3.79.PSYCHIATRY AND RISK OF AGGRESSION:RESULTS OF A SURVEYA. Berti, C. Maberino, S. BomarsiSection of Psychiatry, Department of Neurosciences,University of Genoa, ItalyA questionnaire aimed to identify any aggression suffered from thepatients was distributed to the staff of mental health services of thetown of Genoa during April 2003. The majority of reported assaultswere slight injuries suffered by nursing staff and they mostlyoccurred in a ward. Patients with schizophrenia, affective disordersand personality disorders (especially borderline personality disorder)were most frequently involved. The authors examined possiblerisk factors for an episode of violence, including variables concerningthe patient and variables related to the therapist, particularlycountertransference. The implications of the data for prevention ofthis occupational hazard are discussed.PO3.80.ANALYSIS OF 1019 CASES OF SEXUAL ABUSEA. Berti, C. MaberinoSection of Psychiatry, Department of Neurosciences,University of Genoa, ItalyA questionnaire aimed to assess the prevalence of sex abuse and itscharacteristics in the general population was distributed in the city ofGenoa through the Italian Association for Demographic Education(AIED) during a period of 42 months. Of 1019 respondents, 588reported they had experienced some kind of sexual abuse. The abuseoccurred in 42.2% of cases before the age of 10. The most frequentkind of abuse was by kisses and/or caresses (38.3%). Abusers weremostly acquaintances of the victims (38.8). 46.9% of the subjectsreported the occurrence of dissociative symptoms at the time ofassault. The presence of these symptoms was not correlated to the callfor help. Women and children were the most frequent victims ofabuse. Only 156 respondents asked for help. 35.7% of the abusedsubjects declared they do not want to ask for help for that kind ofexperiences. These data show how widespread is the phenomenon ofsexual abuse and how significant are its emotional consequences.326 World Psychiatry 3:S1 - October 2004

PO3.81.SUBSTANCE USE AMONG JUVENILE DELINQUENTSAT SEKOLAH TUNAS BAKTI, KUALA LUMPURC.C. Low, H. Aili, J. Stephen, G. JesjeetUniversity Malaya Medical Center, Kuala Lumpur, MalaysiaUsing an ad-hoc questionnaire, we surveyed 61 out of 103 inmates froman approved school in Kuala Lumpur, selected by random sampling.The questionnaire included questions on tobacco, alcohol and drug useand on the crimes they had committed before being sent to the school.We found that about 95% of the inmates used tobacco, with a mean ageof first usage at 12 years old. Cannabis (61%) was next to tobacco in thelist. Alcohol contributed to about 54% and solvents to about 31% ofthe sample. Amphetamines and heroin usage is now on the rise, bothcontributing to about 16%. Of the crimes committed, vehicle theftformed the majority (36%), followed by house breaking (24.6%), andstealing (19.7%). Adolescent drug use and delinquency should not betaken lightly, as these behaviors may persist into adulthood. Interventionat this early stage may decrease the likelihood of aggression due tosubstance abuse and of delinquent behavior in later years.PO3.82.PROSPECTIVE EXAMINATION OF THE COURSEAND STABILITY OF PERSONALITY DISORDERSIN DIFFERENT ETHNIC GROUPSC.M. Grilo 1 , M.T. Shea 2 , C.A. Sanislow 1 , A.E. Skodol 3 ,J.G. Gunderson 4 , R.L. Stout 2 , M. Pagano 2 , L.C. Morey 5 ,M.C. Zanarini 4 , T.H. McGlashan 11 Yale University, New Haven, CT; 2 Brown University, Providence,RI; 3 Columbia University, New York, NY; 4 Harvard University,Boston, MA; 5 Texas A&M University, TX, USAThis study aimed to examine and compare the course and stability ofschizotypal (STPD), borderline (BPD), avoidant (AVPD) and obsessive-compulsive(OCPD) personality disorders (PDs) among threeethnic groups over two years of prospective multi-wave follow-up.The Collaborative Longitudinal Personality Disorder Study (CLPS) isa National Institute of Mental Health (NIMH)-funded prospectivenaturalistic study of personality disorders and major depressive disorderbeing conducted at four institutions (Brown, Columbia, Harvard,and Yale Universities) in the United States. Seven hundred and thirty-threeparticipants who met criteria for one or more of the four PDsor for major depressive disorder (MDD) without any PD were recruitedfrom multiple clinical settings. The current report is based on 680participants for whom follow-up data were available; of these, 108 areAfrican-American, 94 are Hispanic-American, and 478 are Caucasian.Criteria were rated and diagnoses established by experiencedresearch clinicians using the Diagnostic Interview for Personality Disorders-IV(DIPD-IV). Follow-up assessments, conducted at 6, 12,and 24 months following the baseline assessment, included monthlyratings of all criteria for the four study PDs (DIPD-FAV). Inter-rater,test-retest, and longitudinal reliabilities were good for the diagnosticassessments. Lifetable survival analyses, with Kaplan-Meier methods,were used to compare the rates of “remission” from the four PDgroups across the three ethnic groups. Overall, PD “remission” ratesranged from roughly 25% to 40% for a clinically significant and stringentdefinition of improvement (12 consecutive months with two orfewer PD criteria). Survival analyses revealed no significant differencesin the time to remission by ethnicity for STPD, AVPD, andOCPD groups. For BPD, the three groups differed significantly(Wilcoxin test for equality of rates, p=0.04), with the Hispanic groupshowing significantly less remission (15%) than the African-American(35%) and Caucasian (31%) groups. In conclusion, viewed ascategories, PDs show moderate levels of stability over 24 months offollow-up, and their course may show some different patterns acrossdifferent ethnic groups.PO3.83.DEVELOPMENT AND EVALUATION OF A COGNITIVEBEHAVIOUR THERAPY PROGRAMME FORPATIENTS WITH PERSONALITY DISORDERSP. Zorn, V. Roder, M. Thommen, W. TschacherUniversity Hospital of Social and Community Psychiatry,University of Bern, SwitzerlandSome studies have showed favourable effects of cognitive behaviourtherapy on the course of personality disorders. Nevertheless there isstill a paucity of standardised cognitive behaviour group therapyapproaches targeted at a wide spectrum of indications, and whichcan be meaningfully integrated into existing health care concepts.Against this background, we developed a new group programme(Bern Integrative Therapy, BIT) for patients with personality disordersfrom all clusters (A to C; DSM-IV). The therapeutic methodologyof BIT is primarily oriented towards psychoeducation, clarificationof different styles of dysfunctional personality states and modificationof cognitive, emotional and behavioural processing, receivingand sending abilities. Currently a multi-centre study is being conductedevaluating the BIT. 70 patients with personality disorders(according to DSM-IV) participate. The experimental group (n=35)receives the new therapy programme, the control group (n=35) istreated with a "classical" behaviour therapy approach (social skillstraining, SST). After a therapy phase of 15 weeks, a catamnesticphase of 37 weeks follows. Allocation to the two treatment conditionsis randomised. The data collected till now indicate an improvementof self-efficacy, emotional coping, and maladaptive interpersonalbehaviour styles in the experimental group. Furthermore, areduction of symptomatic impairments and the individual sufferingas well as an improvement of the level of psychosocial functioningcan be observed. These first results might indicate that our new therapyapproach could be used in psychotherapeutic standard carewithin and outside psychiatric hospitals.PO3.84.NOT DEFICIT BUT EXCESS:COPING IN PERSONALITY DISORDERSO. Puig, F. Gutiérrez, J.M. Peri, X. Torres, J. Jaén, B. SuredaPsychiatric and Psychology Clinic Institute, Hospital Clínic,Barcelona, SpainDSM diagnoses of personality disorder (PD) lack a theoretical backgroundand are useless for guiding psychotherapy. A number ofattempts are currently undergoing in order to adapt the Axis II taxonomyto more informative, useful, and theoretically sound psychologicalconstructs, such as coping. Furthermore, the modification of copingstrategies improves the PDs’ prognosis. The aim of this work is tostudy the coping strategies that characterize PDs and, accordingly,should be the focus of the psychological interventions. We studied382 outpatients with a broad range of PD severity. We used the PersonalityDiagnostic Questionnaire (PDQ-4), which assesses DSM PDcriteria and the COPE, which assesses the disposition to use 15 differentcoping strategies structured in three wider coping dimensions:problem-focused, emotion-focused and dysfunctional. Subjects wereassigned to several levels of PD severity by means of the PDQ-4 andinter-group differences in coping were tested by ANOVA. The use of327

some adaptive coping strategies slightly decreased with the severity ofPD (‘positive reinterpretation’ and ‘acceptance’), whereas dysfunctionalstrategies (‘venting emotions’, ‘denial’, ‘mental disengagement’,‘behavioral disengagement’ and ‘alcohol/drug use’) were markedlyincreased. A strong relationship between PD severity and the relativeuse of adaptive and maladaptive strategies was found. PDs, as awhole, are more characterized by the over-utilization of dysfunctionalstrategies than by a deficit on adaptive ones. Psychological interventionsshould primarily focus on the extinction or blockade of dysfunctionalstrategies.PO3.85.IMPULSIVITY, APATHY AND COGNITIVEEXECUTIVE FUNCTIONSR. Cambria, L. Cortese, M. Magistro Contenta, A. Bruno,M.R.A. Muscatello, D. La Torre, R. Zoccali, M. MeduriDepartment of Psychiatry, University of Messina, ItalyImpulsivity, apathy and cognitive executive dysfunction are all neuropsychologicalfeatures which may be present in the context of bothaxis I and axis II psychopathology. Moreover, they can be consideredas “trait” features within non-clinical personality organizations. 50non-clinical subjects (20 males and 30 females, mean age 42.08±15.9)underwent a psychometric and neuropsychological examination withthe Marin Apathy Scale, the Barratt Impulsiveness Scale, the WisconsinCard Sorting Test (WCST) (number of completed series andperseverative errors), the Stroop Colour Word (attentional resistanceto interference), and the AB-AC (proactive mnestic interference relatedto learning) for the evaluation of executive functioning. Negativecorrelations were observed between apathy and impulsivity, positivecorrelations among lower performances at WCST, apathy and impulsivity.Moreover, attentional resistance to interference and proactivemnestic interference related to learning were related with perseverativeerrors but not with the number of completed series at WCST. Nocorrelations were observed with apathy and impulsivity. A growingbody of research supports the role of executive functioning in thedimensions of apathy and impulsivity in clinical samples of axis I andaxis II disorders. The present study showed that also in non-clinicalsamples executive functions may contribute to plasticity of apathicand impulsive behaviors. In this context, as executive functioning is acomplex organization which involves forward planning, cognitiveflexibility and self-regulation, it would be more useful to identify thesimpler, specific processes that underlie the global executive function.PO3.86.COGNITIVE SYMPTOMS IN PSYCHOSESAND NEUROBIOLOGICAL HYPOTHESES:A CONTROLLED STUDYF. Bolino, S. Marinelli, V. Di MicheleDeparment of Mental Health, Pescara, ItalyThought disorders are among the most important cognitive symptomsin psychoses. They occur with a high frequency in schizophrenia andaffective psychoses, and within the families with affected individuals.The aim of the present study was to explore the discriminant significanceof cognitive symptoms in bipolar and schizophrenic patients.The sample consisted of 10 schizophrenic patients and 10 bipolarpatients (DSM-IV criteria) and 10 healthy controls. We used the Italianversion of the Thought Disorder Index (TDI). We found statisticallysignificant differences between schizophrenic and bipolarpatients and between bipolar patients and controls. Qualitativeanalysis suggested some specific features in the two diagnosticgroups. Two alternative hypotheses about thought disorders as indicatorsof concurrent and construct validity of the concept of psychosiswere formulated: a) anomalies in excess of semantic memoryand b) deficit of working memory.PO3.87.QUETIAPINE IN BORDERLINEPERSONALITY DISORDERV. Marola, R. Pollice, E. Di Giovambattista, M. CasacchiaDepartment of Psychiatry, University of L'Aquila, ItalyWe present the preliminary data on six outpatients with borderlinepersonality disorder (DSM-IV criteria), treated with quetiapine for 12weeks. The target sample will consist of 15 patients. Quetiapine clinicalefficacy has been evaluated by means of the Hamilton Depressionand Anxiety Rating Scales, the Brief Psychiatric Rating Scale (BPRS),the Modified Overt Aggression Scale, and Clinical Global Impression(CGI). Possible side effects have been assessed by the KrawieckaManchester Rating Scale (KMRS). Cognitive functionality has beenanalysed using a neuropsychological set of tools to assess attention,cognitive flexibility, psychognosis, and cognitive functions. All thepatients (5 females, 1 male; mean age 34±4.5 years) completed treatment.The mean quetiapine dose was 300 mg/day (range 250-550mg/day). Impulsivity, aggressiveness, depression, and anxiety remarkablydecreased (p

PO3.89.ATTACHMENT STYLES, ALEXITHYMIA,DEPRESSIVE AND ANXIETY SYMPTOMSIN UNIVERSITY STUDENTSD. Sorrentino, A. Tonni, G. Piegari, S. Garramone, F. Mancuso,A. Mucci, M. MajDepartment of Psychiatry, University of Naples SUN,Naples, ItalyEvidence has been provided that insecure attachment is a risk factorfor psychiatric disorders. In the present study, the attachment stylewas investigated in 267 university students by means of theBartholomew Scale (BS), the Attachment Style Questionnaire (ASQ)and the Parental Bonding Instrument (PBI). Alexithymia was evaluatedby means of the Toronto Alexithymia Scale-20 items (TAS-20).Psychopathological assessment was carried out by means of the ZungSelf-Rating Anxiety Scale (SAS) and the Zung Self-Rating DepressionScale (SDS). An insecure attachment style was observed in 56% ofthe subjects, alexithymia in 33%, anxiety and depressive symptoms in43% and 33% respectively. Subjects with anxious symptoms andthose with depressive symptoms, as compared with subjects withoutsymptoms, showed: a) less confidence in self and others, more needfor approval, higher emotional involvement and discomfort withcloseness, as assessed by the ASQ; b) a perceived parental attachmentpattern characterized by overcontrol and lower care, as assessed byPBI; c) more difficulty in the identification and description of feelingson the TAS-20. Insecure attachment style, alexithymia, anxious anddepressive symptoms were significantly related to each other. Ourfindings suggest that an insecure attachment style may be a risk factorfor anxiety and depressive symptoms and that this relationship ismediated by an impairment in the identification and description offeelings.PO3.90.EMOPHANIA, A “POSITIVE”VIEW OF BORDERLINEPERSONALITY DISORDERA. TortosaAssociation d’Aide aux Personnes Etats Limite Borderline,Lille, FranceOne of the most significant fears of a person with borderline personalitydisorder (BPD) is "to lose oneself" in a therapy. Many are thosewho think (wrongly) that it is their borderline disorder which madethem what they are now. Thus, some may violently reject the BPDdiagnosis because, in their mind, they would no more be "me" but "mydisorder", a situation which would be highly destabilizing. Therefore,they say: "if I am sensitive it is because I have BPD" or "who would Ibe without this disorder?" The truth is that "it is not because I sufferfrom a borderline disorder that I am sensitive, but because I am sensitiveI was in a population at risk to develop a BPD". Therefore, "recoveryfrom the disorder is not to lose my sensitivity but to get rid of myBPD". In my experience, BPD people have almost all (at least inside ofthem) of the following traits defining emophania: altruism, self-derision,kind-hearted, curiosity, empathy, enthusiasm, very demanding ofoneself, strength of character, generosity, modesty, naivety, openmindedness,taking a new look at oneself, sensitivity, probity. What isthe connection between "being emophane" and "having a borderlinedisorder"? According to my theory, a person suffering from BPD is an"emophane". An "emophane" person may not suffer from any disorder,or he/she may have developed psychiatric disorders such as anavoidant personality disorder or BPD.PO3.91.SPECT VIDEO EMOTIONAL ACTIVATIONPARADIGM IN BORDERLINE PERSONALITYDISORDER: A PILOT STUDYC. Lai, S. Daini, M.L. Calcagni, F. Cirillo, S. De RisioInstitute of Psychiatry and Psychology, Catholic University,Rome, ItalyBorderline personality disorder is mainly characterised by instability ofself-esteem, interpersonal relations and mood. The tendency to react tofrustrations with acting outs suggests the presence in such patients of adifficulty in the symbolising process, that does not allow a correct"mentalization" and therefore the attribution of a meaning to the stressfulevents. Several neurobiological studies of borderline personality disordershow a pattern characterised by hypoactivity of frontal and prefrontalareas and a malfunctioning of amygdala. We performed singlephoton emission tomography (SPECT), using a video emotional activationparadigm, in a patient with borderline personality disorder anda control subject. Faced with violent scenes in the video, the patient,but not the control subject, showed an activation of limbic areas andprefrontal cortex. This activation pattern may be the neurobiologicalcorrelate of a cognitive activity put in action in order to manage thestrong emotion triggered by the video, absent in the control subject.PO3.92.THE ROLE OF FAMILY FACTORS IN THEDEVELOPMENT OF GENDER IDENTITY DISORDERM.A. BesharatDepartment of Psychology, University of Tehran, IranGender identity disorder, characterized by strong and persistentcross-gender identification accompanied by persistent discomfortwith one’s assigned sex, is a multifactorial clinical condition. Biological,psychological, social and family factors each play a determinantrole in the development of the disorder. The aim of this study was toexamine the role of family factors. Eighteen male referrals for treatmentof gender identity disorder and their family members wereincluded. A semistructured interview was carried out to investigatefamily variables including closeness/distance, hierarchies, and interactions.Gender identity disorder was shown to be significantly relatedto family factors of “mother-son enmeshed relationship”, “higherposition of the mother in family hierarchy”, and “mother-son conflictualinteraction”. Mother-son enmeshed relationship develops,reinforces and/or establishes the opposite sex characteristics through“identification” mechanism. Higher position of the mother at the topof family hierarchy serves to continue the pathological process ofidentification with opposite sex (the mother) through the mechanismof “paradoxical authority”. Although “mother-son conflictual interactions”are a product of the prementioned family factors, they can persistand interfere with the process of psychotherapy, predictingrelapse.PO3.93.LIVING WITH CONTRADICTIONS:EXPERIENCES OF SAME-SEX ATTRACTED MENWITHIN HETEROSEXUAL MARRIAGED.J. HigginsDeakin University, Geelong, AustraliaMarried or previously married men who have sex with men are confrontedby a unique range of issues and challenges in regards to selfidentityand the negotiation of transitions between personal and pub-329

lic identities. Such challenges highlight the complex interrelationshipsbetween the lived experience of same-sex attraction, and the discursivecontext in which such attraction occurs for them: heterosexualmarriage. In-depth interviews were conducted with 25 men who havesex with men who were previously, or currently, married to a woman.Open-ended questions were used to elicit participants’ childhoodexperiences, identity and disclosure issues, reasons for marriage, sexualbehaviours, children, mental health issues, their regrets, and theirhopes for the future. Some thought of themselves as ‘gay’ before theymarried; some realised after; a few saw themselves as attracted to bothmen and women. A common theme was the importance of children, asa reason for marriage (along with other societal pressures and theinternal pressure to be ‘straight’), and as one of the best things abouttheir life. The men described their periods of confusion and inner turmoilin terms of sadness and pain, some reporting depression and suicidality.Most situated themselves in a caring stance in relation to theirwife/ex-wife, expressing concern for her well-being, regret for the painthat they directly or inadvertently caused her. Some situated themselvesin an antagonistic stand-off. These self-representations are discussedin the light of the previous literature, with a focus on suggestionsfor therapeutic goals and strategies.PO3.94.MENTAL HEALTH TREATMENT IN FAMILIESWITH INCESTUOUS RELATIONSC. Cohen, G.J. Gobbetti, J.R. Lippi, A.B. Rocha, R. Iyama,C.S.A. BomfimFaculdade de Medicina da Universidade de São Paulo, BrazilThe Center for Studying and Attending Relations with Sexual Abuse(CEARAS) provides mental health treatment to families with incestuousrelations referred by the courts. The existence of other incestuousrelations in the same family, the previous knowledge of the incestuousrelation by the mothers, and the lack of a symbolic perception of theboundaries, are among the features which have been observed in thefamilies. The data have been obtained through the analysis of 114incestuous families in 4 years. Other incestuous relations beyond thedenounced ones have been found in 40% of the families. The mother’sinvolvement has been observed through her difficulty ofdenouncing the partner. 42% of the incestuous relations involvingfather or stepfather (71% of total) have been denounced by the mother.However, 47% of these denouncements have been made after separationof the couple and the others have occurred as a consequenceof the conflicts between the couple. As an illustration, mother’s complaintsabout use of alcohol and other drugs by the partner haveappeared in 69% of these families whose mothers have denouncedthe current partner, contrasting with the percentage of these complaintsin the rest of the sample which involves fathers or stepfathers:17%. We consider the genital sexual relation between members of thefamily only a symptom of an incestuous familiar dynamics. For thisreason the treatment must involve the whole family.PO3.95.PERSONALITY, LIFE EVENTS ANDDISSOCIATIVE SYMPTOMS IN SUBJECTSWHO EXPERIENCED A CAR ACCIDENTM. Civiero, A. Gatti, E. Mercuriali, M. PierriDepartment of Neurological and Psychiatric Sciences,University of Padua, ItalyThis study analyses personality, life events and dissociative symptomsin a sample of car accident subjects, following a psychodynamic orientation.We collected a sample of 50 accident subjects, hospitalizedin a traumatological ward, and a control sample without a history ofaccidents for at least two years. The samples were matched for age,sex and education. We administered a semistructured interview focusingon the accident, the Paykel’s Interview, the Minnesota MultiphasicPersonality Inventory (MMPI) and the Dissociative ExperienceScale (DES). There was a significant difference (p=0.002) in theprevalence of life events (Paykel’s interview) in the six months beforethe accident: the probands experienced more life events, above all inthe undesiderable and uncontrollable categories. The MMPI’s Simulationand Hypochondria scores were higher in the accident sample.Probands also had significantly high scores on factor 2 (“typical activityof dissociated states”) and factor 3 (“depersonalization-derealization”)of DES. We intend now to explore the relationships betweendissociative symptoms, personality and life events.PO3.96.REPETITION, DISSOCIATIONAND LIFE EVENTS IN ACCIDENTSM. Civiero, M. Zordan, F. Carniello, G. Mazzi, C. Cecchetto,M. PierriDepartment of Neurological and Psychiatric Sciences, Universityof Padua, ItalyRoad traffic, job, home and leisure accidents are an important causeof morbility and social problems in the industrialized world. The aimof this study is to investigate the psychological factors related to havingan accident, referring to a psychodynamic theoretical background.We examined 338 subjects, aged 14-65, coming to an emergencyward between 15 and 22 March 2004, using a semi-structuredinterview, Paykel’s Interview for Recent Life Events and the DissociativeExperiences Scale (DES). 107 of them completed both the interviewand the tests: 81% reported at least one other accident in theirlife, 46% in the last two years; 46% reported at least one eventbelieved to be traumatic. 46% of the subjects expressed their awarenessabout recent life changes and 48% accepted responsibility aboutthe accidents. There was a strong correlation between total life eventsand mean DES values (p=0.003); factor 1, imaginative absorptioninvolvement(p=0.002); factor 2, dissociative states related activities(p=0.041); and factor 3, depersonalization-derealization (p=0.037).PO3.97.ACCULTURATIVE STRESS:A COGNITIVE-SOMATIC TREATMENT MODELJ. LippincottKutztown University Counseling Services, Kutztown, PA, USAThis presentation outlines an acculturative stress treatment modelderived from extensive research with subjects from over 20 countries.Acculturative stress (“culture shock”) is a reaction of internationalsojourners to cross-cultural conflicts, often developing when one’sinternalized cultural norms, both conscious and unconscious,become threatened or confused. A frequent symptom is cognitiveanxiety, referring to the cerebral processes that produce worry and theeffects of worry, including concentration difficulties and the experienceof anxiety-provoking thoughts and images. Another commonsymptom is somatic anxiety: the presentation of physical/bodily complaintsin response to stress. The model is a short-term treatmentdesigned to provide culture-specific knowledge and support and tomediate the effects of acculturative stress, particularly cognitive anxietyand somatization. It employs an integrated approach involvingpsychotherapy, psycho-education and psychotropic medication. Ini-330 World Psychiatry 3:S1 - October 2004

tial sessions assess the stressors affecting the patient, the patient’ssymptomatology, and appropriate treatment. The presentation outlineseffective cognitive interventions utilized by the model, intendednot to alter the patient’s cultural belief system, but to identify andmodify conflicts induced by cross-cultural inconsistencies. It suggestswhen anti-anxiety or other medications may be indicated. It also discusseseffective treatment of somatic discomfort via an establishedrelaxation training protocol enabling the patient to identify and ultimatelycontrol distressful physiological cues. The model uses diagnostictests to rule out underlying psychopathology in select casesand suggests when psychotropic medications may be indicated.The model’s combination of integrative mind-body therapeuticapproaches has proven to reduce symptoms and promote lastingacculturative adjustment.PO3.98.OBSERVATIONAL STUDY ON PSYCHIATRICSYMPTOMS IN IMMIGRANTS IN A FIRST AIDSETTINGC. Cremonese, N. Campagnola, F. SessaPsychiatric Section, Department of Neurological and PsychiatricSciences, University of Padua, ItalyWe studied a sample of 834 patients referred for psychiatric consultationin a first aid setting during the first six months of 2003. Immigrantsrepresented 9.3% of the sample. The average age of Italianpatients was 46 years, that of immigrants was 33 years. Among immigrants,the most represented area of origin was East Europe, followedby North Africa and Sub-Saharan Africa. The most prominent disordersin the Italian group were depressive and anxious-depressive syndromes,while in the immigrant group they were psychotic syndromesand anxiety disorders (p=0.03). We are now extending the sample,and analyzing quali-quantitative differences in presented symptoms(in particular in the characteristics of psychotic symptomatology),with a specific focus on transcultural and ethnical issues.PO3.99.THE SICK BUILDING SYNDROME:A BRAZILIAN STUDYW. Dunningham, W. AguiarFaculty of Medicine, Federal University of Bahia, BrazilThe sick building syndrome (SBS) is a condition in which occupantsof a building experience acute health effects that seem to be linked totime spent in a building, but no specific illness or cause can be identified.Building occupants complain of symptoms associated withacute discomfort: headaches; eye, nose and throat irritation; a drycough; dry or itchy skin; dizziness and nausea; difficulty in concentrating;fatigue; mood disturbances (depression and irritability) andsensitivity to odors. Specific causes of SBS remain unknown. Wereport the results of a Brazilian clinical study investigating aggressionin relation to serum testosterone in patients with SBS. We applied theAggression Questionnaire Revised, Brazilian Version (AQ-RBV) to16 females with SBS. The results suggest that aggression and irritabilityin female SBS patients can be increased by elevated testosteroneserum concentration.PO3.100.NEUROPSYCHIATRIC MORBIDITYIN WALL PAINTERS EXPOSED TO SOLVENTSIN RIO DE JANEIRO, BRAZILA.A. de Miranda Ramos 1 , J.F. da Silva Filho 1 ,S. Rodrigues Jardim 1 , R. Curi de Souza 2 , F. Costa 2 , M. Menezes 2 ,A. Schuenck Guilande 2 , L. Ramos Moreira 21 Institute of Psychiatry, Federal University of Rio de Janeiro;2 Centre for the Study of Health and Human Ecology,Fiocruz, BrazilOccupational exposure to solvents can cause neuropsychiatric problems.We carried out a clinical and neuropsychological evaluation ofpainters exposed to solvents in the maintenance department of theFederal University of Rio de Janeiro, comparing them with nonexposedworkers. Exposed workers (n=58) and non-exposed workers(n=20) underwent clinical evaluation, laboratory tests, occupationalanamnesis, standard psychiatric anamnesis. We used the Clinical InterviewSchedule (CIS), the Q-16 test, the Rey Osterreith Complex Figure(ROCF) Test, the Coding Subtest of the Wechsler’s Adult IntelligenceScale (WAIS), the Computerized Visual Acuity Test (TAVIS2R) andboth series of Manual Dexterity Tests. The workers were male, with anage ranging from 41 to 50 years, and 13 years of average employmenttime. Among the exposed workers, about 70% had another incomesource and the most frequent occupation was that of free lance painter.As regards CIS in the exposed group, 93% were considered “negative”for values >19; the highest scores were found for reported symptomssuch as irritability, sleep disturbance and lack of concentration. All thenon-exposed workers were considered “negative”. The Q-16 testrevealed 79% of “negative” workers in the exposed group and 100% inthe non-exposed group. The neuropsychological evaluation found significantdifferences between the two groups.PO3.101.SELF-INJURIOUS BEHAVIOUR IN ADULTSWITH INTELLECTUAL DISABILITYG.P. La Malfa, S. Lassi, M. Campigli, M. Venturi, M. Bertelli,G. PlacidiDepartment of Neurological and Psychiatric Sciences,University of Florence, ItalyIt has been reported that self-injurious behaviour occurs in 2-13% ofpeople with intellectual disability and that is commoner in males, insevere intellectual disability and in autism. To investigate this, weassessed the presence of self-injurious behaviour through a directclinical observation in a sample of 48 adults with intellectual disability(23 females, 25 males; age range 25-34 years; average 41.4 years; 7with mild, 27 with moderate, 8 with severe and 6 with profound intellectualdisability; all from a semiresidential structure). 7 subjects(14.58%) presented self-injurious behaviour (1 eye poking, 2 skinpicking and scratching, 3 biting and 1 head banging): 3 were females,4 males; 2 with moderate, 4 with severe and 1 with profound intellectualdisability; 3 with a diagnosis of pervasive developmental disorder.Two were taking risperidone 2 mg/day, 2 fluvoxamine 200mg/day, 1 risperidone 9 mg/day and fluvoxamine 100 mg/day, 1sulpiride 200 mg/day and 1 was without pharmacological treatment.The results of this study seem to confirm international literature dataand therapeutical implications of self-injurious behaviour in peoplewith intellectual disability.331

PO3.102.EATING DISORDERS AND OBESITYIN PEOPLE WITH INTELLECTUAL DISABILITYG.P. La Malfa, S. Lassi, L. Cardini, E. Angeli, R. SalviniDepartment of Neurological and Psychiatric Sciences,University of Florence, ItalyIn this study a sample of 48 not institutionalised adults with intellectualdisability (23 females, 25 males; age range 25-34 years, average41.4 years; 7 with mild, 27 with moderate, 8 with severe, 6 with profounddisability) was investigated for eating disorders, using the DiagnosticAssessment for the Severely Handicapped-II (DASH-II) andICD-10 or DSM-IV-TR diagnostic criteria. 4 subjects (8.33%) werediagnosed as suffering from an eating disorder (1 male, 3 females, 1with mild and 3 with moderate disability). The diagnosis was bingeeating disorder in one case, eating disorder not otherwise specified intwo and anorexia nervosa in one. As a second step, the body massindex (BMI) was calculated for every single subject. Three subjects(6.2%) had a BMI30 (3 receiving antipsychotics).PO3.103.QUALITY OF LIFE IN PEOPLE WITH INTELLECTUALDISABILITY OR MENTAL DISORDERSM. Bertelli 1 , G. La Malfa 2 , E. Angeli 3 , S. Lassi 3 , R. Salvini 3 ,E. Bestini 3 , D. Scuticchio 31 Mental Retardation Section, World Psychiatric Association;2 Italian Association for the Study of Quality of Life; 3 Departmentof Neurological and Psychiatric Sciences, University of Florence,ItalyThe Quality of Life Instrument Package (QoL-IP) was translated toItalian through four revisions. The final instrument was administeredto a sample of 200 adult subjects, randomly chosen among patientswith intellectual disability (ID), mood disorders or schizophrenia,and healthy people. ID affected QoL less significantly than mentaldisorders. People who were considered clinically recovered from apsychiatric disorder still had significantly higher scores than healthycontrols.PO3.104.A NEEDS ASSESSMENT IN PATIENTS WITHFORENSIC LEARNING DISABILITYP. Quinn, M. BurnsYorkshire Centre for Forensic Psychiatry, Wakefield, UKWe report the results of a needs assessment conducted on a group ofpatients with forensic learning disability originating from two adjoiningStrategic Health Authority areas in Northern England. We foundthat patients described under the rubric of forensic learning disabilityare a heterogeneous group with wide ranging psychiatric needs. Themajority of population studied were cared for outside their geographicalarea of origin, either in specialist national health service (NHS)facilities or the independent sector. Those with an additional diagnosisof mental illness were most likely to be detained in NHS facilitieswithin the region; a diagnosis of personality disorder was associatedwith placement in either a high secure setting or the independent sector.Individuals with no diagnosis other than mental retardation weremost likely to be detained in services provided by specialist learningdisability/mental health trusts out of the area. There were a smallgroup of female patients who were all placed outside the region.Offending behaviour was most likely to consist of violence againstperson, sexual offences and arson. The majority of the populationassessed were felt to have long-term needs. The study raised importantconsiderations for statutory provision of forensic services acrossthe area, particularly the need to offer services with a treatmentregime germane to the needs of the population under review.PO3.105.INTEGRATION OF HANDICAPPEDCHILDREN IN THE COMMUNITYA. RacuIon Creanga Pedagogical State University, Chisinau, MoldovaOur study focused on children with psychic/motor problems, withspecial regard to their adjustment within the family and their work andsocial integration after leaving school. The investigation allowed us toelaborate a number of tools (medical, psychic-pedagogical, social,etc.) which can help to face the problem of handicapped children.PO3.106.PRENATAL AND POSTNATAL FACTORSPREDISPOSING TO PSYCHIC/MOTORDISTURBANCES IN CHILDREN IN MOLDOVAT. PlamadealaHumanitas, Chisinau, MoldovaWe investigated the prenatal and postnatal factors predisposing topsychic/motor disturbances in the newborn children in Moldova. Atthe same time, we elaborated a programme of prevention focusing onthese factors. Among the ecological predisposing factors, are the consequencesof the Chernobyl catastrophe and the irrational use ofchemicals, pesticides, exfoliates in agriculture. Among the psychosocialfactors, is the unstable socio-economic situation in Moldova, as aresult of the transition from a totalitarian state system to a democraticone.PO3.107.MOOD OR ANXIOUS DISORDERS IN SIGNIFICANTOTHERS OF PSYCHIATRIC PATIENTSG. Tavormina 1 , S. Corea 2 , A. Citron 3 , M. Tavormina 1 , P. Siriani 11 Center for Psychiatric Studies, Provaglio d’Iseo, Brescia; 2 P.A.Faccanoni Hospital, Sarnico, Bergamo; 3 Castelfranco VenetoHospital, Treviso, ItalyWe studied the significant others (SOs) of 264 adult patients withmood and anxious spectrum disorders, with the aim to explore inhow many of them the same disorder of the patient was present. Allreliable sources of information were used. 44% of the SOs had thesame disorder of the patient. A review of the above sample after threeyears and a study of a further group of 266 adult outpatients confirmedthe above results. Further studies should explore whether thedisorder of the SOs preceded their life in common with the patient orinstead arose from a difficult interpersonal relation.332 World Psychiatry 3:S1 - October 2004

PO3.108.COMBINING FUNCTIONAL NEUROIMAGINGAND BEHAVIORAL EXPERIMENTS TOINVESTIGATE THE FUNCTIONAL INTEGRITY OFBRAIN SYSTEMS IN PSYCHIATRIC DISORDERSO. Gruber, P. FalkaiDepartment of Psychiatry, Saarland University Hospital,Hamburg, GermanyThe interpretation of abnormal activation patterns in functional neuroimagingstudies under specific task conditions is only possiblewhen patients can perform the task correctly. This prohibits directinvestigation of the neural substrates of cognitive deficits in psychiatricdisorders. Therefore, in order to identify specific dysfunctionalcortico-subcortical brain networks in psychiatric patients, it is necessaryto combine functional neuroimaging studies in healthy humansubjects with corresponding behavioral experiments in both patientswith circumscribed brain lesions and patients with psychiatric syndromes.This approach may also allow to explore possible compensatoryneuronal mechanisms in patients with normal task performance.We will exemplify this approach in the area of executive functionswhich are disturbed in several psychiatric disorders. First, we willreview recent functional neuroimaging studies providing evidence forthe co-existence of two working memory systems in the human brainwhich differ from each other in terms of their functional-neuroanatomicalimplementation and presumably also with respect totheir evolutionary origin. These two brain systems may also have differentfunctional roles in the cognitive control of goal-directed action.We will then show results from behavioral and neuroimaging experimentsin brain-lesioned patients which served to validate this functional-neuroanatomicalmodel of human working memory. Finally,we will report corresponding behavioral investigations in patientswith schizophrenia and affective disorders that revealed specific dysfunctionsof these brain networks involved in executive functions.The findings of these studies may be helpful to improve diagnosticaccuracy and therapeutic efficiency.PO3.109.INTERPRETING INDIVIDUAL CHANGEON THE ANCHORED VERSION OF THE BRIEFPSYCHIATRIC RATING SCALEG. Iverson, R. Lange, J. BrinkUniversity of British Columbia, Riverview Hospital, and ForensicPsychiatric Hospital, Vancouver, CanadaThere is remarkably little information regarding how to interpretchange on the Brief Psychiatric Rating Scale. The purpose of this studywas to develop a new, psychometrically sophisticated method fordetermining whether a psychiatric inpatient has improved, remainedstable, or deteriorated. Lachar et al. conducted an exploratory factoranalysis on 1,556 patients that yielded four subscales for the test, andthen replicated them using confirmatory factor analysis on 1,234patients. The internal consistency of these subscales, as measured byCronbach’s alpha, was: resistance .78, positive symptoms .79, negativesymptoms .74, and psychological discomfort .81. Simultaneous ratingsof 131 inpatients by an attending psychiatrist and a resident yieldedthe following intraclass correlation coefficients: resistance .84, positivesymptoms .73, negative symptoms .60, and psychological discomfort.69. The above data from Lachar et al. was used to create reliablechange tables for the four factor scores and the total score. The standarderror of difference was computed for each subscale using the intraclasscorrelations and the standard deviations from each rater, andthen multiplied by z-scores creating reliable change confidence intervals(70%, 80%, and 90%). A quick reference table was created forroutine clinical use. To be 80% sure that a patient has improved ordeclined beyond the probable range of measurement error, his or herscore must change by 4 points for resistance, 6 points for positivesymptoms, 5 points for negative symptoms and psychological discomfort,and 13 points for the total score.PO3.110.BIAS IN THE LOCF METHOD FOR IMPUTINGMISSING DATA ILLUSTRATED WITH CLINICALTRIALS DATAR. Knapp 1 , Y. Palesch 1 , R. Martin 1 , W. Zhao 1 , M. Mueller 1 ,E. Yim 1 , C. Kellner 21 Medical University of South Carolina, Charleston, SC;2 University of Medicine and Dentistry of New Jersey, Newark,NJ, USAThe last-observation-carried-forward (LOCF) is a popular method fordealing with missing data on patients who prematurely drop out ofthe study. Because missing data are rarely missing completely at random,psychiatric researchers and biostatisticians increasingly arebecoming concerned with bias in outcome assessment that can resultthrough its use. We characterized, through a simulation study, thebias in estimating endpoint values resulting from the LOCF methodfor imputing missing data. Using real data from a psychiatry clinicaltrial, we simulated data loss at different time points and for 5-45%amounts of loss. The difference between the “true mean” HamiltonRating Scale for Depression (HAM-D) using complete data set andthe mean of the simulated data sets was used as a measure of LOCFeffect (bias). The probability of bias of a given magnitude for differentamounts of missingness was determined. Bias increased as theamount of missing data increased, ranging from near 0 when only 5%of data were missing and the missingness occurred near the end of thetreatment course, to 7.1 when 45% of data were missing and the missingnessoccurred early in the treatment course. The probability of biasof magnitude ≥3 was approximately 0.12 when 20% of the data weremissing and the missingness occurred uniformly over time. Theseresults illustrate that the difference between the “true” measure ofendpoint computed from complete data and that estimated usingLOCF can be large and its impact may depend upon the time andamount of missing data.PO3.111.WORKING WITH THE CULTURALOUTLINE (DSM-IV) IN DIFFERENT WAYSB. HäkanssonTranscultural Centre, St. Göran Hospital, Stockholm, SwedenThe Cultural Outline, CO (DSM-IV) is not widely known, and hardlyever used, in Swedish health care. The Stockholm County TransculturalCentre has addressed this issue by spreading information about,and encouraging the use of the CO within the multicultural health caresystem of Stockholm. Various reasons are given for not using thisinstrument, e.g. lack of familiarity, disagreement with the claim thatculture may be of importance in psychiatric diagnostics. Even thosewho agree that cultural aspects are important, never or rarely make useof the CO. Lack of time is an often mentioned reason. While time pressureis very much a clinical reality, there are still possibilities to makeconstructive use of the CO, not only within general psychiatric praticebut also in a liaison psychiatry setting, if it is used in an informal and333

imaginative way. The example to be presented is the author’s work aspsychiatric “pain consultant” at the St. Göran Pain Clinic. The clinicserves the entire population of Stockholm County on referral basisand offers psychiatric consultation as part of its multidisciplinary painmanagement and rehabilitation program. Approximately 40% of theclinic’s patients have an immigrant background. The CO has shownitself to be a useful tool for both patients and caregivers.PO3.112.AMERICAN INDIAN ADOLESCENTS’ PATHWAYS TOPSYCHIATRIC SERVICESA.R. Stiffman, S. Freedenthal, L. House, E. BrownGeorge Warren Brown School of Social Work,Washington University, St. Louis, MO, USAMental health service research on American Indian youth is virtuallynonexistent, despite their known high needs. This paper details the specialtyand nonspecialty service pathways of 401 American Indian Southwesternyouth. We examine the services of 196 urban and 205 reservationAmerican Indian youth, using the Service Assessment for Childrenand Adolescents (SACA). Questions were refined to include culturallyrelevant services from healers and informal providers (family, elders,etc.). 190 of the youth’s providers were interviewed to assess their training,salaries, and extent of services provided. The most common pathwayinto mental health, addiction, or behavioral services was throughthe courts or police (n=58). Informal helpers (parents, extended family,elders) were next (n=44), followed by self-referrals (n=29), teacher referrals(n=20), social worker referrals (n=19), and friend referrals (n=8). Noyouth was referred by a physician. Youth got to psychiatric services primarilyfrom informal helpers, to school services from informal helpers orteachers referral, to healers from informal helpers, and to nonspecialtysocial services from informal helpers or the courts. The most importantfindings were the absence of referrals from physicians, the key role ofinformal helpers, court, and self-referral in accessing psychiatric services,and the high referrals from the court and informal helpers. Toincrease access to mental health services, it is imperative to providepotential referrers training and referral support.PO3.113.MENTAL HEALTH SERVICE UTILIZATION IN CHILES. Saldivia, B. Vicente, R. Kohn, P. Rioseco, S. TorresDepartment of Psychiatry and Mental Health,University of Conceptión, ChileIn order to address the growing burden of mental health problems inLatin America, a better understanding of mental health service utilizationand barriers to care is needed. Many Latin American countrieshave nationalized health care systems that could potentiallyimprove access. The Chile Psychiatric Prevalence Study was a nationalhousehold survey of 2987 persons over the age of 15 in whomDSM-III-R diagnoses were obtained using the Composite InternationalDiagnostic Interview. The survey included a section that examinedmental health service utilization in the past six months, andexplored barriers to obtaining psychiatric treatment. Although therewas a high utilization of health care services in general, a large proportionof individuals who had a psychiatric disorder did not receivecare. The severity of the psychiatric disorder correlated with increasinghelp-seeking. Only a small proportion of individuals with a disordersought specialized mental health care services. Regional disparitiesand inequities in access to care exist in Chile. In addition, indirectbarriers to care are important deterrents to service utilization, in particularamong those with lower socio-economic status.PO3.114.REGIONAL DIFFERENCES IN PSYCHIATRICDISORDERS IN CHILEB. Vicente, R. Kohn, P. Rioseco, S. Saldivia, G. Navarrette,P. Veloso, S. TorresDepartment of Psychiatry and Mental Health, University ofConceptión, ChilePsychiatric epidemiological surveys in developing countries frequentlyare conducted in regions not necessarily representative of the entirecountry. These studies are often generalized to provide data on largepopulation pools. The Chile Psychiatric Prevalence Study using theComposite International Diagnostic Interview was conducted in fourdistinct regions of the country on a stratified random sample of 2,978people. Lifetime and 12-month prevalence and service utilizationrates were estimated. Significant differences in the rates of majordepressive disorder, substance abuse disorders, non-affective psychosis,and service utilization were found across the regions. The differentialprevalence rates could not be explained by socio-demographicdifferences between sites.PO3.115.PSYCHIATRIC DISORDERS AMONGTHE MAPUCHE IN CHILEB. Vicente, R. Kohn, P. Rioseco, S. Saldivia, S. TorresDepartment of Psychiatry and Mental Health, University ofConceptión, ChileThe Mapuche are the largest indigenous group in Chile. The studyexamined the prevalence rates of DSM-III-R psychiatric disorders andservice utilization among this group compared to the non-indigenouspopulation. The Composite International Diagnostic Interview (CIDI)was administered to a stratified random sample of 75 Mapuche and 434non-Mapuche residents of the province of Cautín. Lifetime prevalenceand 12-month prevalence rates were estimated. Approximately, 28.4%of the Mapuche population had a lifetime and 15.7% a 12-month psychiatricdisorder compared to 38.0% and 25.7%, respectively, of thenon-Mapuche. Few significant differences were noted between the twogroups; however, generalized anxiety disorder, simple phobia, and drugdependence were less prevalent among the Mapuche. Service utilizationamong the Mapuche with mental illness was low. This is a preliminarystudy based on a small sample size. Further research on the mentalhealth of indigenous populations of South America is needed.PO3.116.THE MINI-MENTAL STATE EXAMINATION:NORMS FOR A LATIN AMERICAN POPULATIONP. Rioseco, B. Vicente, R. Kohn, S. Saldivia, S. TorresDepartment of Psychiatry and Mental Health, University ofConceptión, ChileThe Mini Mental State Examination (MMSE) is used widely internationally.Normative data outside the United States are rare. The CompositeInternational Diagnostic Interview (CIDI) with the MMSE wasadministered to a stratified random household sample of 2,978 individualsaged 15 or more in Chile. DSM-III-R lifetime prevalence rateswere estimated. The average MMSE score ranged from 16 to 29depending on the level of educational attainment. Age, marital status,population density and income heavily influenced MMSE scores.When the MMSE scores were controlled for sociodemographic variables,those with any psychiatric disorder had significantly lowerscores, but this effect was not found for any specific diagnosis.334 World Psychiatry 3:S1 - October 2004

PO3.117.THE CLINICAL REAPPRAISAL STUDYIN THE ESEMeD PROJECTF. Mazzi 1 , G. de Girolamo 2 , G. Polidori 3 , P. Morosini 3 ,G.P. Guaraldi 11 University of Modena and Reggio Emilia, Modena; 2 Departmentof Mental Health, Local Health Unit, Bologna; 3 NationalInstitute of Health, Rome, ItalyThe European Study of the Epidemiology of Mental Disorders(ESEMeD) is a project co-funded by the European Commission andGlaxoSmithKline. In three of the ESEMeD countries, France, Italyand Spain, we have conducted a clinical reappraisal study, in subsamplesof the population interviewed, in order to address the issue ofthe possible discrepancies between lay interviews with fully structuredinstruments (Composite International Diagnostic Interview,CIDI) and clinical expert interviews with more flexible clinical instruments(Structured Clinical Interview for DSM-IV, SCID). The clinicalreappraisal study will allow us to address the criticism that epidemiologicalstudies overestimate prevalence and focus on disorders thatare not clinically significant. In this paper we report the data aboutthe Italian sample (192 subjects). The concordance between CIDIand SCID expressed as Cohen’s kappa is the following: major depression0.36 (CI 0.13-0.58), any mood disorder 0.27 (CI 0.07-0.47),panic attack 0.34 (CI 0.2-0.9), any anxiety disorder 0.5 (CI 0.33-0.66),any disorder 0.39 (CI 0.23-0.54). The sensitivity and specificity are:major depression 0.33, 0.96; any mood disorder 0.25, 0.96; panicattack 0.24, 0.99; any anxiety disorder 0.48, 0.95; any disorder 0.42,0.91. These findings support the hypothesis that CIDI generallyunderdiagnosed disorders because of false negative assessments.PO3.118.THE NEW ORGANIZATIONOF PSYCHIATRIC SERVICES IN ARMENIAS. Sukiasyan, N. ManasyanCenter of Mental Health, Yerevan, Republic of ArmeniaThe organization of psychiatric services in Armenia is going to beimplemented as follows. In every region of the country a regional dispensarywill be created as the central regional institution of psychiatriccare, able to carry out the administrative management. This dispensarywould include the mental health cabinet, with psychiatrists,psychotherapists, clinical psychologists and social workers. Theinternists of the regional policlinic would collaborate to this cabinet.The regional service would also include the psychiatric inpatientdepartment in the structure of the dispensary or in the general hospital;a psychotherapy department; a narcological department; a socialrehabilitation workshop; a psycho-neurological sanatorium andpatients’ colonies. Such institutions may be governmental or nongovernmental.The goals of this regional mental health service will bepsychological counselling of the population as a whole; medical-psychologicalhelp to patients (including non-psychiatric patients); psychiatrichelp to patients; medical, psychological and social rehabilitationand legal advice.PO3.119.THE INTERDEPARTMENTAL MENTAL HEALTHCENTER AS A NEW MODEL OF SPECIALISEDEXTRAMURAL PREVENTIVE SERVICEV.Y. Semke, I.E. Kupriyanova, Z.A. Sitdikov, V.A. Semke,E.V. Yanygin, N.V. Shinkevich, E.S. Baykova, A.A. MarkovMental Health Research Institute, Tomsk, RussiaThe new paradigm of “preventive psychiatry” has been repeatedlydescribed in documents of the World Health Organization (WHO)and in the scientific literature. In Tomsk we have developed an interdepartmentalmental health center as a new model of specializedextramural preventive service, offering the following functions: a)organisation, co-ordination and implementation of mental healthcare in the population jointly with the district administration, includingthe health care board; b) conduction of psychopreventive examinationsof various social-professional and age contingents of the populationwith the use of automated methods; c) active detection ofpatients with neurological and mental disorders and adjustment disorders;d) dynamic observation and outpatient treatment of patientswith borderline states; e) referral to hospital of patients with majormental disorders. The center’s activity is mainly based on the use ofindividual and group psychotherapeutic methods.PO3.120.PSYCHIATRIC EMERGENCIES AND THEIRTREATMENT IN A GENERAL HOSPITALM. Conde, M.D. Barroso, S. Romero, C. Esteban, L. Rosado,R. Dorado, M. Masegoza, E. SantistebanPsychiatric-Legal Study Group of Andalucia, Andalucian HealthServices, Sevilla, SpainA descriptive study of psychiatric emergencies treated in the Virgendel Rocío Hospital during the year 2003 (about 4,500 consultations/year)is presented. In this hospital, the on duty psychiatry teamworks 24 hours a day examining psychiatric outpatients who come tothe hospital emergency service, as well as providing urgent consultationfor inpatients either in the emergency service, in other hospitalservices, or in the psychiatric admission unit. Starting from a data registerof the examined patients, the study analyzes the origin of thedemand for care, the reasons for the consultation, the syndromicdiagnosis, the therapeutic action and the patient's destination. Thesample analysis, that included more than 1000 cases, shows that selfinjuriousbehavior is the main reason for consultation. The study alsoanalyzes the most frequent diagnosis in relation to the reasons for theconsultation, the type of intervention (individual, familial, pharmacological)and the patient's destination.PO3.121.SOME REFLECTIONS ON THE ROLEAND THE LIMITATIONS OF THE ITALIANGENERAL HOSPITAL PSYCHIATRIC WARDSL. Orso, N. GiacchettiGeneral Hospital Psychiatric Ward, Viterbo, ItalyThe reform of psychiatric services in Italy, which started in 1978, led tothe deinstitutionalization of psychiatric patients, allowing only generalhospital psychiatric wards to admit patients in situations of urgencyand/or emergency or against their will. The following are some criticalissues emerging from clinical experience: a) the request for admissionis more frequently based on a social emergency than on a clinicalurgency; b) the management of a ward in which several different men-335

tal disorders which require very different therapeutic interventionscoexist is very complex; c) those pathologies which are not very clamorousdo not receive appropriate care; d) the response to pathologiesemerging in some specific age groups, such as adolescents and the elderly,is not adequate; e) financial resources are inadequate to face anincreasing request for intervention, which involves a progressivereduction of the duration of hospitalizations and does not allowadmission of patients who need a long-term hospitalization.PO3.122.THE ROLE OF THE PSYCHIATRIC HOSPITALIN THE HEALTH CARE SYSTEM TODAYV.F.M. Canez, R. Rocha, C.M. Schöepping, R.S. Menezes,J.S.P. Godoy, L.A.S.P. Godoy, J.F. Barcellos, L. Luz, R.O. Silveira,G.S. Oliveira, M. Vaz, M.S. Pereira, A. Breitembach, A. Haubert,R. MargisMental Health Interdisciplinary Center, Porto Alegre,Rio Grande do Sul, BrazilThe role of the psychiatric hospital has been questioned along the lastdecades. New legislations and changes in the society have determinedsignificant innovations in psychiatric care all over the world. In thiscontext, the psychiatric hospital has been criticized as the symbol ofthe social stigmatisation of people with mental disorders. However, asspecialized hospitals can be useful in cardiology or pediatrics, there isno technical contraindication to the existence of institutions specificallydesigned to the promotion of the health and the quality of life ofpeople with mental disorders. The authors studied several institutionsat the local, national and international level, through visits, interviewsand revision of the literature. What emerges from this study isthe need to approach this subject in a scientific and medical way, inthe perspective of the defense of the human rights, the autonomy andthe quality of life of patients. Rather than with the political issue ofwhether mental hospitals should be closed or not, the society shouldbe concerned with the quality of the care to the individuals with mentaldisorders, be it provided in the community, in outpatient units orin hospital wards.PO3.123.DESCRIPTIVE RESEARCH ON YOUNGPATIENTS WITH PSYCHOSIS OR MANIA AT FIRSTADMISSION TO A PSYCHIATRIC WARDC. Cremonese, F. Vignaga, K. Ngaradoume, G. Pigato, A. Menardi,L. PavanPsychiatric Section, Department of Neurological and PsychiatricSciences, University of Padua, ItalyThe study is based on the clinical records of young patients (less than30 years of age) admitted for the first time to our Psychiatric Clinicbetween 1996 and 2002. We examined social and demographic characteristics,positive and negative symptoms, depressive and manicsymptoms, consciousness impairment. Data concerning the periodbetween the onset of the symptoms and the hospital admission werealso collected. The sample consisted of 32 subjects with a mean age of22.56±3.08 years. 93% of them had positive symptoms, 87% haddelusions, in particular of persecution (59%), 34% had auditory hallucinations.Consciousness was impaired in 31% of cases. Manicsymptoms were present in 20% of the sample.PO3.124.SATISFACTION ABOUT CAREIN PSYCHIATRIC INPATIENTSU. Corrieri, M. Cerretini, G. Sgaragli, G. CorlitoMental Health Department, Grosseto, ItalyThe aim of this study was to evaluate the quality of treatment as perceivedby psychiatric inpatients. Along 8 months (July 2003-February2004) we administered two anonymous questionnaires, the GeneralSatisfaction Questionnaire for use with psychiatric in-patients (GSQ-8) and the Questionnaire on the Opinion of Users, to all psychiatricinpatients at the moment of their discharge. Of 97 inpatients, 58 gaveback at least one filled questionnaire. Preliminary data suggest that allthe evaluations (16 items) were clearly positive, with the exception oftwo: the global improvement in living since the first contact with ourpsychiatric service and the information about drugs’ advantages andside effects. The free comments contained in both questionnairesconverged in two positive opinions (about kindness of doctor andnurses and their unitary working as a group) and two negative ones(about food and some boring because of lack of activities). In conclusion,the administration of the two questionnaires during eightmonths allowed us to monitor how our activities are perceived bypatients and better evaluate their needs and expectations during hospitalization.We are planning to improve the weak aspects and introducenew group activities. Meanwhile we are keeping on administeringthe questionnaires.PO3.125.COMPARATIVE STUDY OF INTERVENTIONSIN A MENTAL CRISIS CENTER IN 1999-2003G. Cadlovski, M. Polazarevska, T. Tockova, A. Saveska,Z. Babonkostova, M. Kostic, A. ConevaPsychiatric Clinic, Medical Faculty, Skopje, Republic ofMacedoniaOur mental crisis center for children and adolescents is active since1993, with a SOS phone line and the availability of appropriate treatmentin a counseling center, specialized for mental crisis. The preventiveand therapeutic activity involves a team of psychiatrists andpsychologists. In this ten-year transition period the need of this kindof mental crisis center for children and adolescents became moreessential. This study discusses some data concerning the clientsreferred to our center. During the period 1999-2003 our SOS phoneline provided 2030 therapeutic interventions of which the most frequentwere: for emotional problems 44.6%, for depressive conditions8.1%, for problems in communication with peers 6.4%, for familyproblems 6.1%, for intimacy problems 5.5%, for physical, mental andsexual abuse 5.3%, for school problems 4.4%, for addiction 3.7%, foradolescent crisis 2.1%, for problems in communication with parents2%.PO3.126.URGENT PSYCHIATRIC CONSULTATIONSIN A GENERAL HOSPITALS. Daini, C. Lai, F. Tonioni, M. Gaglione, F. Maiorino, S. De RisioInstitute of Psychiatry and Psychology, Catholic University,Rome, ItalyDuring the year 2003, 728 urgent psychiatric consultations were carriedout by our unit. The activity concerned 202 males (mean age:45.1 years) and 203 females (mean age: 43.4 years). The highest numberof visits has been requested by the infectious diseases, emergency336 World Psychiatry 3:S1 - October 2004

and medicine units. The distribution for disorders appears similar toprevious years, with a predominance of alcoholism and substanceabuse in males, depression, anxiety disorders and eating disorders infemales. Data show that the focus of urgent intervention is firstscreening diagnosis and psychopharmacological intervention ratherthan integrated treatment.PO3.127.A GROUP APPROACH IN PATIENTS HOSPITALIZEDIN AN ACUTE PSYCHIATRIC WARDA. BastianiS. Filippo Neri Hospital, Rome, ItalyWe describe the group approach applied in our acute psychiatricward. The group with patients takes place in the ward three times aweek. During this activity, patients must be free from any otherengagement. They are stimulated to participate by the conductor andby the professionals. A conductor, a nurse and a trainee take part inthe group at every meeting. The professionals give the continuity andthe space-time stability to the group. The patients stay in the group fora short period, linked to the hospitalization, with a wide emotionalrelationalspace useful for the reciprocal enrichment. Everytime theprofessionals report to each of the new patients the previous experience.At the end of each session, the professionals meet for a discussionof the outcome of the session. An emotional and educationalsupport is offered to the professionals both by a structured supervisionand by meetings among peers.PO3.128.APPLICATION OF THE DRUG ATTITUDEINVENTORY IN A PSYCHIATRIC DAY HOSPITALA. Sbardella, D. AccorràS. Filippo Neri Hospital, Rome, ItalyThe purpose of the study was to explore, through the Drug AttitudeInventory (DAI), the attitude toward the use of drugs, especiallyantipsychotics, and the possible relationships between this variableand recurrences of the disease. The questionnaire has been administeredto all patients admitted to a day hospital in 2003. More than halfof the patients had a diagnosis of schizophrenia. Among thesepatients, the sensitivity of the instrument was found to be higher inthose with mood or personality disorders.PO3.129.AN OUTPATIENT SERVICE WITHOUT WAITINGLIST FOR PSYCHIATRIC EMERGENCIESC. Bressi, M. Bonfiglio, C. Cattaneo, M. Porcellana, I. Iandoli,P. Frongia, G. Piccinini, G. InvernizziPsychiatric Clinic, State University, Milan, ItalyAn outpatient service without waiting list was set up in 1998 at thePsychiatric Clinic of Milan State University, with the purpose ofquickly providing a diagnostic picture and suitable indications fortreatment. Users have free access to the service, which allows thepatient to be immediately accepted for treatment. From 1998 to 2003,865 patients used the service. During their consultation, the requestsmade by users were evaluated by specialists who collected their casehistory and, following a diagnostic assessment, fixed an appointmentwith one of the outpatients’ departments of our clinic or one of thecentres in the area best equipped to offer suitable treatment. Most ofthe 865 users were women (59.4%) and were young to middle-aged(45.1 years). Most of the subjects had been referred by their generalphysicians (39.7%) or by other specialists (24.5%). The most frequentdiagnoses were mood disorders (30.3%) and panic disorder (10.5%).37.3% of subjects were sent to the psychosocial centres in the area,21% to the psychotherapy service, and the remainder to other outpatientfacilities or specialized services.PO3.130.A PSYCHOTHERAPY SERVICE IN A PUBLICINSTITUTION: ANALYSIS OF DROP-OUTSC. Bressi, C. Cattaneo, S. Manenti, P. Boato, C. Oggionni,G. Piccinini, C. Manoussakis, G. InvernizziPsychiatric Clinic of Milan State University, Milan, ItalyThe aim of this study was to analyze any underlying dynamics leadingto drop-out at the Psychotherapy Service of the Psychiatric Clinic,Milan State University. In this service, patients undergo a clinicalassessment and test phase (level I). A team discussion of the case follows,ending in the formulation of a diagnosis and indications as tothe treatment required (level II) and, subsequently, possible acceptancefor brief analytic psychotherapy (PBA) or brief crisis psychotherapy(PBC) (level III). Among 86 patients attending the service,a total of 23 (26.7%) dropped out: 4 (17.4%) at level I, 13 (56.5%)at level II, and 6 (26.1%) at level III. The level I drop-outs had relationalproblems with a significantly higher frequency (p=0.04) thandrop-outs of the other levels. Analysis of the drop-out phenomenonmay provide a useful tool in order to improve the running and efficacyof a mental health service and to investigate the dynamics occurringwithin the therapeutic process.PO3.131.JAPANESE BRAZILIAN PSYCHIATRIC OUTPATIENTSIN JAPAN AND IN BRAZIL: PROFILE OF THOSEREMAINING AND THOSE RETURNINGL.S. Miyasaka 1 , S. Canashiro 2 , Y. Abe 3 , K. Otsuka 4 , K. Tsuji 5 ,T. Hayashi 6 , S.B. Andreoli 7 , D. Nakagawa 8 , I. Shirakawa 7 ,A.N. Atallah 1 , S. Kato 41 Department of Emergency Medicine, Federal University of SãoPaulo, Brazil; 2 Beneficiencia Nipo Brasileira Clinic, Brazil;3 Department of Psychology, University of Meijigakuin, Japan;4 Department of Psychiatry, Medical School, Jichi, Japan;5 Department of Human Studies, University of Musashino, Japan;6 Department of Neuropsychiatry, University of Kyoto, Japan;7 Department of Psychiatry, Federal University of São Paulo,Brazil; 8 Sunrise Clinic, BrazilThe Japanese immigration to Brazil started in 1908. Almost a centurylater their descendants in Brazil become the largest community ofJapanese descendants outside of Japan. But the economic situationchanged. The growth of the industries demanded the opening of thecountry for the immigrants to work in the factories and in 1990 theGovernment of Japan allowed the Japanese descendants to returnand work in Japan. We compared the sociodemographic data anddiagnosis of all consecutive Japanese Brazilian psychiatric outpatientsin Japan (remaining group) and in Brazil (returning group) from1997 to 2000. The group in Brazil were mostly male, not married,lived alone in Japan, had a short stay period there and were classifiedin the schizophrenia group. In Japan they were mostly female, married,living in family or with friends, had a long stay period and wereclassified in the anxiety group. In the logistic regression analysis themost significant factor associated with the returning group (in Brazil)were living alone and the short stay period.337

PO3.132.RELATIONSHIP BETWEEN THERAPEUTICALLIANCE AND OUTCOME IN A PSYCHIATRICDAY-HOSPITALR. Pulido 1 , M. Monari 2 , F. Villanedi 1 , N. Rossi 11 Department of Psychology, University of Bologna; 2 Day HospitalCasalecchio di Reno, Bologna, ItalyThe aim of this research is to evaluate the therapeutic alliancebetween patients and clinical staff and to analyze its development ina day-hospital context. Our hypotheses are that the early therapeuticalliance between patient and staff correlates positively with outcome,and that the patient’s pre-treatment characteristics do not correlatesignificantly with the therapeutic alliance between patient and staff.The sample is composed by 23 patients with psychotic, affective orpersonality disorder who completed for the first time a partial hospitalisationtreatment at our day-hospital. Before the start of treatment,the symptom level (Short-Check List-90, SCL-90), global function(Global Assessment Scale), attitudes toward the institution and thetreatment and psychosocial perceived support were measured. Afterone week, the therapeutic alliance established between the patientand the staff was measured with an adaptation of the WorkingAlliance Inventory Short form (WAI-S). At the end of the treatmentboth the symptom level and the therapeutic alliance were retested.The global symptom level reduction was taken as outcome measure.The main preliminary result is the lack of a significant correlationbetween early therapeutic alliance and outcome, and a positive correlationbetween the development of therapeutic alliance and outcome.Only one of the pre-treatment patient characteristics – attitudestoward institution and treatment – correlates positively with earlytherapeutic alliance.PO3.133.A FOLLOW-UP OF PATIENTS HOSPITALIZEDIN A PSYCHIATRIC CLINIC IN ATHENS AFTERTHE 2000 REFORMM. Diallina, K. Drosataki, K. Alexandropoulos, D. Sakkas,C. Christodoulou, P. Georgila, M. MarkantonakiPsychiatric Clinic, G. Gennhmatas General State Hospital,Athens, GreeceIn the year 2000, the Ministry of Health of Greece decided a reductionin the number of beds of psychiatric departments in Athens(2000 beds less) and created mixed departments for voluntary andinvoluntary admissions. This study was carried out by telephoneinterviews in patients who were hospitalized at a psychiatric clinicduring the year 2002. The sample included 252 patients. Of these, 140accepted to participate in the study, 53 refused to participate, 53could not be traced because their telephone number was not availableor was wrong, and 6 had died or gone to foreign countries. 79.3% ofinterviewed patients had not been re-hospitalized, 17.1% had beenre-hospitalized, and 3.6% were still in the psychiatric clinic while weconducted the study. In spite of the difficulties we had to face and theshort duration of our hospitalizations (around 20.4 days), theseresults can be regarded as satisfactory. The majority of our patientsdid not undergo a further hospitalization.PO3.134.THE GLOBAL MENTAL HEALTHASSESSMENT TOOL (GMHAT)A. Cummins 1 , V. Sharma 21 Egremont Medical Centre Birkenhead and Wallasey PrimaryCare Trust; 2 Mental Health Resource Centre Cheshire and WirralPartnership Trust, UKThe Global Mental Health Assessment Tool (GMHAT) is a computerised,semi-structured clinical interview developed to identifyand risk stratify a range of common mental health problems. Itprovides a computer-generated diagnosis, symptom rating, riskassessment (including risk of self-harm) and generates a referralletter to psychiatric services. This study aimed to assess its usefulness,its comparison with clinical diagnosis and Hospital AnxietyDepression (HAD) rating and its inter-rater reliability. The UKDepartment of Health’s National Service Framework (NSF) formental health cites the general practitioner (GP) as a central playerin the diagnosis and management of common mental healthproblems. There are few usable tools to aid the GP in this and thoseavailable are of limited usefulness. Proposed changes to mentalhealth care services in the UK such as the provision of “gatewayworkers” mean that a usable computerised tool could be potentiallyvaluable to primary healthcare teams. Patients came from threesources: GP surgery, psychiatric outpatients and psychiatric inpatients.All patients were assessed using HAD rating prior toGMHAT. GP patients also had simultaneous rating by GP and psychiatrist.Inter-rater agreement on mental health symptom groupsranged from 0.67 to 1.0 (Pearson’s correlation). The computer-generateddiagnosis correlated highly with the clinical diagnosis. Therewas significant agreement between HAD and GMHAT scores.GMHAT-PC required brief training to use, was easy to administerand was completed within 10-15 minutes. It has potential value forprimary healthcare teams.PO3.135.FREQUENT ATTENDERS OF PRIMARY CARE:MEDICAL, PSYCHIATRIC AND PSYCHOSOMATICCOMORBIDITYS. Ferrari, G.M. Galeazzi, M. RigatelliConsultation Psychiatry Service, Department of Psychiatryand Mental Health, University of Modena and Reggio Emilia,Modena, ItalyAnxiety, mild-moderate depression and somatoform disorders, the commonmental disorders described by Goldberg, may affect up to 60% ofpatients in the primary care setting and have proven to play a causal rolein the phenomenon of high utilization of health care services, especiallywhen they are combined with medical morbidity. The 50 top most frequentattenders (FAs) at a general practitioner (GP) clinic in the north ofItaly were compared to 50 randomly selected average attenders. Sociodemographicand medical data were collected from GP files. The StructuredClinical Interview for DSM-IV, SCID-brief version for researchand the Diagnostic Criteria for use in Psychosomatic Research (DCPR)were administered to both patient groups. Quality of life was also evaluatedthrough the WHOQOL brief version. 98% of FAs suffered from atleast one medical disorder and 68% from at least one psychiatric disorder,versus 54% and 6% respectively in the control group. Moreover,66% of FAs gave positive results in all three diagnostic fields (medical,psychiatric and psychosomatic), versus 4% of controls, proving medical-psychiatriccomorbidity to be more frequent in the case group.Quality of life was found to be significantly poorer among FAs. Exces-338 World Psychiatry 3:S1 - October 2004

sive utilization of primary health care services may be associated withmedical-psychiatric comorbidity: there is a need for the development ofdedicated diagnostic and therapeutic tools addressing the specific needsof medical patients with concurrent psychological distress.PO3.136.DIFFERENCES BETWEEN MEDICAL ANDSURGICAL PROFESSIONALS IN REFERRINGORGANIC PATHOLOGY TO LIAISON PSYCHIATRYCONSULTATIONS. Tamasan 1 , G. Zarie 2 , D. Reisz 31 Timis County Hospital No. 1; 2 Timisoara Municipal Hospital;3 V. Babes Medical University, Timisoara, RomaniaThe present study is based on a sample of 1300 patients of the TimisCounty Hospital, referred to the liaison psychiatrist from the differentdepartments of the hospital over a time-span of 18 months betweenMay 2002 and December 2003. We analyzed in closer detail 316patients who presented organic psychiatric disorders. Approximatelyone quarter of the psychiatric pathology was organic. 93% of thesepatients were referred from medical departments. Over half ofpatients with organic disorders had organic depressive (44%) or anxious(9%) disorders, mostly referred from the medical departments.Of the patients referred from medical departments, 55% had organicdepressive and anxious disorders, while the respective percentagewas only 27% for the surgical wards. The rest of the pathology includedAlzheimer’s and mixed dementias (16%), organic personality disorder(11.4%), mild cognitive disorders (9%), delirium (5.4%) and5% other disorders (hallucinosis, organic dissociation, other organicand unspecified disorders). These data suggest that medical wardsrefer to the liaison psychiatrist mostly affective and anxious disorders,while the surgical wards refer mostly agitated and flagrantly disturbedpatients. Surgeons prefer to demand emergency psychiatric consultationand treatment, while medical wards expect the liaison psychiatristto share the responsibility of medical care.PO3.137.REFERRAL PATTERN OF NEUROLOGICALPATIENTS TO PSYCHIATRIC CONSULTATION-LIAISON IN A GENERAL HOSPITAL IN TAIWANH.-Y. Liang 1 ,Y.-Y. Juang 1,2 , C.-Y. Liu 1,3 , E.-K. Yeh 41 Department of Psychiatry, Chang Gung Memorial Hospital,Taoyuan; 2 Department of Psychiatry, St. Paul’s Hospital,Taoyuan; 3 Department of Psychiatry, Chang Gung University;4 Department of Psychiatry, Taipei Medical University, TaiwanA high prevalence of mental illness has been found among patientswith neurological disease. However, there are only a few studies relatedto this issue. The aim of this preliminary study is to investigate thecharacteristics of psychiatric consultation in patients with neurologicaldisease. Fifty-six patients hospitalized in a neurological ward werereferred to a consultation-liaison psychiatric service over 10 months.This retrospective study is to determine the demography, reasons forreferral, psychiatric comorbidity, and the different opinion on thediagnosis between the neurologist and the psychiatrist. Psychiatricdiagnosis was made by a psychiatric consultant according to theDSM-IV criteria. The rate of psychiatric referral from neurologicalward was 6.15%. The mean age of patients was 40.8±13.2 years.Common reasons for referral were differential diagnosis (49.2%),excessive emotional reaction (16.9%), psychotic symptoms (12.3%),previous psychiatric history (12.3%), and suicide attempt at ward(6.2%). Psychiatric diagnoses included mood disorder (26.2%), delirium(26.2%), organic mental disorder (15.4%), psychotic disorder(10.8%), anxiety disorder (7.7%), dementia (4.6%), and somatoformdisorder (1.9%). Different opinion between neurologist and psychiatristoccurred in 29.2% of all the patients. The rate of neurologists followingthe psychiatric recommendation for further psychiatric outpatientfollow-up was only 20%. Enhancing the liaison with neurologistsis important to improve the service of psychiatric consultation.PO3.138.THE BURDEN OF PSYCHIATRIC DISORDERIN PRIMARY CARE: ENCOURAGING PATIENTINITIATIVEJ.E. Helzer, M.R. Naylor, G. Rose, J. SearlesUniversity of Vermont, Burlington, VT, USAThere is evidence that behavioral intervention for minor psychiatricdisorders in primary care settings can be highly effective. A successfulexample is brief intervention for heavy/problem drinkers. There is evidencethat a physician initiated intervention of no longer than 3-5minute results in a statistically significant and long-term change indrinking patterns. However, there are many impediments to behavioralinterventions in primary care clinics, including lack of time, providerreluctance, and lack of reimbursement. Even when heavy/problemdrinkers are identified immediately before the primary care visit, briefintervention is done in a minority of cases. One possible solution to thisproblem is to develop cost-effective technologies for patient self-directedtreatment that could be used in primary care. In this presentation wewill discuss our work with interactive voice response (IVR), an automatedtelephone system that can be used to guide patient self-directedscreening and treatment remotely. IVR is a low-cost system that can beaccessed by patients from their home telephone. We will describe andillustrate how an IVR system operates. We will then present resultsfrom our use of a simple IVR-based intervention for primary carepatients with heavy/problem drinking. Finally we will describe ourplans for using this system for self-directed screening and interventionfor problems such as alcohol misuse and other behavioral problemsthat are commonly encountered in primary care settings.PO3.139.PSYCHIATRIC LIAISON IN PRIMARY CARE:USEFULNESS OF AN ATTITUDE SCALEJ. D. Adeyemi, P.O. OlonadeDepartment of Psychiatry, College of Medicine, Universityof Lagos, NigeriaThe study aims to explore the potential of an attitude scale in categorizingdoctors for the purpose of educational intervention aimed atenhancing clinical skills in primary care. A 25-item questionnairedesigned to measure attitude to referral was administered to a crosssectionof doctors seen in primary care. The study was conducted inrandomly selected walk-in primary care facilities in Lagos metropolis.One hundred and twenty-six doctors (males 83.3%) were studied.Responses to questionnaire items were subsequently classified as positive,non-committal or negative, and weighted +1, 0 or –1 respectively.The sum of the weighted scale was computed to determine thescore for each doctor. Principal component analysis indicated a 10factor solution accounting for 64% of the variance. Screen plotrevealed that the three most important factors have Eigenvalue2.3468, 2.0201 and 1.8751, respectively corresponding to avoidance,self-doubt and pessimism. The first three discriminant functions thatemerged accounted for 76.6% and 78.7% respectively of the variancesof the two (high or low scorers) groups. Correct classification of339

high scorers was 66.7% and for low scorers 53.2% of the groupedcases. Older age (0.744), female sex (0.579), more years since graduated(0.729) had the largest absolute pooled correlations betweenvariables and standardized canonical discriminant functions for lowscorers. For high scoring doctors, longer duration of undergraduatepsychiatry training (0.573), having postgraduate medical qualifications(0.692) and younger age (-0.542) had the highest correlations.The scale may be useful for determining predictor variables in referralattitude to psychiatry, and for the selection of doctors for interventionsto improve the attitude. Continuing educational needs for lowand high score individuals may not be the same.PO3.140.A CONSULTATION SERVICE FOR COMMONPSYCHIATRIC DISORDERS IN PADUA, ITALYN. Magnavita, D. FilippoDepartment of Mental Health, Padua, ItalyAnxiety and depressive disorders have a high prevalence in primarycare. An anonymous questionnaire was sent to 76 general practitioners(GPs) working in the catchment area of a mental health service.The questionnaire included 20 items composing 5 sections: training,knowledge of the service network, relationship between physicianand patient, needs and proposals. 58% of the respondents declaredthey were treating between 20 and 30 patients with anxiety disorders,and 38% more than 31 patients; 50% of the respondents declaredthey were treating more than 30 patients with depression; 24% of therespondents declared they were treating more than 30 patients withsomatic complaints without medical confirmation. The results of thequestionnaire revealed that the GPs perceive the task to treat mentalpatients, and in particular the so-called common mental disorders, asclearly demanding. The consultation service for primary care isintended to facilitate communication between physicians throughformal consultation-liaison meetings and a telephone consultationservice.PO3.141.COUNSELLING SERVICES FOR GENERALPRACTITIONERS: A PILOT EXPERIENCEA.M. Ferro, M.M. Benedetti, E. Cossetta, J. Avantaggiato,P. Manzotti, A. TerziDepartment of Mental Health, Local Health Unit, Savona, ItalyIn Italy the relationship between psychiatry and general medicine ison the whole still in an embryonic phase. Despite this, several pilotexperiences exist, which have developed improved methods of collaboration.One of these is in operation at the Department of MentalHealth in Savona. Since the mid 1990s, several psychiatric and psychologicaloutpatient consulting rooms for use by general practitionershave been established in our region. The clinics are staffed by professionalswith a specific training in the diagnosis and treatment of avariety of illnesses. These include depression, panic disorder, obsessive-compulsivedisorder, somatoform disorders, adjustment disorders,disorders common in the elderly, eating disorders, geriatric disordersand psychoncological disorders.PO3.142.QUALITY CONTROL OF COUNSELLINGOFFERED TO GENERAL PRACTITIONERSA.M. Ferro, E. Cossetta, E. Garassino, S. Lugaro, M. Mellino,D. PolleroDepartment of Mental Health, Local Health Unit, Savona, ItalyThe Department of Mental Health of Savona, after developing variousforms of collaboration with general practitioners (GPs), evaluatedthe quality of the counselling offered, by administering a questionnaireto 246 GPs working in the area. The questionnaire consists of21 multiple-choice questions subdivided into three areas. The firstoutlines the typology of the sample. The second concerns the level ofinformation offered, the method of communication and the evaluationof the interventions. The third explores further needs. The resultsare presented and their implications are discussed.PO3.143.DOES THERAPY LIVE UP TO EXPECTATIONS?M. Gabbay 1 , C. Shiels 1 , B. Sibbald 2 , M. King 31 Department of Primary Care, University of Liverpool; 2 NationalPrimary Care Research and Development Centre, University ofManchester; 3 Department of Psychiatry and BehaviouralSciences, Royal Free and University College Medical School,London, UKPatients presenting with depression in primary care have varyingexpectations of how successful treatment will be. We investigatedpatient and professional predictions of treatment success within a primarycare randomized controlled trial of cognitive behavioural therapyand non-directive counselling for depression (Beck DepressionInventory, BDI>13). Formulations were derived from a list of 13potential problems on self-completed questionnaires. Patients andtherapists also predicted the likely success of the three treatmentoptions for each of the problems identified in the formulation using aseven point Likert scale. Patients and therapists then rated successafter treatment (four months) and patients self-rated again at 12months. We report changes between predicted and self-rated successfor each problem identified in formulations for 411 patients recruitedinto the trial, of whom 362 received therapy. Significantly better thanpredicted treatment success (measured using Wilcoxon paired rankstest) was reported by patients at four months for: depression (47%,p=0.02), work-related problems (60%, p=0.03) and confusion (51%,p=0.03). At 12 month follow up, patients reported significantly betterthan expected improvements in: family problems (67%, p=0.008),relationships (52%, p=0.003) and childhood related issues (71%,p=0.008). Therapists also reported better than predicted treatmentsuccess for depression (43%, p=0.009), work-related problems (47%,p=0.005), family problems (47%, p=0.003) and relationships (46%,p=0.03), as well as anxiety (48%, p=0.006) and stress (44% p=0.04).Interestingly there were no significantly worse than anticipated treatmentsuccesses for either patients or therapists for any of the problemheadings. Patients and professionals may be unnecessarily pessimisticabout the likely impact of talking therapies across a range of problemspresenting among patients with depression in primary care. Outcomeoften surpasses expectations.340 World Psychiatry 3:S1 - October 2004

PO3.144.DOES IT MATTER IF THERAPISTSAND PATIENTS AGREE UPON WHAT IS WRONG?M. Gabbay 1 , C. Shiels 1 , B. Sibbald 2 , M. King 31 Department of Primary Care, University of Liverpool; 2 NationalPrimary Care Research and Development Centre, University ofManchester; 3 Department of Psychiatry and BehaviouralSciences, Royal Free and University College Medical School,London, UKGood communication is a crucial clinical skill, particularly in mentalhealth care. Previous research indicates a link between improvedclinical outcomes and agreement between practitioners and patientsabout the patients’ core presenting complaints. However, our recentlypublished study suggested that this detailed mutual baseline understandingmay be less important in determining outcome from depressionin primary care, than agreement that the problem is psychologicalin nature, and referral for psychological therapy appropriate. Wecompared problem formulations completed by patients and therapistsfor subjects participating in a primary care randomized controlledtrial of cognitive behavioural therapy and non-directive counsellingfor depression (Beck Depression Inventory, BDI>13). Formulationswere derived from a list of 13 potential problems on self-completedquestionnaires. Outcome measures included BDI at four and 12months, failure to attend any therapy after referral, dropout from therapy,and patient satisfaction. Among 464 patients recruited into thetrial, 395 were referred for talking therapy. We conducted logisticregression analysis controlling for baseline BDI, therapy type, patientage, gender and satisfaction. Patient recovery at four months(BDI

status and functioning of the family, as well as the referral source areunrelated to compliance in both samples. On the contrary, the type ofproblem presented by the child and the type of recommended treatmentare correlated with treatment compliance. These results are discussedwith respect to the re-examination of certain aspects of our service’sfunctioning and consequent modifications with respect to itstechniques concerning admission and intervention.PO3.148.THERAPEUTIC CONTRACT AND TREATMENTADHERENCE IN PSYCHIATRIC PRACTICEL. Ghio, G. TibaldiCentro Studi e Ricerche in Psichiatria, Turin, ItalyEnsuring patients’ adherence to treatment is a major challenge in psychiatryas well as in general medicine. A review of the literature showsthat the rates of non-adherence in psychiatry range from 20 to 90 percentand are strongly associated with clinical (relapse, rehospitalization,mortality and poor outcomes) and economic consequences.This paper presents the main factors associated with poor treatmentadherence in seriously mentally ill outpatients and the strategies forimproving treatment adherence, highlighting the role of therapeuticalliance and therapeutic contract as the main tools to build up a collaborativepartnership, in which both the patient and the practitionerassume the responsibility to develop a treatment regimen to which thepatient can adhere.PO3.149.SOCIAL NETWORK AND MENTAL ILLNESSE. Re, G. MarangelliDepartment of Mental Health, Niguarda Ca’ Granda Hospital,Milan, ItalyThe project “Social network and mental illness” began in 1999. It provides“natural helpers”, recruited in the natural social network ofpatients, in order to take care of users on a voluntary basis. For eachhelper-user couple, a specific program is planned by the service tohelp the user in his rehabilitation process and to address his needs.Up to now 43 users have been involved. They are mostly middle-aged,single and alone. The process is standardized and the outcomes areevaluated by validated as well as original instruments. One outcomeof the program is an improvement in the quality of life of users.Results are also observed in the relationship between the psychiatricservice and the community and in the social perception of mentally illpeople. The best responders are very disabled users, with an agebetween 35 and 54. The project also showed that natural helpers wholive in the neighbourhood are a better resource than those who live inthe same building of the users.PO3.150.REHABILITATION IN THE HISTORY OF PSYCHIATRYG. Salomone, R. ArnoneDepartment of Mental Health, Local Health Unit 1,Nocera Inferiore, Salerno, ItalyAccording to Pinel, “madness is not the loss of reason, but only another way in which Man expresses himself”. On this basis, Pineldeveloped his “moral” treatment of psychiatric patients. “MadHouse” private institutions were created to host mad people so thatthey could leave from their families and social environment, whichwas considered an important cause of their illness. The most interestingpart of “moral” treatment was the type of work that the patienthad to do, which could be either manual or intellectual. Our studyaims to review this kind of approach in different countries andthrough different periods of time. A better knowledge of the past mayenable us to better understand the present.PO3.151.PSYCHIATRIC REHABILITATION THROUGH THEIMPLEMENTATION OF A SOCIAL STRUCTUREGENERATING PRODUCTIVE ACTIVITIESW. Di Munzio, G. SalomoneDepartment of Mental Health, Local Health Unit 1,Nocera Inferiore, Salerno, ItalyPsychiatric rehabilitation has to find practical solutions for the integrationof the psychiatric patients who, step by step, have been excludedand isolated from human relationships. For this reason, our departmentjoined the regional project on the elaboration of activities aimingto the social and working integration of schizophrenic patients. Wehave developed the following projects: ancient book-bidding and setting,artistic pottery, graphic arts, computerized publishing trade, cartoons.Labs were set in the premises of the former mental hospital inNocera Inferiore. We aim to increase of at least 20% the number ofyoung patients with serious psychiatric pathologies who are includedin programs of rehabilitation and vocational training, and to decreaseof at least 20% the rate of hospitalization in acute psychiatric wardsand private structures of the patients participating in the project.PO3.152.CINEMA AND PSYCHIATRIC REHABILITATIONW. Di Munzio, G. Salomone, G. d’Aquino, A. PisapiaDepartment of Mental Health, Local Health Unit 1, NoceraInferiore, Salerno, ItalyIt is well known that a film gives us more details than what thescriptwriter originally set out to convey. Its capacity to stimulate usand its ambiguity enables us to interpret these images in numerousways. The cinema has always represented new ideas, changes in societyand changing mentality and is an instrument (for psychiatrists,patients and their families) in which we can “recognise ourselves”,see our ideas clearly, our attitudes and our behaviour. “Seeing ourselves”in a film image is not a form of self protagonism or identifyingoneself in a film role, but a way of arriving at self criticism and consequentlybeing able to change. The ability to change is a dynamicprocess that in therapy is useful for both patients and psychiatrists.The cinema can be used as a form of therapy and rehabilitation. Onthis basis we have created a computerised data base which containsaccess to about 400 films.PO3.153.PSYCHOSOCIAL FACTORS AFFECTINGSPECIALITY CHOICEL. Estévez Vaticón 1 , E. Barahona Ruiz 2 , A. Huerta Arroyo 2 ,B. Nacarino Alcorta 2 , M. Nombela Arrieta 2 , P. Ortiz Lucas 2 ,R. Osorio Suárez 11 12 Octubre Hospital; 2 Complutense University, Madrid, SpainMedical doctors develop their professional activities under strongpressure. Not many descriptive studies address the psychosocial situationof medical practitioners or the motivational and risk factors predictingfuture situations of malpractice, stress or professional burnout.This was a descriptive study of first year medical residents in the12 Octubre Hospital, focusing on the relationship between speciality342 World Psychiatry 3:S1 - October 2004

choice and psychosocial aspects, life events, parental relationship,influence of teaching figures, important illnesses within the family,and different incentives. We used an ad-hoc questionnaire for psychosocialcharacteristics, the Paykel Scale for life events, and theParental Bonding Instrument. The chosen specialities were medical(48%), surgical (24%), support (11%), primary care (17%). The specialitychosen was determined in 25% of the residents by some seriousillness suffered in their families. The lower the education level oftheir parents, the higher was the respondents’ interest in social prestige.A higher number of life events directed towards closer contactwith patients. Maternal overprotection seemed to affect significantlythe choice between support and internal medicine and primary carespecialities.PO3.154.CHARACTERISTICS OF PERSONALITY INA GROUP OF PRIMARY CARE PRACTITIONERSA. Miranda-Sivelo 1 , J.A. Aguado-Mañas 1 , R. San Miguel 21 Psychiatry Service, Hospital Universitario; 2 Centro Hospitalario,Benito Menni, Valladolid, SpainWe assessed personality traits in 30 primary care practitioners (73%women; age 26-28 years), by using the International Personality DisordersExamination (IPDE). The mean dimensional scores were:paranoid 10.71; schizoid 21.42; schizotypal 9.25; histrionic 23.75;antisocial 5.92; narcissistic 16.66; borderline 21.84; obsessive 29.58;dependent 20.83; avoidant 39.16. The highest scores were obtainedfor cluster C (anxious, dependent and obsessive) disorders. Perhapsobsessive characteristics are important for medical work so theycould be enhanced during the years of medical specialization.PO3.155.MORAL SENSITIVITY IN BRAZILIANPSYCHIATRIC PRACTICEM. Liboni, C. CohenDepartment of Legal Medicine, Medical Ethics,Social and Work Medicine, University of Sao Paulo, BrazilThe Moral Sensitivity Questionnaire (MSQ) has shown to be a validand specific instrument for the evaluation of psychiatrists’ moral sensitivityattitudes. In this study, we administered the Brazilian versionof the instrument to 522 Brazilian psychiatrists. The Cronbach’salpha for the instrument as a whole was 0.75. This result is similar tothat reported for the original version. There was a total agreementconcerning the constructs of autonomy, human integrity and relationship.A partial concordance was achieved for benevolence andprofessional practice. A strong disagreement was found for conflicts.The variables significantly related to the scale’s constructs were age,religion, length of professional experience, type of psychiatric practiceand region of origin.PO3.156.A NEW SYSTEM OF EDUCATION AND TRAINING INPSYCHIATRY: THE EXPERIENCE OF GEORGIAZ. Beria, G. NaneishviliGeorgian Psychiatric SocietyAfter a reform of the system of medical education, there are now threestages of the development of a specialist in Georgia: higher medicaleducation (undergraduate), postgraduate professional training (residency),continuing medical education (CME). At medical universities(more than 20 in Georgia), training in psychiatry usually takes placein the fourth and fifth year. Undergraduate training is not uniformthroughout the country. At the postgraduate level, instead, there is aunified system of education, a modern system of residency training,which is based on the law of "professional training of medical staff inoccupational residency" (1999). We have a three year training in generalpsychiatry, child and adolescent psychiatry, alcohol and drugabuse and psychotherapy. Since 1998, according to the law of "medicalactivity", we implemented the system of certification. Medicalactivity is authorized only for those who have the state certificate. Thephysician must prolong the certificate every 5 years. Recertificationcan be obtained through passing an examination or obtaining a definitenumber of credit hours. The Postgraduate and CME Council,including 31 members who represent professional associations, highmedical schools, scientific institutions, medical clinics and the Ministryof Labor, Health and Social Affairs, manages the medical educationsystem in every stage.PO3.157.INTERNATIONAL DIFFERENCESIN PSYCHIATRIC TRAININGD. Bussé 1 , V. Tort 2 , S. Olivieri 31 Serveis Assitencials Emili Mira i López, Diputació deBarcelona, Spain; 2 Sant Joan de Déu Serveis de Salut Mental,Barcelona, Spain; 3 Winchester and Eastleigh NHS Trust, UKPsychiatric training systems differ between countries. Training programscan be seen as a parameter of the mental health quality careprovided in any community. We performed a descriptive qualitativeand quantitative analysis of 24 worldwide psychiatric training systems.The characteristics of psychiatric training, the level of training,the access to training systems differ significantly from country tocountry. There is a need to encourage evidence based mental health,and to improve systems of evaluation and control of the quality ofcare. Clinical supervision needs to be broadly implemented. There isa need to standardise and validate medical training across differentcountries. Training in psychiatry must contain more clinical and medicalcomponents in order to improve the system of specialisation. Itmust encourage a long-term learning culture, searching for processeswhereby simple information is converted into expert knowledge.PO3.158.A NO-PROFIT WEB SITE ON MENTAL ILLNESS:A TWO-YEAR ITALIAN EXPERIENCEE. Poggi, B. Del Papa, F. Spagna, A. Frangione, M. Miniati,A. LenziDepartment of Psychiatry, Neurobiology, Pharmacologyand Biotechnology, University of Pisa, ItalyA no-profit web site dedicated to people with mental illness has beenactivated two years ago in Italy, with the purpose to provide informationand to answer questions regarding the most important psychiatricdisorders. During this two-year period, 4782 questions wereaddressed to the ‘meet the expert’ direct line of the web site. ‘Anxiety’(1111 contacts), ‘depression’ (1030), ‘panic disorder’ (681) and‘insomnia’ (190) were the most common topics considered. Moreover,relatives of people with mental illness were interested to receiveadditional information on psychotic symptoms, namely ‘hallucinations’or ‘delusion’, or on ‘schizophrenia’ spectrum disorders. Regardingtreatment options, the most frequently asked questions were onselective serotonin reuptake inhibitors, namely paroxetine (1088),sertraline (428), citalopram (405) and their side effects. Questionsrelated to alcohol or substance abuse (198) were also addressed to343

web site experts. These preliminary data should be interpreted cautiously.Internet is a powerful way to provide information or toanswer questions, but it cannot substitute the direct doctor-patientrelationship. Nevertheless, this preliminary experience may help tounderstand the needs and doubts of people with mental illness andtheir relatives.PO3.159.THE PSY.CH.E. INTERVIEW: AN INSTRUMENT FORTHERAPEUTIC CHANGE EVALUATIONA. Picello, A. Picardi, E. Caroppo, G. Di Carlo, G. RuggeriCentre for Advanced Study and Research in Psychotherapy,Institute of Psychiatry and Psychology, Catholic University,Rome, ItalyThe aim of our research is to analyse the psychological changeinduced during psychiatric treatments, either psychotherapeuticand/or psychopharmacological. In order to assess the distinctive featuresof this therapeutic change we have elaborated a specific instrumentof evaluation, the Psychological Change Evaluation – PSY.CH.E.Interview. This interview consists of seven sections. Each section,composed of ten items, concerns a specific dimension of the psychologicalchange (e.g., the “expected change” deals with the expectationsabout the coming change; the “change matrices” considers the factorsthat mainly promote the change; the “problem mastery” evaluates thecontrol of the patient over psychological difficulties, etc.). A clinician,not involved in the therapeutic intervention, administers this interview,separately, both to the patient and to the therapist; the administrationcan be repeated during treatment.PO3.160.THE V.I.E.W. QUESTIONNAIRE:AN INSTRUMENT FOR EVALUATION OFTHERAPEUTIC AND TEACHING ACTIVITIESCARRIED OUT IN VIDEOCONFERENCEG. Di Maria, E. Caroppo, G. Massacci, A. Picello, G. RuggeriCentre for Advanced Study and Research in Psychotherapy,Institute of Psychiatry and Psychology, Catholic University,Rome, ItalyThe use of “telepresence” represents a methodology with a highpotential for psychological therapy (telepsychiatry, telepsychotherapy)and for teaching. We are carrying out tele-psychiatry interventions(V.I.T.A. Project) and tele-teaching activities; therefore we are interestedin analysing the experience of “videoconferencing”, in comparingits effectiveness with the “face to face” experience and in improvingthe efficacy of this kind of intervention. We elaborated a questionnaire(Video Intensive Experience Willingness – V.I.E.W.) to beadministered to patients and students following psychotherapy sessionsor lectures carried out in videoconference. By means of thisquestionnaire we try to evaluate the experience in different moments(before/during/after the session or lecture) and to analyse the “therapist-patient”or “teacher-student” relationship according to severalaspects: expectations, psychological involvement, cognitive and emotionalparticipation, etc.PO3.161.TELEPSYCHIATRY AND TELEPSYCHOTHERAPY:A STUDY ON THE EFFICACY OFTHERAPEUTIC TREATMENTS CARRIEDOUT IN VIDEOCONFERENCEE. Caroppo, A. D’Ercole, C. Fanciulli, F. Tremolada, G. RuggeriCentre for Advanced Study and Research in Psychotherapy,Institute of Psychiatry and Psychology, Catholic University,Rome, ItalySince some years our research group has been carrying out psychiatricand psychotherapeutic interventions by means of videoconference.Here we present the results of the analysis of verbal and nonverbalcommunication between therapist and patient during a psychotherapeutictreatment carried out in videoconference. Sessionshave been selected from different phases of the treatment and havebeen analysed by independent assessors according to two specificgrids of evaluation. The preliminary results seem to support the therapeuticefficacy of this kind of treatment. Some considerations aboutdefining general outlines of these clinical interventions will be proposed.PO3.162.THE V.I.T.A. PROJECT: AN EXPERIMENTAL STUDYOF PSYCHIATRIC AND PSYCHOTHERAPEUTICINTERVENTIONS IN TELEMEDICINEE. Caroppo, G. Di Maria, G. RuggeriCentre for Advanced Study and Research in Psychotherapy,Institute of Psychiatry and Psychology, Catholic University,Rome, ItalyThe “telepresence” allows innovative strategies of intervention in psychiatry.Within this general framework the authors present the VelletriIntensive Telepsychotherapy Assistance - V.I.T.A. Project. Theproject was started three years ago and is based on psychotherapeutictreatments systematically carried out in videoconference. It is aimedto define the feasibility criteria (technical and psychopathological) ofthis kind of treatments; to compare it with “face to face” psychotherapy;to pinpoint its elective fields of application in psychotherapy,especially with regard to acute episodes of "crisis". Psychiatric consultingassistance and psychotherapeutic treatments are carried outby means of regular video connections between the research centreand patients who are living in towns near Rome. These treatments arecompletely tape-recorded, transcribed and submitted to independentassessors for specific scoring.PO3.163.CAPACITY TO CONSENT TO TREATMENTE. Rutledge, H. KennedyNational Forensic Mental Health Service, Dublin, IrelandThis study investigated the ability of patients with schizophrenia toconsent to treatment with oral antipsychotics. Their capacity to consentto treatment was compared with their fitness to plead, asassessed by the MacArthur Fitness to Plead Tool. 45 inpatients withan ICD-10 diagnosis of schizophrenia or schizoaffective disorderwere recruited. Levels of capacity were compared with psychiatricsymptoms and subject’s global assessment of functioning. Twentysubjects (44.5%) chose oral antipsychotics, fourteen (31%) chose notreatment and eleven subjects (24.5%) were unable to make a choice.Those who chose no treatment had lower levels of understanding,appreciation and reasoning than those who chose oral antipsy-344 World Psychiatry 3:S1 - October 2004

chotics. The former group also had higher scores on the Positive andNegative Syndrome Scale (PANSS) positive scale and Global Assessmentof Functioning (GAF) scale. Those who could not make achoice had the lowest level of capacity and worse scores on thePANSS positive scale and GAF scale. These data suggest that thecapacity of those who refuse to consent to treatment is more impairedthan those who consent to treatment. Those who are unable to makea choice have the least capacity. Reduced capacity in those whochoose no treatment and those who cannot choose is associated withpositive psychiatric symptoms and poorer global functioning.PO3.164.CAPACITY TO CONSENT TO A COURT REPORTAND ‘DOCTORS PRIVILEGE’E. Rutledge, H. O’Neill, H. KennedyNational Forensic Mental Health Service, Dublin, IrelandThe objective of this study was to examine the relationship betweenthe amount of information given and the uptake rate in a simpledichotomous choice, to consent to be assessed for a court report ornot. Uptake rates are compared for two different consent protocols,one giving minimal material information, the other giving a greateramount of information. 33 inpatients with a diagnosis of schizophrenia,all of whom were on remand and required a court report, wererecruited to the study. These individuals were asked to provide writtenconsent to the preparation of a court report using 2 different consentforms. Their psychiatric symptoms and measures of capacitywere compared with their refusal or acquiescence to the preparationof a court report. We used the MacArthur Fitness to Plead competenceassessment tool and the Brief Psychiatric Rating Scale (BPRS).Twenty-three (70%) of the subjects consented, when shown the shortconsent form, whereas only twenty-one (63.6%) of subjects consentedwhen presented with the more detailed version. Three subjects(9%) changed from consent to refusal when they were presented withmore information, while one subject (3%) changed from refusing toconsent. These data suggest that giving more information does detersubjects from giving consent, particularly those with least capacity.Those who withheld consent had significantly lower scores on scalesof understanding, reasoning and appreciation. Capacity to consentwas not correlated with severity of psychosis, as measured by theBPRS. Those who changed their mind were the most impaired of thegroup in terms of psychiatric symptoms.PO3.165.WHO DO I WORK FOR? THE PHYSICIAN’SROLE IN NON-MEDICAL DECISIONSM. ScottCommittee on Psychiatry in the Workplace, American PsychiatricAssociationDramatic improvements in public health and the diagnosis and treatmentof mental and physical illness have changed the nature of medicalcare and the very nature of illness itself. Diagnosis is early, treatmenteffective. End organ damage and disability are long delayed andwork is no longer as physically demanding as it was. Most illnesstoday is chronic; most people can work while receiving treatment.These positive changes in health, treatment, illness and work haveblurred the line between health and illness, between the capacity towork and disability. But physicians are pressured by employers,patients and insurers to make a decision about the patient’s workcapacity based on strictly medical facts. Employers assume that gettingwell and being able to work are synonymous. Patients assumetheir subjective feelings are a reflection of illness and expect thephysician to advocate for them. None of the parties acknowledge theimpact of psychiatric issues, benefits, work structures, and other nonmedicalissues on the decision and are aware of the long-term financial,social and emotional consequences of it. The presentation willexplore how non-medical, psychiatric and motivational issues impactthe decision to leave or return to work and physician approaches tothe dilemma of responding to the question “Can this patient work?”PO3.166.HERMENEUTICS IS A TOOL FOR GOODPSYCHIATRIC PRACTICEP. PortwichUniversity Hospital of Social and Community Psychiatry,Bern, SwitzerlandPsychiatry as well as the other medical disciplines is dominated bybiological methods, while humanities do not play a relevant role. Thispredominance of the biological paradigms influences the medical wayof thinking and acting: the interaction between patient and doctor issuperimposed by the performance of biotechnical procedures, psychiatricpractice sticks to the results of randomized controlled trialsand meta-analyses. However, the criticism of patients and society ofthe reductionistic medical view grows and an increasing number ofpatients undergo alternative care. These developments indicate a tendencytowards deprofessionalization in medicine and require a fundamentalchange. This change might be performed by the intentionalintroduction of hermeneutics in psychiatric practice. Hermeneutics isthe contextual understanding of meaning and sense of human phenomena(methodology of humanities). Hermeneutical thinkingenables to perceive the patient with his specific pattern of relations,abilities, desires, personal values, and limitations; the patient can becomprehended as a unique individual. The long and outstandinghermeneutical tradition of psychiatry (philosophy, history, psychotherapy)provides a basis for a revival of hermeneutics as anappropriate tool to meet the requirements of new mental health carein postmodern society.PO3.167.OVERCOMING THE DEPERSONALISATIONOF THE THERAPEUTIC RELATIONSHIPA. DangelliaPsychiatric Clinic, University of Tirana, AlbaniaIn the world of high tech, the man often feels threatened and devalued.This is reflected in our relationship with mentally sufferingpatients. It seems, in the relations with our clients, that our words arelosing the power of transmission of meanings. The verbal capacity ofdoctors risks to be substituted by the language of the apparatus. Thetime spent with our clients is becoming short and the doctor-patientdyad is being threatened. This serves as a bell of the risk of changingattitudes of the psychiatrists toward their patients. We know that thebase of such a dyad is the exchange of feelings and ideas between twopartners. The patients are expecting in our times from their doctorsmuch more than before. Medicine is advancing rapidly. It is up to thedoctors to find a balance between their engagement with theirpatients on one side and their culture-bound attitude on the other. Toovercome the depersonalization of the therapeutic relationship in ourtimes of high tech, we should keep in our minds the humanisticapproach in psychiatry as an element that provides the stability andconfidence in the doctor-patient dyad. It is of primary importance toavoid the narcissistic biases seen sometimes in our relations with the345

clients. The patient should not be considered only as an object, butbefore all as a subject, as a human being in relations with others, thatneeds feelings and meanings of others. First of all, we must expelthose tendencies seen in medical practice when the doctors “gain theupper hand” in relations with patients. It would be inhuman to convertin a sort of trade such relations. Nowadays we must represent ourrole as “professional partners”, which means to be with patients in arelationship of mutual respect. Communicative equality means totake seriously the communicative needs and interests of the patient.The medical work today seems to be dominated much more by theevidence-based knowledge and technical procedures than by the artof communication. Our patients need warm communication. It isimportant to keep the therapeutic aspects of the communicationprocess. The quality of the communication should be improved byacquiring deep knowledge and experience. In our everyday medicalpractice there is a continuous need for the improvement of such acommunication. To fight against the depersonalisation of the doctorpatientdyad, we need to train continuously in the skills of the communication.It remains then to us to integrate such skills in clinicalpractice.PO3.168.COMMUNICATING RISK: ANOTHER TOWER OFBABEL?G.S. GosallEdenfield Medium Secure Unit, Manchester, UKA series of medical reports about mentally ill patients by consultantpsychiatrists from general adult psychiatry and forensic psychiatrywere analysed for statements describing the risk of harm to self and/orothers. The phrases used were collated. Psychiatrists and members ofthe legal profession were then asked to study these phrases and specifytheir perception of the likelihood of a risk occurring in percentageterms as described by each phrase. An answer of 0% would indicatethat there was no risk at all, while an answer of 100% would indicatethat the risk event would definitely occur. The results showed thatthere was a wide variation in the perceived risk amongst professionalsfor each phrase used to communicate risk, such that the use of suchphrases is almost meaningless without more information.PO3.169.ETHICAL AND LEGAL ASPECTSOF PSYCHIATRIC TREATMENT IN BULGARIAV. Velinov, P. MarinovDepartment of Psychiatry, Clinic of Forensic Psychiatryand Forensic Psychology, Medical University, Sofia, BulgariaIn Bulgaria, ethical and legal aspects of psychiatric care are a majorfocus of attention. Ethical issues are an integral part of student curriculumand post-graduate education. The WPA Declaration ofMadrid is included in each issue of the Bulletin of the Bulgarian PsychiatricAssociation (BPA); a special link to the Section on Ethics andPsychiatry is present on the BPA website; an Ethics Committee hasbeen established in the BPA; a consensus statement on risk assessmentin dangerous behavior has been produced. Ethical and legalguarantees for keeping patients’ rights are emphasized: early interventionof legal institutions; public procedure, accepting participationof media and human rights organizations; obligatory lawyerdefense; treatment based only on clinical indications; obligatory riskreassessment for a period no longer than 6 months.PO3.170.THE USEFULNESS OF THE ASSESSMENT OFQUALITY OF LIFE IN PSYCHIATRIC PATIENTSA.V. Semke, V.N. ShadrinMental Health Research Institute, Tomsk, RussiaWe assessed indices of quality of life in patients under treatment at theMental Health Research Institute of Tomsk. We also assessed theinfluence of quality of life indices on conducted therapy and on theattitude of the patient toward the stay in the hospital. A semistructuredinterview including a questionnaire for the assessment of socialfunctioning and quality of life of mentally ill was administered to 20patients with a verified diagnosis of schizophrenia. We found thatinclusion of indices of quality of life allows to improve the efficacy ofconducted psychopharmacotherapy. An advantage of this approachis involving the patient him/herself into the therapeutic and rehabilitativeprocess, strengthening the therapeutic alliance and reinforcingthe patient’s sense of responsibility for his/her social behaviour andhis/her health.PO3.171.THE SHADOW LINE:PSYCHIATRY AND DRUG INDUSTRYV. Fricchione PariseMental Health Department, Local Health Unit 2, Avellino, ItalyHealth care costs are more and more rising, and national healthservices’ officers are making hard decisions about how and where tospend public resources. Facts testify that over the past ten years therehas been a very expensive change in the medications used to treatmental illnesses: new generation antidepressant and antipsychoticdrugs have replaced many pre-existent patent medicines; anti-epilepticdrugs are being recommended with greater frequency as mood stabilizers.The newer medicines offer the promise of ever-increasingefficacy and lesser side effects; at the same time their prices are goingup remarkably. The pharmaceutical industry is the most profitablebusiness in the G-7 countries. Marketing costs currently exceed 30%of revenues, far surpassing outlays for both research and developmentand drug production. Several psychiatrists attend sponsored continuingmedical education events and lunches organized by drug companies,and have their expenses for participation in meetings covered bycompanies. The once clear boundary between academic medicineand industry has become increasingly blurred; industry donors are ina special position to both foster academic work and determine whichplan is conducted. Some published research tends to favour drugcompany sponsored products, and some clinically important studiesremain unpublished or are published with a long delay. A substantialliterature confirms the considerable impact of promotional activitieson the opinions and prescribing patterns of physicians. There areassociated ethical problems, including: a) higher costs of pharmaceuticals;b) non-rational prescribing; c) waste of national health systemfunds; d) limited development of alternative, independent sources ofcontinuing education, information, and verification of drug effectivenessand side effects. While it is unwise to advocate the total separationof the academic and medico-professional communities fromindustry, more transparency in this complicated relationship is warranted.346 World Psychiatry 3:S1 - October 2004

PO3.172.THE RELATIONSHIPS OF PSYCHOLOGICALWELL-BEING AND PSYCHIATRIC DISORDERSTO COGNITIVE SCHEMATA AND WORKP. Morosini, A. Gigantesco, F. MirabellaItalian National Centre of Epidemiology, Surveillanceand Health Promotion, National Institute of Health, Rome, ItalyIn psychiatric literature, studies that investigated the presence of psychiatricdisorders and psychological well-being at the same time areabsent. The aim of the present study was to identify the relationshipsof psychiatric disorders and well-being to cognitive schemata and satisfactionwith work in a population of health care workers. The studywas carried out in a general hospital located in an urban area in centralItaly. A sample of 514 health care workers completed an anonymouspreviously validated instrument including four scales assessingpsychiatric disorders, psychological well-being, satisfaction withwork, and cognitive schemata. The one-year prevalence of workerswith a psychiatric diagnosis according to the Composite InternationalDiagnostic Interview (CIDI) was 22%. The absence of psychiatricdiagnosis was associated with well-being and satisfaction with work.Psychological well-being was correlated with satisfaction with workand negatively associated with most of dysfunctional cognitiveschemata (all cognitive schemata except three: alarmism, perfectionismand hostile attitude). Satisfaction with work was negatively associatedwith hostility and poor control of the outside events. The presenceof a psychiatric disorder diagnosis was associated with most ofdysfunctional cognitive schemata (all cognitive schemata exceptthree: perfectionism, difficulty to change, and hostile attitude). Ourfindings suggest that psychological well-being could be equated withthe absence of psychiatric disorders, with the absence of the majorityof dysfunctional cognitive schemata, and with a favourable opinionabout work conditions.PO3.173.OUTCOME EVALUATION IN PSYCHOTHERAPY: AGENERAL SELF-ADMINISTERED QUESTIONNAIREG. Palumbo 1 , P. Morosini 1 , A. Carcione 21 Centre of Epidemiology, Surveillance and Health Promotion,National Institute of Health; 2 Third Centre of CognitiveBehavioural Psychotherapy, Rome, ItalyOutcome evaluation in ordinary care, i.e. evaluation of effectiveness,is becoming a requisite in treatment research. In psychotherapy, themost promising tools are questionnaires which are self administeredby clients/patients. We present a self-administered questionnaire,known as the Psychotherapy Outcomes Questionnaire, which hasbeen developed by the Mental Health Unit of the Italian NationalInstitute of Health, to evaluate psychotherapy effectiveness. Thequestionnaire integrates perceived efficacy of psychotherapy (5 questions)and opinion about the psychotherapeutic process and cost (7questions). It ends with a general satisfaction question. All answersare expressed on a 7 level scale. A test-retest study at 2 weeks distancewas performed on 30 subjects with very good reliability results. Factoranalysis will be performed on more than 100 clients/patients.PO3.174.PILOT STUDY ON THE THERAPEUTICPROCESS IN CRISIS PSYCHOTHERAPYW. Padoani, F. Vignaga, E. Fusco, S. Granà, M. Marini,M. Semenzin, L. PavanDepartment of Psychiatry, University of Padua, ItalyThe aim of this work, which is part of a more extensive study on efficacyof crisis psychotherapy, was to evaluate the therapeutic processand any correlation with outcome in depressed patients. The patientswere consecutively recruited from those attending the crisis psychotherapyoutpatient centre of the Department of Psychiatry ofPadua University (January 2000-December 2002). Twenty-six of themfulfilled the inclusion criteria and were administered the HamiltonRating Scale for Depression (HDRS), the Beck Depression Inventory(BDI), the Structured Clinical Interview for DSM-IV Personality Disorders(SCID-II), the Global Assessment of Functioning (GAF) andthe State-Trait Anxiety Inventory (STAI), on entry into the study andthree, six and twelve months later. The Session Evaluation Questionnaire(SEQ) was also employed to evaluate patients’ feelings andthoughts after each session. Some sessions were also audio-recorded.Results indicated a significant improvement in depression, anxiety,anger and social functioning scores in every follow-up considered.The patient’s SEQ scores and cross evaluation of patient and psychotherapistat each session exhibited significant trends for someSEQ subscales (i.e. depth, positivity, good therapist). The positivitysubscale showed a significant correlation with BDI (r = -.78; p

PO3.176.CULTURAL APPROACH IN PSYCHOTHERAPY:A RUSSIAN PERSPECTIVEE. NikolaevChuvash State University, Cheboksary, RussiaA number of different strategies are used by psychiatrists in theprocess of working with mental patients to reduce their problems andimprove their adjustment. Psychodynamic, humanistic, behaviourand cognitive theories of personality are the basis for fundamentalapproaches to contemporary psychotherapy. Psychotherapy developmentin Russia brought to light some cultural aspects. Russianpatients seem to be more oriented towards seeking help from othersthan mobilizing personal resources. The psychiatrist is often misperceivedas a magician or as a wise adviser. The results of treatment areentirely depending on the doctor's skills and commitment to help.Two cultural trends in psychotherapy are marked out on this basis.The receptive approach includes methods of biological or psychologicaltreatment that produce a positive effect regardless of patient'sefforts. Among them are hypnotherapy, relaxation, talkative therapy,lectures and drug treatment. On the contrary, the productiveapproach demands that initiative in treatment be equally shared bythe patient and the doctor. The psychiatrist encourages patient'sactive position, stimulates aspiration to positive changes in feelings,emotions, behaviour, in the direction of what is called personalgrowth. The concept of cultural-oriented approach in psychotherapymay help mental health professionals in Russia to work out effectiveindividual programmes for certain groups of mental and psychosomaticpatients. It could be also useful in the prevention of burning outduring psychotherapy.PO3.177.THE FAMILY IMAGE TECHNIQUE AS ACOMMUNICATION TOOL FOR TROUBLED FAMILIESK. KameguchiGraduate School of Education, University of Tokyo, JapanThe family image technique (FIT) provides the family and each of itsmembers with the concrete possibility of illustrating clearly the imagethey have of themselves. FIT is particularly useful for families sufferingfrom psychological problems, because, in the reflection of theirown image, the family members can find a breakthrough towards abetter dialogue. The author has been studying many elementary, secondaryschool and university students along with their parents. Themethod turned out to be useful to solve latent conflicts and bring forwardconcealed problems in order to handle with them at their initialstage performing a kind of preventive work. Of course only properfacilities and the presence of skillful personnel can guarantee thefunctionality of this method and that is the reason why is so importantto involve several kinds of experts, like clinical psychologists,probation officers, child guidance center staff, welfare counselors,healthcare counselors, any kind of professional counseling personand so forth and to widen further the field in order to include familysociology, family nursing, family education and family research.PO3.178.PSYCHODYNAMIC PSYCHOTHERAPY FOCUSINGON TRANSFERENCED. Malidelis, P. Papadopoulos, E. Panagoulias, E. Dimopoulou,E. Terzioglou, G. TychopoulosMental Health Centre of Peristeri, Athens, GreeceThis study aimed to evaluate the effectiveness of psychodynamic psychotherapybased on transference in 96 patients (men: 23, women: 73)with a diagnosis on the axis I (n=16), axis II (n=21) or both axes of theDSM-IV. The axis I diagnoses were mood disorders (n=20), anxiety disorders(n=51), eating disorders (n=4). The axis II diagnoses were in clusterA (n=13), B (n=56) and C (n=11). According to Kernberg’s criteria allpatients were classified as borderline personalities. The sample did notinclude patients with an antisocial or narcissistic structure of personality.All patients completed a two-year program of psychotherapy. Regardingsymptomatology, 76% of the patients presented a “major improvement”.Regarding functionality, 50% presented a “major improvement”and 48.9% a “moderate improvement”. Regarding interpersonal relations,the corresponding percentages were 54.2% and 43.8%. Onlypatients completing treatment were included in this analysis.PO3.179.SOCIODRAMA AND PSYCHODRAMATECHNIQUES IN ADOLESCENTS REFERREDTO A MENTAL CRISIS CENTERE. Miceva-Velickoska, V. Micev, V. Calovska-Samardjiska,N. Manuseva, B. Stefanovski, M. PolazarevskaUniversity Clinic of Psychiatry, Skopje, Republic of MacedoniaWe report on the application of sociodrama and psychodrama in adolescentsreferred to a mental crisis center. The techniques allow aspontaneous and creative social role playing and an improvement ingroup communication. The main purpose is to help young people toface many challenges in everyday living, to recognize their own values,to communicate, to deal with important decisions, dilemmas andneeds. Ambivalent emotional attitudes are brought up and addressedthrough a psychodynamic approach.PO3.180.THE EFFECTS OF A PSYCHOMOTORTRAINING ON PATIENTS AFFECTED BY ACUTEMENTAL DISORDERSA. Petito 1 , A. Bellomo 1 , A. Papazacharias 1 , A. De Giorgi 1 ,M. Nardini 21 Chair of Psychiatry and Clinical Psychology, Departmentof Medical Sciences, University of Foggia;2 Department of Neurological and Psychiatric Sciences,University of Bari, ItalyThe aim of the present study is to verify the hypothesis that psychomotortraining (based on the psychophysic self-knowledge education)can improve the outcome in psychiatric hospitalized patientsaffected by schizophrenia, bipolar disorders, major depression disorders,and personality disorders. The study has been conducted comparingtwo groups of patients, having homogeneous diagnoses anddemographic characteristics. The first group has been treated with thetraditional therapy (pharmacologic therapy + psychotherapy) and thesecond group with an experimental therapy (pharmacologic therapy+ psychotherapy + psychomotor training). The evaluation has beenmade by structured interviews for the measurement of compliance,insight, aggressivity level and general psychiatric clinical conditions.348 World Psychiatry 3:S1 - October 2004

Psychomotor training seems to improve the cognitive, emotional andrelational conditions, and reinforce self-knowledge.PO3.181.A NEW THERAPEUTIC INTERVENTION FORPSYCHOSOMATIC AND PSYCHOTIC PATIENTSM. Diallina, K. Alexandropoulos, M. MarkantonakiPsychiatric Clinic, G. Gennhmatas, General State Hospital,Athens, GreeceWe describe our experience with a group intervention for hospitalizedpsychosomatic and psychotic patients, consisting of weekly storytellingand art-therapy group sessions. The goals of these groups arethe sensitization of patients to their inner conflicts and a betterunderstanding and following up of their progress. 83% of the patientsreceiving this intervention found it helpful to understand themselves,66.7% found it essential to express their feelings, and 16.7% found itboring. Of the medical staff, 81.8% assert that the groups are helpful,while 54.5% believe that sufficient information is lacking. Nevertheless,100% advise that the continuation of such groups is essential.Finally, 81% of the nursing staff regard them as a supplement to theirpractice.PO3.182.LANGUAGE AS A DYNAMIC SYSTEM:IMPLICATIONS FOR PSYCHOPATHOLOGYF. Orsucci, M. Mazza, S. De RisioInstitute of Psychiatry, Catholic University, Rome, ItalyIn recent years, considerable work has been done in attempting tounderstand various aspects of speech and language in terms ofdynamic systems. In fact, language organizes and modulates sensoryexperiences, but on the other hand is influenced by action and perception.The aim of our study was to evaluate the presence of subsymbolicpatterns in the speech of psychiatric patients and normalcontrols. We submitted to recurrence quantification analysis (RQA)the elements of an ordered series (the letters constituting selectedspeeches) of clinical and non-clinical (control) non-structured interviews.Empirical evidence is highlighted at two levels: a) psychopathologydefines informational structures of language, but differentialdiagnosis needs further improvements; b) synchronization, i.e.a reliable communication, can be measured and assessed in a robuststatistical context.PO3.183.THE INTANGIBLE DIMENSIONS OF WELLNESSN. Glavish, A. Sweetapple, E. WilsonAuckland City Hospital, Auckland, New Zealandinternal bloodlines cannot be crossed; a fact reinforced by the collectiveconsciousness. If that knowledge is consciously or unconsciouslyignored by individuals, the potency of the mental and physicalimpairment for the child is tangible. The dismissal of the knowledgeis a matter of mind with the inevitable dis-ease of spirit and body, andfurther includes the secondary dis-ruption of the spirit and the bodyarising from the knowledge of the unsolicited damage to the other.This paper explores the counterpoint of two mental health modelscoexisting in a politically sanctioned framework.PO3.184.LORD OF THE RINGS, RETURN OF THE KING:THE END OF THE PSYCHIC JOURNEY TOWARDTHE SELFA. JavanbakhtDepartment of Psychiatry, Mashhad University of MedicalSciences, Mashhad, IranIt is believed that many legends, myths and stories are a reflection ofthe human beings’ psychic elements, evolution, and growth. Theseproducts of the mind are considered as the symbolic language of theunconscious psyche telling its story of growth, maturation, fails, fears,beginning, and destination. The intrapsychic symbolism shows itselfin the body of the heroes of the myth. I have studied the evolution ofthe psyche through the intrapsychic journey in the third book ofTolkien’s “Lord of the Rings”. I first discuss the integration of theAnima to the consciousness of Ego, then the integration of the Shadowto that Ego, and then the identification of the Ego with the Self asthe final destination of the human psychic growth and evolution.PO3.185.ARCHITECTURE AND THE SOULTHROUGHOUT THE AGESG. ParlatoState University of New York at Buffalo, NY, USAThe architecture of a people often reflects their character. The symmetricalproportions of a building, interior and exterior, can be inspiring,soothing and reassuring. When architecture is bad, it can have anunsettling effect. Many psychiatric disorders are thereby manifested:e.g., claustrophobia in a building where the exits are tortuously inaccessibleto a consumer in a shopping mall. Images of architecture willbe presented from the classical era through the renaissance into themodern era when citizens too often feel trapped or bored by an architecturewhich has lost its corporate soul. The psychotherapist must bealert to these environmental factors and stresses.For a Maori the sole source of identity is the Iwi (ancestors’ unconsciousness).This is the cultural arrangement (the conscious collective)which has persisted since the beginning of Maori time to thebiculturalism that reflects modern New Zealand. Treaty law amongother things conferred citizenship upon Maori (equity) and ratifiedcustomary knowledge (taonga). Public health funding endorses theelements of these arrangements. Recent advances in social policy andacademic research recognize a Maori model of (mental) health originatingfrom Iwi, which conceptualises mental illness as a disruptionof spirituality subsequently manifesting itself in the body. Restorationof wellbeing commences with the affirmation of the individual by theconscious collective and customary healing aims to identify the precipitantto the disruption. As an example, the ancestors know that349

SPONSORED SYMPOSIASAS1.FREE YOUR PATIENTS FROM DEPRESSION:TREATING THE SPECTRUM OF SYMPTOMS(Organized by the Lilly/Boehringer IngelheimAlliance)SAS1.1.THE BURDEN OF DEPRESSION: UNCOVERING THEREMAINING NEEDSM. BauerDepartment of Psychiatry and Psychotherapy,University of Medicine, Campus Charité Mitte, Berlin, GermanyDepression is a condition that not only affects the minds of millionsof sufferers, but also takes a toll on their physical well-being. Thesomatic aspect of depression is something that has not been studiedwell enough in the past, yet deserves consideration as an importantpart of the depressive condition. By treating only the emotional symptomsof depression, residual symptoms, which are usually physical innature, remain to complicate recovery, often resulting in relapse. Thiscan be avoided by treating the syndrome of depression completely,resolving both the emotional and painful physical symptoms of eachpatient with depression to bring them to a remitted state.SAS1.2.SEROTONIN AND NOREPINEPHRINE: WORKINGTOGETHER OR WORKING SEPARATELY ON THESYMPTOMS OF DEPRESSION?T. DinanDepartment of Pharmacology and Therapeutics, UniversityCollege Cork, Dublin, IrelandWith the recent upswing in interest towards dual acting antidepressantdrugs, it has become necessary to question why dual acting drugsshould be chosen over single acting drugs. Why should we simultaneouslyaddress the serotonin (5-HT) and norepinephrine (NE) systemswhen addressing each separately seems to alleviate many, if not most,of the obvious symptoms of depression? The answer to this questionwill be reviewed in this presentation. We will discuss studies thatshow that disruptions of both 5-HT and NE are instrumental in causingthe appearance of depressive symptoms. We will review studiesthat show that using drugs that act on both systems produces betterresults than treating a single system alone. Lastly, we will look at howdual acting drugs reduce the severity of the painful physical symptomsthat may accompany depression.SAS1.3.FINDING A SOLUTION:INNOVATIVE AND BALANCED TREATMENTSFOR ACHIEVING REMISSIONA.F. Schatzberg, K.T. Norris Jr.Department of Psychiatry and Behavioral Sciences, UniversitySchool of Medicine, Stanford, CA, USAThe definition of “better” when recovering from depression can be aslippery one. Side effects can often interfere with the recoveryprocess, with up to 40% of patients discontinuing treatment withintwo months. Of those that start antidepressant therapy, up to 45%have no response to their first antidepressant and must be switched toother medications. Even when the therapies are effective with treatingmost of the symptoms, the presence of any residual symptoms correlateswith a huge increase in the rate of relapse compared to patientsin an asymptomatic state. Obviously, something is needed to addressthese issues, and a new class of antidepressants – the serotonin norepinephrinereuptake inhibitors (SNRIs) – may be the answer. TheSNRIs have relatively mild side effect profiles and show much betterefficacy than the specific serotonin reuptake inhibitors (SSRIs),which are the standard treatments for depression today. More importantly,the SNRIs treat both the emotional and the painful physicalsymptoms of depression. In doing this, they treat the completedepressive condition, thus allowing more patients to not only attain,but also sustain, a state of remission.SAS2.ESCITALOPRAM: INNOVATION THROUGHEVOLUTION (Organized by Lundbeck and InnovaPharma)SAS2.1.PHARMACOLOGY OF SEROTONIN TRANSMISSION:UPDATE AND FUTURE PERSPECTIVESG. RacagniCenter of Neuropharmacology, University of Milan, ItalyIn mammals, serotonergic neurotransmission regulates a wide varietyof neurobehavioral processes, including cognition, affective states,feeding behavior, motor control, and sensorimotor integration. Theeffects of the neurotransmitter serotonin (5-hydroxytryptamine, 5-HT)are mediated through 13 distinct heptahelical, G-protein-coupledreceptors (GPCRs) and one (presumably a family of) ligand-gated ionchannel(s). These receptors are divided into seven distinct classes (5-HT1 to 5-HT7), largely on the basis of their structural and operationalcharacteristics, and have been implicated as playing important roles incertain pathological and psychopathological conditions. This degreeof physical diversity clearly underscores the physiological importanceof serotonin. However, evidence for an even greater degree of operationaldiversity continues to emerge. Also, the serotonin transporter(SERT) gene is a particularly interesting candidate for genetic involvementin affective disorders, owing to its role in both the regulation ofserotonergic neurotransmission and the mechanism of action of manyantidepressant drugs. Two different polymorphisms of the SERT genehave been described: a variable number of tandem repeats (VNTR)polymorphisms in intron 2, and a deletion/insertion polymorphism(5-HTTLPR) in the promoter region of the gene, the short variant ofwhich reduces the transcriptional efficiency of the SERT gene. Evidencehas been provided that, although the 5-HTT gene may not bedirectly associated with depression, it could moderate the serotonergicresponse to stress and influence the response to antidepressant medication.The studies on 5-HT receptors and on SERT clearly demonstratethat the development of molecular genetic technology offerspowerful techniques to complement pharmacological approaches tostudy individual 5-HT functions. In particular, gene-targetingapproaches have been applied for the generation of lines of mice withselective and complete elimination of individual 5-HT receptor subtypes(“knockout mice”). The multiplicity and diversity in 5-HT receptorsand SERT suggest that, under both physiological and pathologicalconditions, the status of the 5-HT transmission may vary dramaticallyfrom one subject to another and this could represent the basis for differencesin responder rates to a given treatment.350 World Psychiatry 3:S1 - October 2004

SAS2.2.PHARMACOLOGICAL FEATURES OF SELECTIVESEROTONIN REUPTAKE INHIBITORSN. BrunelloDepartment of Pharmaceutical Sciences, University of Modenaand Reggio Emilia, Modena, ItalyMolecules with identical atomic constitution and sequence of covalentbonds, but with different three-dimensional arrangement of theatoms, are called enantiomers. An enantiomer is a molecule that isnot superimposable on its mirror image. Enantiomers have identicalphysicochemical properties, however they rotate the plane of polarizedlight in opposite directions. The equimolar mixture of two enantiomersis called racemate, and most synthetic drugs which haveasymmetric carbon atoms are produced as racemic mixtures, despitethe fact that pharmacological activity may reside primarily in oneenantiomer. This is in contrast to chiral compounds isolated frombiological sources, where only one enantiomer is usually found.Metabolizing enzymes, protein-binding sites, and/or drug receptorsites have three-dimensional structures that may be better suited tointeract with one enantiomeric form. Thus, the enantiomers ofracemic drugs often differ substantially in their pharmacologicalactivities, protein binding characteristics, and distribution/dispositionprofiles. Using a single enantiomer can result in an improvedtherapeutic index, resulting from presumed higher potency and selectivitywhile removing those side effects that may be due to the lessactive enantiomer. Use of a single enantiomer can thus result in animproved onset of action and duration of action and a decrease in thepropensity for drug-drug interactions. Many commonly prescribedantidepressants are chiral compounds: tricyclic antidepressants andrelated compounds, mianserin and mirtazapine; selective serotoninreuptake inhibitors (SSRIs) (citalopram, fluoxetine, paroxetine andsertraline); serotonin and noradrenaline reuptake inhibitors (SNRIs)(venlafaxine and milnacipran), and the selective noradrenaline reuptakeinhibitor reboxetine. Escitalopram is the dextrorotatory enantiomerof citalopram, and preclinical studies have clearly indicatedthat the property of inhibiting serotonin uptake resides in this isomer,whereas R-citalopram is devoid of any inhibiting activity. Escitalopramis also extremely selective for serotonergic transport proteinsrelative to noradrenergic or dopaminergic binding sites when directlycompared with other SSRIs. Moreover, escitalopram showed nobinding affinity for more than 100 receptors or binding sites tested invitro, including alpha-1 adrenergic receptors, muscarinic receptorsand histamine H-1 receptors. In rat models predictive of antidepressantactivity, escitalopram demonstrated higher activity than theracemic drug citalopram with even a shorter onset of action. Severalmajor clinical studies demonstrate that escitalopram produces statisticallysignificant improvements in depressive symptomatology relativeto placebo and is well tolerated. Additional studies are needed toelucidate the place of escitalopram in the armamentarium of medicationused to treat depression, but at present it appears to hold promiseas a potent, effective and well-tolerated antidepressant that mayoffer a more rapid onset of action than other antidepressants for somepatients.SAS2.3.THE EVALUATION OF NEW ANTIDEPRESSANTSC. MencacciMental Health Department, Fatebenefratelli Hospital, Milan, ItalyUp to a few years ago, psychopharmacological research had a clearobjective: to develop effective therapeutic solutions for mental disorders.This is now an accomplished objective. In fact, modern treatmentsensure good results as far as the improvement of the psychopathologicpicture is concerned. Actually, they allow us to takecare of the social, relational and work reintegration of patients. Atthis point, a different question arises: from now on, what new moleculesdo we need? It is not likely, today, that we can develop an“ideal” antidepressant or antipsychotic molecule, matching therequirements of every kind of patient. On the contrary, the real problemis to identify and describe patients who are able to benefit fromthe peculiar features of each molecule. Nowadays, what we need is anantidepressant drug with a faster than 2-4 weeks onset of action;effective in more than 2 patients out of 3, and able to produce a remission,and to maintain it for a longer period and in a higher percentageof patients. Moreover, clinical practice suggests that we should focuson some variables which often determine the interruption of pharmacologicaltreatment by the patient. They include pharmacologicalinteractions; the activity towards P450 isoenzymes; virtual vs. realdose; sweating, tremor, restlessness; problems with sexual function(ejaculation, anorgasmia, libido reduction); weight gain. Escitalopram,the active isomer of citalopram (equimolecular mixture of theenantiomer S, active and R, inactive) presents an innovative pharmacologicalprofile and clinical activity. The clinical results obtained upto now (the molecule, approved by the Food and Drug Administration,is present in USA, Denmark, Switzerland, Austria, Spain, Englandand now also in Italy) seem to be very favourable. Now the firstresults obtained in clinical trials will have to be confirmed by ordinarypractice.SAS2.4.NEW REFERENCES IN THE THERAPYOF THE ANXIETY SYNDROMESS. PallantiInstitute of Neuroscience, University of Florence, ItalyEscitalopram, the S enantiomer, is the therapeutically active componentof citalopram, while the R enantiomer, also contained in theracemic citalopram, is essentially inactive from the pharmacologicalpoint of view. In animal models, escitalopram demonstrated higherantidepressant, antipanic and antiaggressive activity than RS-citalopram,with 4 fold lower effective doses. The pharmacodynamic profileshows a drug potentially characterized by reduced sedative activity,reduced pro-impulsive activity, lack of influence on body weight,and minor sexual effects. These hypothetical features correspond tothe four main causes of treatment discontinuation or reduced compliancereported for citalopram. Sedation is the principal cause of withdrawalwith selective serotonin reuptake inhibitors both in the shortand long period. Then, escitalopram offers a potentially superioreffectiveness with a low dose and a better tolerability profile. Escitalopramhas been studied on animal models such as “the residentintruder” and “the footshock-induced vocalization”, both on rodents.In the “resident intruder” model escitalopram has showed a reductionof aggressive behaviour in a dose-dependent manner and anincreased flight behaviour without modifying other behaviouralresponses. Citalopram, on the contrary, reduces aggressive behavioursonly at high doses (1 mg/kg) while the flight-submit behaviourincreases at all doses. In this model escitalopram is at least twice aspotent as citalopram. The “footshock-induced ultrasonic vocalization”model showed, with escitalopram and standard level of serotonin,a dose-dependent suppression of vocalization. By increasingthe serotonin levels (25 mg/kg of L-5-HT), the response was evenmore empowered. Citalopram and standard levels of serotoninshowed only a weak inhibition of vocalization. With increased levels351

of serotonin (25 mg/kg of L-5-HT) a complete inhibition of vocalizationwas observed. With R-citalopram and standard levels of serotonin,the inhibition of vocalization is very weak, and with increasedlevels of serotonin (25 mg/kg of L-5-HT) an increase of vocalizationis determined. This experiment concludes that R-citalopram actsinhibiting the anxiolytic effects of escitalopram. Five controlled clinicalstudies examined the use of escitalopram in anxiety disorders.Two studies were carried out in patients with generalized anxiety disorder(GAD). The first was a double-blind, placebo-controlled randomizedstudy on 240 patients with GAD treated with escitalopramfor 8 weeks, in flexible dose (10-20 mg/day). The second was a metaanalysisof three trials showing efficacy on GAD nuclear symptomsafter the first week of therapy compared to placebo. At a flexible doseof 10-20 mg/die, escitalopram was tested in 360 patients with socialanxiety disorder, in a double-blind placebo-controlled trial, for 12weeks: it was found superior to placebo in reducing the total score onthe Liebowitz Social Anxiety Scale and the scores on avoidance andfear/anxiety subscales. Escitalopram was evaluated for 10 weeks in adouble-blind comparison vs. citalopram and placebo in 351 patientswith panic disorder (with or without agoraphobia) with at least 4panic attacks in the prior 4 weeks and 3 panic attacks in the 2 washoutweeks with placebo: remission rates were significantly higherwith escitalopram (10-20 mg/die) in comparison to placebo. Escitalopramhas shown in all the studies an excellent tolerability profile.However, the use of assessment and outcome measures of cognitivefunctions, quality of life, “behavioural toxicity”, rates of complianceand “drug attitude” is needed, and studies longer than 8 weeks, withlong-term compliance evaluation, are warranted. Moreover, we needdirect comparisons between escitalopram and citalopram.SAS3.CONTROVERSIES AND CONSENSUS IN THEMANAGEMENT OF BIPOLAR DEPRESSION(Organized by GlaxoSmithKline)SAS3.1.THE UNIPOLAR AND BIPOLAR PHENOTYPESG.B. CassanoDepartment of Psychiatry, Neurobiology, Pharmacology andBiotechnology, University of Pisa, ItalyThe growing availability of new drugs for the treatment of bipolar disorderhas led to a renewed interest in mood disorders. Although thedistinction between bipolar and unipolar disorder has served our fieldwell in the early days of psychopharmacology, in clinical practice it isapparent that their phenotypes are only partially described by thediagnostic classification systems currently used, and this can thereforelead to misdiagnosis. We argue that clinical variability needs to beviewed in terms of a broad conceptualization of mood disorders andtheir common threshold or subthreshold comorbidity. The spectrummodel provides a useful dimensional approach to psychopathologyand is based on the assumption that early-onset and enduring symptomsshape the adult personality and establish a vulnerability to thesubsequent development of axis I disorders. The importance of subthresholdsyndromes should not be underestimated, as the failure torecognise bipolar spectrum disorder could delay treatment and worsenprognosis. Early detection of lower level phenomenology will preventthe occurrence of more severe, life-disrupting symptomatology.Therefore, clinicians need guidance to aid recognition that, in theabsence of evident mood alteration, fluctuations in energy levels,alternating phases of psychomotor activity, disruptive functioning andlability of psychological drives should be considered as fundamentalindicators of bipolar disorder. Furthermore, the introduction of arefined procedure for the detection and evaluation of a broader rangeof symptoms would improve the accuracy of the diagnosis and thesubsequent treatment of this illness. In response to this requirement, astructured clinical interview (the Structured Clinical Interview forMood Spectrum, SCI-MOODS) was devised to evaluate the wholerange of symptoms, focusing particularly on mild subthreshold manifestations.The SCI-MOODS encompasses the DSM-IV and ICD-10defined core symptoms, subthreshold and subclinical symptoms,atypical symptoms, behavioural patterns related to the core symptomsand personality and/or temperamental traits. Changes in four“domains” are explored to provide a method of classification thatplaces temperament, personality and affective disorders in a continuum:feelings and behaviour associated with physical experiences, suchas eating, sleep and sexual feelings; energy levels, with particularattention to everyday activities, such as work, social life and hobbies;mood, from subclinical depression to severe mixed and manic symptomsand cognitive changes that often occur with mood dysregulation.In the mood spectrum assessment self report (MOODS-SR),items are organized into depressive, manic-hypomanic and rhythmicity/vegetativecomponents. Empirical data demonstrating that thedepressive and manic-hypomanic components are significantly correlatedboth in bipolar and unipolar patients seem to challenge the traditionalunipolar-bipolar dichotomy and support the clinical usefulnessof the spectrum approach. However, the spectrum concept doesnot reject the DSM-IV or ICD-10 affective categories, but provides abroader range of symptoms allowing for the possibility of unclear distinctionbetween different DSM mood categories. Furthermore, byincluding altered mood and mood related features in one spectrumcategory, the model tends to reduce the problem of comorbidityencountered using the categorical classification systems. The systematicuse of instruments such as SCI-MOODS and MOODS-SR withbroader symptomatology investigation will allow even relatively inexperiencedclinicians to recognise clinically significant bipolar spectrumdisorders, identify patients at risk and follow treatment progressby increased awareness of residual symptoms and subtle fluctuationsin mood as a consequence of therapy.SAS3.2.THE BURDEN OF BIPOLAR DEPRESSIONE.G. HantoucheMood Center, Adult Psychiatry Department, Pitié-SalpêtrièreHospital, Paris, FranceBipolar depression is a part of a complex disease and represents byitself a complex phenomenology. This is probably due to many reasons:a) multifaceted clinical presentations, especially with mixed features;b) rich anxious comorbidity (obsessive-compulsive disorder,panic, social anxiety), poly-substance abuse; c) trait mood lability andcyclothymia; d) clinical instability. The EPIDEP French study, conductedat 15 sites, actually showed that 40% of major depressives arebipolar type II and 6% bipolar-I. Beside complexity, the major burdenof bipolar depression is linked to highly frequent misdiagnosis, especiallytoward unipolar depression. Studies revealed that an importantproportion of patients wait more than 10 years to get a correct diagnosisof bipolarity. Recognition of bipolar depression is crucial inorder to reduce recurrence and complications due to bipolarity, andto avoid inadequate treatment. Use of self-rated questionnaires cansubstantially improve the correct recognition of soft bipolarity. Featuresexternal to the phenomenology, such as early age at onset, highdepressive recurrence, seasonality, cyclicity, switching on antidepres-352 World Psychiatry 3:S1 - October 2004

sants (or worsening by antidepressants), postpartum onset, bipolar(often “loaded”) family history, hyperthymic and cyclothymic temperaments,are more useful ways to distinguish bipolar depressionfrom its unipolar counterparts. Beside increased rates of recurrenceand suicide, the burden of bipolar depression is enhanced by the presenceof cyclothymia. Cyclothymic depression represents a distinctand more severe and recurrent depressive form within the bipolar-IIsub-population (this argues for the utility of the “bipolar-II1/2” subentity).Moreover, in cyclothymic depression, a prominent “dark”side (with frequent risk-taking behaviors) characterizes hypomanicepisodes. Finally, the cases of bipolar depression with hypomaniastrictly associated with antidepressants seemed to be a valid soft bipolarsub-entity mostly characterized by the presence of long-standingdepressive traits (double depression), higher depressive severity, andcompleted suicide in the family.SAS3.3.LOOKING TO THE FUTURE: THE NEW TREATMENTGUIDELINES FOR BIPOLAR DEPRESSIONS. KasperDepartment of General Psychiatry, Medical University of Vienna,AustriaIn the treatment of bipolar disorder, the guidelines available for treatingmania are fairly standard worldwide, whereas those for bipolardepression vary, often substantially, between countries. Recently, newtreatment guidelines for bipolar I depression, based on clinical evidencerather than expert opinion, have been developed by an internationalconsensus group. In developing the guidelines, the grouprecognized that some commonly held misconceptions about bipolardisorder might be impediments to having these guidelines adopted.The group stressed that bipolar disorder is a chronic lifelong disorder,and that the whole illness, rather than acute manic or depressiveepisodes, should be taken into account when making treatment decisions.The group treatment recommendations were prioritized on thebasis of clinical evidence. Category 1 evidence was represented byrandomized, placebo-controlled trial(s) in the treatment of acutebipolar depression and in the long-term treatment of both phases ofillness. Category 2 evidence was represented by randomized, placebocontrolledtrial(s) in the treatment of acute bipolar depression or randomized,placebo-controlled trial(s) in the long-term treatment ofone phase of the illness. Finally, category 3 evidence was representedby randomized, controlled trial(s) in any phase of bipolar disordertreatment. Using these levels of evidence, the recommended first-linetreatments for the management of bipolar I depression were lithium,lamotrigine (both category 1 evidence), and olanzapine and olanzapine/fluoxetine(category 2 evidence). For patients who fail to respondto these first-line therapies, the consensus group recommended furtheroptions based on whether or not patients have non-rapid orrapid cycling or psychotic symptoms. They also provided guidance forthe treatment of breakthrough mania. The group concurred that cliniciansshould consider the individual patient when deciding whatfirst-line agent to use in bipolar depression, as well as when decidingwhat treatment to use for patients whose response is inadequate.Although the guidelines focus on drug therapy, the group also emphasizedthat the optimal management strategy for bipolar depressionincludes appropriate psychological interventions.SAS3.4.LONG-TERM MANAGEMENT OF BIPOLARDEPRESSIONG.M. GoodwinUniversity Department of Psychiatry, Warneford Hospital,Oxford, UKLithium is widely considered as the “gold standard” for long-termtreatment of bipolar disorder, with demonstrated efficacy in preventingmood relapse in both phases of the disorder. New data on the efficacyof lithium are available from two large multicentre, randomized,double-blind, placebo-controlled trials comparing lamotrigine andlithium as maintenance therapy in bipolar I disorder. These samestudies established lamotrigine as an effective maintenance therapyfor the prevention of bipolar depression, both in recently manic andrecently depressed patients. A planned combined analysis of the twotrials showed that lamotrigine, but not lithium, was significantly superiorto placebo in prolonging the time to intervention for a depressiveepisode (p

with residual symptoms, we found significant relapse reduction comparedwith continued medication alone, which extends to 3 1 /2 yearsafter cessation of CBT, as shown by follow-up data. However, CBThad only a weak effect in a trial in bipolar disorder, limited to betterprognosis patients with fewer previous episodes.SAS4.2.THE RELATIONSHIP BETWEEN SLEEP ANDDEPRESSION: NEW FINDINGS FOR AN OLDQUESTIOND. Buysse, E. Nofzinger, D.J. Kupfer, E. Frank, C. Reynolds,M. ThaseDepartment of Psychiatry, University of Pittsburgh Schoolof Medicine, Pittsburgh, PA, USASleep disturbances are commonly observed in patients with majordepressive disorder (MDD). However, many questions remain unresolvedregarding the nature of the relationship between sleep disturbancesand depression. New findings from three different areas ofresearch have important implications for this question. First, a growingbody of evidence indicates that sleep disturbances, specificallyinsomnia, are a risk factor for incident and recurrent MDD. At leasteight independent published reports support this conclusion. Thesedata also raise the question whether treating insomnia may modifythe risk of later depression. Second, a number of studies show thatinsomnia symptoms and specific electroencephalography (EEG)sleep characteristics, such as an increase in rapid eye movement(REM) sleep or decrease in slow wave sleep (SWS), confer increasedrisk for poor treatment outcomes in patients with established MDD.Again, the important unanswered question is whether treatment ofthese sleep disturbances may improve overall treatment outcomes indepression. Third, a growing number of functional imaging studiesusing positron emission tomography (PET) have demonstrated consistentpatterns of metabolic change associated with REM and NREMsleep in humans, and alterations in these patterns among patientswith depression. These changes bear some similarities, but also somedifferences, from waking PET studies in MDD, suggesting that sleepmay be a useful naturalistic probe for studying the neurobiology ofdepression. Taken together, these three types of findings suggestunique relationships between sleep and depression that may lead notonly to improved understanding of pathophysiology, but uniqueopportunities for intervention as well.SAS4.3.HOW DO ANTIDEPRESSANTS ACT ON THE BRAIN?NOVEL DRUGS, NOVEL CONCEPTSM. HamonINSERM U288, Faculté de Médecine Pitié-Salpêtrière, Paris,FranceThe need for more effective and more rapid antidepressants has stimulatedresearch on the physiopathological mechanisms of depression,and novel drugs acting at the hypothalamo-pituitary adrenal axis oraimed at promoting cell proliferation in the hippocampus have beenidentified as potential antidepressants. In addition, alterations in circadianbiological rhythms are other symptoms most often associatedwith depression, and evidence has been reported that endogenouscircadian rhythm disorganization can be causally related to affectivedisorders. Because melatonin is the key neurohormone for biologicalrhythm synchronization, it was hypothesized that a drug mimickingits actions might be of potential interest to alleviate mood disorders,especially severe depression. This consideration led to the synthesisof agomelatine (S 20098) as a potent (Ki = 0.1-0.5 nM) agonist athuman melatonin MT1 and MT2 receptors. Extensive binding assaysshowed that agomelatine, but not melatonin, also binds to 5-HT 2Creceptors, at which it acts as an antagonist in the dose range producingclear-cut antidepressant-like effects in several validated paradigms(chronic mild stress, forced swimming test, etc.) in rodents. Asexpected from 5-HT 2Creceptor blockade, agomelatine enhancedextracellular levels of both dopamine and noradrenaline, but notserotonin, in the frontal cortex of freely moving rats, and this effectpersisted all along chronic treatment with the drug. Altogether, thesedata demonstrate that the unique association of MT1/MT2 receptoragonist properties and 5-HT 2Creceptor antagonist properties as thatachieved in the molecule of agomelatine yielded a potent antidepressantdrug with a completely novel mechanism of action.SAS5.THE PSYCHIATRIC PATIENT: NEW TREATMENTPERSPECTIVES ACROSS THE LIFESPAN (Organizedby Janssen-Cilag)SAS5.1.NEW ANSWERS IN THE TREATMENT OF PATIENTSIN THE ACUTE PHASEV. CurtisInstitute of Psychiatry, London, UKPatients that require treatment for acute episodes often present withsevere agitation, aggression, hostility or violent behaviour with orwithout psychotic symptoms. These symptoms are often a result ofmania, schizophrenia or substance abuse. In the acute setting, treatmentchoices are driven by symptoms, rather than disease classification.Treatment approaches vary, although the optimal approach maybe an atypical antipsychotic agent, with a benzodiazepine given ‘asneeded’. Besides treatment setting, other factors that affect treatmentdecisions include the clinician’s level of experience, first episode vs.repeat episode, as well as regional differences. In addition, patientfactors, such as prior medication history and level of cooperation, aswell as medication factors, such as cost, formulation and sedativeeffects, can influence atypical antipsychotic selection. In the first twohours it is important to eliminate organic causes and substance abuse,and the patient should be monitored at least every 15 min. Treatmentshould be determined on the severity of symptoms and the risks to thepatient and others (suicidal behaviour, violence, etc.). A rapidly dissolvingformulation is preferred over standard oral forms. Intramuscularforms should be the last resort. Combination therapy is acceptable,but never a requirement and high doses are not necessarily thebest. Calmness is a better endpoint than sleep, except for sleepdeprivedmanic patients, but is difficult to measure. The primary concernin the 2–24-hour period is to establish a therapeutic alliance withthe patient and to continue the psychiatric evaluation. Monitoringshould continue at least every 2 hours, more frequently for sedatedpatients. Atypical antipsychotics are preferred over conventional neuroleptics,but meta-analysis reveals that only risperidone, olanzapineand amisulpiride are superior. The preferred adjunct is a benzodiazepine,followed by valproate or lithium if necessary. Other treatmentoptions (e.g. antidepressants) should be considered at this stageand the patients’ preferences (e.g. light on/off, decreasing stimulationvs. distracting from hallucinations) and basic needs (food, clothing,bathrooming) should be accommodated. It is essential to establish agood working relationship between patient and psychiatrist as earlyas possible in order to forge plans for long-term collaboration. This354 World Psychiatry 3:S1 - October 2004

will help the patient understand the diagnosis and treatment options.After the first 24 hours, an early start of psycho-education is essential.Long-term success depends upon compliance as this prevents relapsesand hastens recovery and social integration. The dose or agentshould be changed only if the response is inadequate, or the drug ispoorly tolerated or not accepted by the patient, although the best formulationfor long-term treatment may not be the same as the one usedduring the acute phase. Treatment must be individually tailored toeach patient’s needs. Compliance monitoring is easiest with long-actinginjectable antipsychotics, and if used should be started early. Inbipolar disease, several double-blind, controlled trials, involvingmore than 1,250 patients, have demonstrated the efficacy of risperidone(monotherapy or added to a mood stabilizer) for a broad rangeof symptoms. In both the monotherapy and add-on trials, risperidonesignificantly and rapidly improved the Young Mania Rating Scalescores when compared to placebo, as early as day three and at least byweek 1, as well as at subsequent assessments. Manic patients withand without psychotic symptoms responded similarly well to risperidonetherapy. Risperidone was also well tolerated in these acute treatmenttrials.SAS5.2.REDUCING THE RISK OF EARLY TRANSITIONTO PSYCHOSIS: USING LONG-ACTING ATYPICALANTIPSYCHOTICS IN YOUNG PATIENTSM. DavidsonUniversity of Tel Aviv, IsraelA considerable proportion of young individuals who manifest isolatedpsychotic symptoms transit within 6-12 months into a full blownpsychosis and schizophrenia. Although most of them achieve symptomaticremission, more than half relapse again within the following12 months despite treated with conventional antipsychotics. Furthermore,they are particularly vulnerable to adverse effects (AE) of thetreatment. Hence, protracted and carefully dosed pharmacologicalintervention is essential in ensuring remission of symptoms and optimaloutcome in this population. The FutuRis study is the largest andmost comprehensive study comparing an atypical and a conventionalantipsychotic in early psychosis using appropriately low dose of medication.This randomized, double-blind trial compared the effect oftreatment with risperidone or haloperidol on the long-term outcomeof early psychotic patients. Forty-nine investigators from 11 countriesparticipated. Subjects (n=535) received trial medication for at leastone year and were followed up for a minimum of two and a maximumof four years. This study demonstrates that risperidone was associatedwith a reduced risk of relapse among remitted, first-episode andearly psychotic patients. Furthermore, risperidone was associatedwith less extrapyramidal symptoms, protracted abnormal movementsand akathisia compared with equivalent doses of haloperidol. Also,akathisia, which is characterized by intense feelings of restlessnessand has been occasionally associated with increased risk for suicide,was seen in fewer patients treated with risperidone compared tohaloperidol. Indeed, in this study, fewer risperidone treated patientsattempted or committed suicide. Unfortunately, a large proportion ofindividuals who achieve good remission discontinue treatment prematurely.Among the solutions to poor treatment adherence is administrationof long-acting medication. However, until recently thisoption has been considered mostly in chronically ill patients. Therecent availability of long-acting atypical drugs with better AE profilehas raised the possibility that more recent onset psychotic patientsshould be considered for treatment with long-acting drugs.SAS5.3.COMPLIANCE: NEW STRATEGIES FOR IMPROVINGTREATMENT ADHERENCE AND PATIENTBEHAVIOURR. CavallaroDepartment of Neuropsychiatric Sciences, Vita-Salute UniversityMedical School, Milan, ItalyThe optimal long-term aim of antipsychotic treatment is re-integrationinto the community. This can only be achieved by maintaining patientsin a state of remission for as long as possible. Without antipsychotictreatment, the rate of relapse is very high. With each successive relapse,the patient’s long-term prognosis deteriorates and previous levels offunctioning are rarely achieved. Patients relapse for a multitude of reasons,including psychosocial stressors, residual mood and psychoticsymptoms and drug or alcohol abuse. Non-compliance with antipsychoticmedication is thought to be the most important predictor ofrelapse. Continuous treatment has been shown to reduce the risk ofrelapse compared to intermittent treatment. With no antipsychoticmedication, as many as 70% of patients will experience relapse overone year. It is often difficult to predict which patients will adhere totheir regimen and most patients are likely to show some degree of noncompliancein the long-term. Adherence to medication regimens ispoor in many disease areas but patients with schizophrenia often strugglewith additional issues. The condition itself can be a factor as thepatients may have little insight into their illness. Other factors that mayaffect compliance include cognitive dysfunction, psychotic symptoms,side effects of medication, socio-cultural issues and co-morbid substanceabuse. Compliance can be improved by using various strategies:educating the patient about the illness and its treatment with emphasison the link between stopping medication and relapse; improving therelationship between the healthcare professionals and the patient,which may include specialized clinics and regular contact, and finallychoosing a medication that is tailored to the individual patient’s needsand that balances efficacy and side effects. Atypical antipsychotics havebeen shown to moderately improve adherence rates. However, nonadherencewith oral atypical antipsychotics remains considerable andtherefore interventions which can further improve adherence are warranted.Non-compliance with oral medication can be partly overcomeby using long-acting depot formulations that only require administrationon a weekly/monthly basis. Until recently only conventional depotantipsychotics were available and these are associated with poor tolerability(especially with regard to motor side effects) and little effect onnegative and affective symptoms compared to the atypical antipsychotics.The advent of a long-acting atypical injection has fulfilled apreviously unmet need. How do the different treatments affect relapserates? Conventional antipsychotics are associated with 1-year relapserates in the range 30-50%. There is some evidence to suggest thatrelapse rates for conventional antipsychotics can be further improvedby using depot formulations that improve adherence. Adams et al., intheir systematic review of depot antipsychotics, were however unableto demonstrate a statistically significant difference; one explanation forthis could be that patients participating in trials were reasonably compliantwith oral medication. Studies of atypical antipsychotics havedemonstrated relapse rates in the range of 20-30%. In a recent systemicreview and exploratory meta-analysis of randomised controlled trials,Leucht at al. confirmed that, as a group, regardless of whether they canimprove adherence, atypical drugs are significantly more effective in theprevention of relapse than conventional drugs. Therefore, combiningthe benefits of an atypical antipsychotic with those of a long-acting formulationmay further reduce relapse rates and enhance community reintegration.355

SAS5.4.REMISSION: NEW PERSPECTIVEIN THE TREATMENT OF SCHIZOPHRENIAJ. KaneZucker Hillside Hospital, Glen Oaks, NY, USAWithout a general consensus on the definition of remission inpatients with schizophrenia, relatively few clinical trials have includeda measure of remission as a primary outcome measure. However,with the availability of newer, more effective therapeutic interventionswith significant impact on patient outcomes, research studiesare now attempting to evaluate the effectiveness of antipsychotictreatment in producing remission of symptoms and in promotinglong-term recovery. Liberman and Kopelowicz suggested that “continuousmedication is almost always a necessity for sustaining highfunctioning among persons diagnosed with schizophrenia”. However,continuous antipsychotic treatment is the exception rather thanthe rule. Estimates of non- or partial-compliance with medication inschizophrenia range from two-thirds to more than 80%. Long-actingantipsychotics minimize compliance issues and disruptions in treatment,and numerous studies have shown that long-acting injectabledrugs are more effective than their oral equivalents. Long-actinginjectable risperidone, the first long-acting formulation of an atypicalantipsychotic, combines the advantages of an atypical antipsychotic(in terms of effectiveness and tolerability) with the consistent therapyand assured delivery of a long-acting formulation, and as such representsan important advance in the treatment of schizophrenia.Recently, Martin et al. reported on clinical experience in four patientswho were switched to long-acting risperidone for reasons includinginsufficient control of symptoms, adverse events and convenience.Over a year, all four patients showed symptomatic improvements andconsiderable reductions or disappearance of preexisting extrapyramidalsymptoms. They became more socially interactive, with no signsof sedation, fatigue, confusion, depression or anxiety, and nonerelapsed or required hospitalization. Three of the four had no signs ofillness after a year, one had returned to college and another to work.These reports demonstrate the suitability of long-acting risperidone inpatients who benefit from long-term treatment and suggest its potentialin all such patients. We will examine an analysis of the data fromthe year long trial of risperidone long-acting injection that takessymptomatic remission as the outcome criterion. The objectives wereto assess long-term outcomes for patients who were or were not inremission at study entry. The results suggest that by switching torisperidone long-acting injection, previously stable patients can experienceadditional improvements, so that more patients can achieveand sustain remission.SAS6.BEYOND DEPRESSION AND ANXIETY:UNDERSTANDING TREATMENT MYTHS AND FACTS(Organized by Pfizer)SAS6.1.PUBLIC HEALTH RELEVANCE OF TREATINGDEPRESSION AND ANXIETYN. SartoriusUniversity of Geneva, SwitzerlandDepressive disorders are a public health problem. They are frequentand it is probable that their incidence and prevalence will grow in theyears to come. They have a negative impact on the prognosis of physicalillness if they are comorbid with it. If left untreated they can havegrave consequences, ranging from diminished working capacity andfailure in social roles to social isolation and even suicide. Treatmentof depressive disorders is possible and can be provided in primaryhealthcare and in other settings. It is effective and significantlyreduces the severity and the prevalence of the illness and its consequences.Currently, only a small proportion of people with depressiveand anxiety disorders receive appropriate care and treatment. Theirdisease often passes unrecognized, and even when recognizedpatients do not receive therapy that could improve their condition.There are ways to improve this situation, as has been shown in severalstudies in the past few decades.SAS6.2.COMORBID DEPRESSION AND ANXIETY:TREATMENT CONSIDERATIONSN. SussmanNew York University School of Medicine, New York, NY, USAComorbid depression and anxiety is present in approximately 50% ofindividuals with these disorders. Psychiatric comorbidity is frequentin all age groups, and is associated with increased severity of illness,poorer social function, increased somatic symptoms, and greater suicidality.It is also linked to poor treatment outcome, possibly resultingfrom delayed or diminished response to treatment, or reduced compliance.Although highly prevalent, comorbid depression and anxietyis underdiagnosed, and undertreated despite the availability of effectivetherapies. There is therefore a need to raise awareness amonggeneral practitioners to ensure optimal treatment for patients, and toovercome public misconceptions regarding psychiatric disorders andmedications. Clinical trials of antidepressant efficacy in anxiety ordepression often exclude patients with psychiatric comorbidity. Thispresentation will review recent studies demonstrating the efficacy ofsome agents in patients with a variety of comorbid psychiatric disorders.In a double-blind, placebo-controlled trial, sertraline andimipramine were highly effective in patients with both panic disorderand depression, with sertraline offering greater tolerability and compliance.In patients with major depressive disorder (MDD) andcomorbid obsessive-compulsive disorder, sertraline was shown to bemore effective in reducing symptoms than desipramine. Venlafaxinetreatment has also been reported to benefit patients with MDD andcomorbid generalized anxiety disorder. Both sertraline and paroxetinehave shown efficacy in patients with post-traumatic stress disorderand comorbid depression or anxiety. These studies indicate thatsome antidepressants are as effective and well tolerated in patientswith psychiatric comorbidity as in single mood and anxiety disorders.SAS6.3.TREATING DEPRESSION IN PATIENTSWITH COMORBID MEDICAL ILLNESSA.H. GlassmanColumbia University College of Physicians and Surgeons,New York, NY, USARates of depression may be up to 10 times greater in the medically illcompared with healthy individuals; up to 40% of patients with medicalillness suffer depression. Comorbid depression complicates treatment,has negative impacts on outcome and recovery, and increasesthe economic and healthcare burden. In patients with ischemic heartdisease, comorbid depression dramatically increases mortality.Depression in patients with ischemic heart disease is common butoften untreated. This is possibly because of the perceived frailty of356 World Psychiatry 3:S1 - October 2004

these patients, or perhaps because such depressions are seen asunderstandable and therefore not in need of treatment, even thoughcomorbid depression increases cardiovascular mortality 3- to 4-foldin post-myocardial infarction patients. The Sertraline AntidepressantHeart Attack Randomized Trial (SADHART), the first large placebocontrolledtrial of a selective serotonin reuptake inhibitor in patientswith acute coronary syndromes (myocardial infarction or unstableangina), demonstrated that sertraline was a safe therapy in thispatient group, alleviating depression and improving patients’ qualityof life with no adverse cardiovascular effects. Sertraline was also associatedwith a reduction in platelet/endothelial activation, a potentialadvantage in this patient population. These data demonstrate thatthere are significant benefits in actively treating depression in patientswith cardiovascular disease, which may translate into reduced cardiovascularmorbidity and mortality.SAS6.4.PREVERS: A UNIQUE STUDY DESIGNED TOEVALUATE LONG-TERM PREVENTION OFDEPRESSIONP. BoyerDepartment of Neurosciences and Psychopathology, ParisUniversity (Paris 7-Jussieu), Paris, FranceDepression is a highly recurrent disorder, and fewer than 50% ofpatients remain free of symptoms for at least 2 years after recoveryfrom an original depressive episode. Therefore, in addition to alleviatingacute phase symptoms, a major goal of antidepressant therapy isthe prevention of relapse, and ultimately complete recovery. It is currentlyrecommended that successful acute phase pharmacotherapy isfollowed by at least 6 months of continued treatment to preventrelapse. Long-term prophylactic therapy may also be necessary inmany patients. Several studies assessing the long-term effects of selectiveserotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrinereuptake inhibitors (SNRIs) in major depressive disorderhave suggested that they prevent the recurrence of depression. However,these trials were not designed specifically to address the prophylacticability of these agents, and have a number of methodologicallimitations. They are therefore of limited use as a basis for recommendinglong-term prophylactic therapy in patients at risk of recurrence.The PREVERS (PREVEntion of Recurrences with Sertraline)study was designed to address these methodological concerns andspecifically to evaluate the prophylactic efficacy and safety of theSSRI sertraline. The index depressive episode was treated by an antidepressantother than sertraline to identify a pure “maintenance”effect. The design included a single-blind placebo phase to verify stabilityof remission (eliminating relapsing patients). During the following18 months of double-blind, randomized treatment, the rate ofrecurrence, the time to first recurrence, and the relative risk of recurrencewere significantly lower with sertraline than with placebo.SAS7.INTEGRATING SCIENCE AND MEDICINE:STRATEGIES FOR THE MANAGEMENT OF BIPOLARDISORDER (Organized by Lilly)SAS7.1.BUILDING THE FOUNDATION TO REACH MOODSTABILIZATIOND.J. KupferDepartment of Psychiatry, University of Pittsburgh, PA, USAIn the last decade, we have made considerable progress in the treatmentof acute mania. Current availability of several atypical antipsychoticshas improved our outcomes in acute mania. However, weneed to continue research efforts to improve the long-term treatmentof bipolar disorder after the resolution of mania. The major goals areto: prevent future episodes of mania; prevent mixed episodes; preventepisodes of depression; and diminish the presence of subsyndromaldepression over extended periods of time. Strategies following theresolution of the manic index episode are either to continue the treatmentthat was successful initially or alternatively to use first atypicalantipsychotics for the acute episode of mania and then switch to oradd “mood stabilizers” for maintenance treatment. Despite theimportance of this public health problem, the empirical basis for ourchoices is rather limited. This presentation will review the data availablecurrently on lithium, valproate, lamotrigine and olanzapine asprophylactic treatments. It is expected that additional databases forlong-term treatment will become available soon. These studies mayhelp us to redefine what constitutes a mood stabilizer. Furthermore,we may need to reconsider the use of monotherapy in the long-termtreatment of bipolar disease.SAS7.2.NEW ADVANCES IN TREATMENT OPTIONS DURINGTHE MAINTENANCE PHASE: TWO PIVOTALMAINTENANCE STUDIESM. TohenLilly Research Laboratories, Indianapolis, IN, USAPsychiatrists view the treatment of bipolar disorder in three dimensions:mania, depression, and maintenance. Efficacious maintenancetreatment should help patients remain in remission and preventrelapse into mania. Since the 1970s, lithium has been accepted as thestandard of care maintenance treatment for patients with bipolar disorder.More recently, anticonvulsants, antipsychotics, and antidepressantshave been evaluated for efficacy in different dimensions of bipolardisorder. According to the American Psychiatric Association PracticeGuidelines, there is limited evidence that maintenance antipsychoticagents are effective in prophylaxis against recurrence and noevidence that their efficacy in maintenance treatment is comparableto lithium or valproate. In September 2002, the first randomised, double-blindcomparison of olanzapine and lithium was presented at theThird European Stanley Foundation Conference on Bipolar Disorder.Rates of relapse into mania were significantly less with olanzapinethan with lithium (14.3% vs. 28.0%, p

SAS7.3.TREATMENT ADHERENCE AND FUNCTIONINGIN BIPOLAR DISORDER: WHAT SHOULD OUROBJECTIVES BE?E. FrankDepartment of Psychiatry, University of Pittsburgh, PA, USAOnce considered a ‘good prognosis’ disorder, bipolar disorder is nowknown to be associated with considerable functional impairmentover the patient’s lifetime and, in many instances, with a deteriorativecourse. It is also a disorder in which treatment adherence representsa major therapeutic challenge. This presentation will review the mostrecent data on impairment in bipolar disorder, the relationshipbetween treatment adherence and impairment and then focus largelyon strategies for enhancing both treatment adherence and functionaloutcomes. The role of more structured psychotherapy in this processwill be discussed. Strategies common to those interventions leadingto improved outcomes will be reviewed, including a) psychoeducationabout the illness and the medications used to treat it, b) managementof medication side effects, c) promotion of a regular sleep-wakecycle, d) regular monitoring of mood states and collaborative illnessmanagement strategies. The presentation will conclude with a discussionof how these strategies can be implemented in everyday practicewith individuals suffering from bipolar disorder.SAS8.CLINICAL STRATEGIES IN MANAGINGSCHIZOPHRENIA AND BIPOLAR DISORDER(Organized by AstraZeneca)SAS8.1RESOLVING ACUTE SYMPTOMS WITHOUTCOMPROMISING LONG-TERM TREATMENT GOALSC. ArangoServicio de Psiquiatria, Unidad de Adolescentes, GregorioMarañon Hospital, Madrid, SpainAcute management is often required when a patient first presentswith psychotic symptoms or experiences a relapse following previouslysuccessful interventions. In addition to experiencing delusionsand hallucinations, such patients can prove uncooperative, displayaggressive and hostile behaviour, and may represent an immediatedanger to themselves and others. Current guidelines recommendtreatment of acute psychosis with second generation antipsychoticsin the majority of situations, because of their efficacy across a broadrange of symptoms and more favourable side effect profiles comparedwith conventional antipsychotics. Second generation antipsychoticshave beneficial calming properties and successfully treat the symptomsof aggression, anxiety and hostility that can accompany acuteexacerbations of schizophrenia. Together with proven clinical efficacy,the second generation antipsychotic quetiapine shows dose-independenttolerability and high patient acceptability, features which arelikely to promote patient adherence to medication and an improvedquality of life. To achieve optimum clinical effectiveness it is essentialto implement the correct dosing regimen. A rapid initiation schedulecan be used to provide well-tolerated, effective treatment in hospitalisedpatients with acute schizophrenia. Furthermore, while currentprescribing information recommends that quetiapine be administeredat doses up to 750 mg/day, there is growing evidence that higherdoses are well tolerated by some patients.SAS8.2.COMPARISON OF QUETIAPINE, OLANZAPINEAND RISPERIDONE IN A RANDOMIZED STUDYIN PATIENTS WITH SCHIZOPHRENIAE. Sacchetti, P. Valsecchi, C. Regini, A. Galluzzo, P. CaccianiUniversity School of Medicine and Spedali Civili, Brescia, ItalySeveral studies comparing atypical antipsychotics with conventionalagents have shown the former to have comparable efficacy and superiortolerability. However, few studies have directly compared the efficacyand tolerability of atypicals. This study is the first direct comparisonof three atypicals in patients with schizophrenia. This multicentre,randomised, parallel-group, rater-blinded study was designed tocompare the efficacy and tolerability of quetiapine with olanzapineand risperidone in patients with a DSM-IV diagnosis of schizophrenia.Eligible patients had a Positive ad Negative Syndrome Scale(PANSS) total score of ≥70 including a score ≥4 on at least two itemsof the positive subscale. Patients received a flexible dose of 400-800mg/day quetiapine, 10-20 mg/day olanzapine or 4-8 mg/day risperidone.Efficacy measures included PANSS total and subscale scores,and Brief Psychiatric Rating Scale (BPRS) hostility cluster score (sumof scores for anxiety, tension, hostility, suspiciousness, uncooperativeness,and excitement). Extrapyramidal symptoms (EPS) were assessedusing the Simpson-Angus Scale (SAS) and the Barnes Akathisia Scale(BAS). Interim results are reported following 8 weeks of treatment.Mean scores were calculated on a last observation carried forwardbasis. Patients were randomised to quetiapine (n=25), olanzapine(n=21) or risperidone (n=19). Baseline PANSS total scores were 103.5,99.5 and 93.2, respectively. PANSS total scores were reduced by34.3% with quetiapine (mean dose 592 mg/day), 30.3% with olanzapine(mean dose 15.2 mg/day) and 24.5% with risperidone (mean dose4.5 mg/day). PANSS positive and negative subscale scores werereduced from baseline by 38.9% and 30.6% (quetiapine), 38.2% and21.0% (olanzapine) and 36.7% and 17.2% risperidone, respectively.PANSS general psychopathology subscale scores were reduced by31.3% (quetiapine) 30.0% (olanzapine) and 24.0% (risperidone).BPRS hostility cluster scores decreased by 40.1% (quetiapine), 34.2%(olanzapine) and 31.7% (risperidone). With respect to EPS, changesin SAS scores were observed (quetiapine: 2.9 to 2.5; olanzapine: 3.4 to2.6; risperidone: 3.8 to 6.0) and BAS scores changed from 1.2 to 0.9(quetiapine), 0.7 to 0.5 (olanzapine) and 0.3 to 1.4 (risperidone).Mean weight gain from baseline was 1.6% (quetiapine), 4.6% (olanzapine)and 2.5 (risperidone). These interim data suggest that all threeagents have similar efficacy. However, quetiapine demonstrated a bettertolerability profile overall, as treatment-emergent EPS occurredwith risperidone and weight gain with olanzapine and risperidone.SAS8.3.CURRENT APPROACHES IN THE DIAGNOSISAND TREATMENT OF MANIAE. VietaHospital Clinic, University of Barcelona, SpainMania is still often misdiagnosed, especially when psychotic symptomsare present, resembling schizophrenia, or when symptoms aremild, resembling personality disorders (histrionic, antisocial, andborderline) or substance use disorders. The first and main issue in thetreatment of mania is to make the correct diagnosis. The use of atypicalantipsychotics in the treatment of bipolar mania is becoming morewidespread. Research to date suggests that atypical agents are as efficaciousas conventional antipsychotics (and traditional mood stabiliserssuch as lithium) for the treatment of manic, psychotic and358 World Psychiatry 3:S1 - October 2004

affective symptoms. Abnormalities in dopaminergic transmission areimplicated in the psychotic symptoms associated with severe mania,and since atypical agents specifically modulate dopaminergic systems,this may explain their broad-based efficacy. In fact, treatmentguidelines now recommend the use of atypical antipsychotics as firstlinetherapy for acute mixed or manic episodes, administered eitheralone or in combination with a mood stabiliser, depending on theseverity of the episode. Quetiapine has recently been licensed for thetreatment of bipolar mania. In a combined analysis of data from two12-week, randomised, double-blind, placebo-controlled trials, treatmentwith quetiapine (n=208) resulted in a statistically significantreduction in manic symptoms, assessed with the Young Mania RatingScale (YMRS), from baseline to endpoint, compared with placebo(n=195). This reduction in the YMRS score with quetiapine was significantlygreater from as early as day 4 (p

mazepine, and lamotrigine. Their use, alone or in combination witheach other and perhaps earlier in the illness course, is the subject ofcurrent debate. There is an increasingly pressing need for furtherlong-term studies of prophylaxis to compare new drugs head-to-headand in combination with lithium. To be useful, such studies will haveto be large, and if they are to be large, they must be designed in a waythat makes them extremely user-friendly for busy clinicians. A cultureneeds to be established in ordinary clinical practice to facilitate theentry of patients with bipolar disorder into simple trials that candetermine moderate but worthwhile benefits for treatment.SAS9.4.BIPOLAR DISORDER IN OLD AGE: DIAGNOSTICAND MANAGEMENT ISSUESA.C. Altamura, R. BassettiChair of Psychiatry, L. Sacco Hospital, University of Milan, ItalyThere is conflicting evidence concerning the prevalence of bipolardisorder in old age. Epidemiological studies report a 0.1% prevalenceof bipolar disorders in patients over 65 years, compared to 1.4% inpatients aged 18-44 and 0.4% in patients 45-64 years old. Among hospitalizedpatients over 60, mania is diagnosed in 5-10% of cases.Studies comparing incidence and prevalence rates of elderly bipolardisorders vs. younger adults have produced inconsistent results. Amajor issue when considering a diagnosis of bipolar disorder in oldage is the differentiation between late-onset bipolar disorders andrecurrent episodes of an illness that began at a younger age. Newcases appear to be more frequently depressive recurrences than manicepisodes. Mania is often related to organic causes, such as cerebrovascularor endocrine diseases, or focal lesions, particularly in theright hemisphere. As a consequence, a neurological and neuromorphologicalevaluation can be useful for differential diagnosis. Thepharmacological management of bipolar disorder in late life is complicatedby physiological changes associated with aging, higher sensitivityto develop side effects, concomitant medical disorders withdrug-drug interaction phenomena (due to polypharmacy) and complianceproblems. These factors need to be carefully taken intoaccount when selecting drugs (mood stabilizers, antidepressants orantipsychotics) for the treatment of elderly bipolar patients. Concerningpharmacokinetics, there are differences in the absorption, distribution,metabolism and excretion among the various drugs. Pharmacokineticparameters are influenced by changes in gastrointestinalmotility and renal function, atherosclerosis, muscular mass reductionand increased body fats, which are related to volume distribution andbioavailability differences observed in the elderly compared to adults.Among mood stabilizers, valproate appeared to be better tolerated inelderly patients. The use of atypical antipsychotics (e.g. risperidone)in old age patients is recommended because of their proven efficacyand their lower propensity to cause extrapyramidal side effects.SAS10.ATTENTION-DEFICIT/HYPERACTIVITY DISORDER(ADHD), A LIFE-LONG IMPAIRING DISORDER: ANINTERNATIONAL PERSPECTIVE (Organized by Lilly)SAS10.1.CURRENT CONCEPTS ON THE NEUROBIOLOGY OFATTENTION-DEFICIT/HYPERACTIVITY DISORDERJ. BiedermanHarvard Medical School, Boston, MA, USAAttention-deficit/hyperactivity disorder (ADHD) is an early onset,clinically heterogeneous disorder of inattention, hyperactivity andimpulsivity. In contrast to the acceptance of ADHD as a childhooddiagnosis, its prevalence in adults and its implications for clinicalpractice remain a source of controversy. Family studies consistentlysupport the assertion that ADHD runs in families. Heritability datafrom twin studies of ADHD attribute about 80% of the etiology ofADHD to genetic factors. Adoption studies of ADHD implicate genesin its etiology. Molecular genetic data are bolstered by considerationssuggesting that DRD4 and DAT genes may be relevant for ADHD.Independently of genes, prenatal exposure to nicotine and psychosocialadversity have been identified as risk factors for ADHD. Structuraland functional imaging studies consistently implicate catecholamines-richfronto-subcortical systems in the pathophysiology ofADHD. The effectiveness of stimulants, along with animal models ofhyperactivity, point to catecholamine dysregulation as at least onesource of ADHD brain dysfunction. Although not entirely sufficient,changes in dopaminergic and noradrenergic function appear necessaryfor the clinical efficacy of pharmacological treatments forADHD, providing support for the hypothesis that alteration ofmonoaminergic transmission in critical brain regions may be the basisfor therapeutic action in ADHD.SAS10.2.ATTENTION-DEFICIT/HYPERACTIVITY DISORDERFROM A EUROPEAN PERSPECTIVEH.-C. SteinhausenDepartment of Child and Adolescent Psychiatry,University of Zurich, SwitzerlandSince the beginning of the last century, a dominant European traditionhas stressed brain involvement in hyperkinetic disorders (HD), whereasthe later evolving North American tradition has both stressedbehavioural and social functioning in attention-deficit/hyperactivitydisorder (ADHD). In addition, there are slight differences in EuropeanICD-10 criteria for HD and North American DSM-IV criteria forADHD. These and other factors have contributed to a marked variationof prevalence rates in epidemiological studies. Evidence-basedstandards for the assessment of ADHD converge between Europe andNorth America. However, as indicated by the Attention-Deficit/Hyperactivity Disorder Observational Research in Europe (ADORE)study, there are marked variations of treatment within Europe. Pharmacoepidemiologicalstudies indicate similar trends of increasing prescriptionrates on both sides of the Atlantic. However, the increase inEurope as compared to North America is on a lower scale. RecentEuropean studies on the course and outcome of ADHD have added tothe conclusion that this is frequently a chronic disorder requiring longtermtreatment.360 World Psychiatry 3:S1 - October 2004

SAS10.3.COMORBIDITY AND DIFFERENTIAL DIAGNOSIS INCHILDREN AND ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDERG. Masi, S. MillepiediStella Maris Scientific Institute of Child Neurologyand Psychiatry, Calambrone, Pisa, ItalyThe core symptoms of attention-deficit/hyperactivity disorder(ADHD), that is hyperactivity, impulsivity and inattentiveness, can befound in other mental disorders. Furthermore, at least 75% of ADHDchildren present comorbid psychiatric disorders. Many of these disordersare both involved in comorbidity and in differential diagnosis.Thus, comorbidity and differential diagnosis are strictly related. Theaim of this presentation is to analyze the more challenging differentialdiagnoses and comorbidities of ADHD, namely with other disruptingbehavior disorders (oppositional defiant disorder, conduct disorder),anxiety disorders, mood disorders (both depression and bipolar disorder),obsessive-compulsive disorder with or without Tourette’s syndrome,and pervasive developmental disorders.SAS10.4.ATOMOXETINE: A NEW, NON-STIMULANT DRUGFOR ADHD. RESULTS FROM A LARGERANDOMIZED DOUBLE-BLIND STUDYIN CHILDREN AND ADOLESCENTSA. Zuddas, P. Cavolina, B. AncillettaDepartment of Neuroscience, University of Cagliari, ItalyDespite worldwide awareness of attention-deficit/hyperactivity disorder(ADHD), outside Northern America the nature of the disorder isoften considered with skepticism and the appropriateness of specifictreatment questioned. The disorder is typically treated over extendedperiod, although few placebo-controlled, long-term studies of efficacyhave been reported. Different cultural values and social attitudes inspecific countries may have induced, in several European countries,higher social acceptance of mild to moderate forms of the disorder.Atomoxetine is a selective inhibitor of norepinephrine uptake, effectivein ameliorating inattention, hyperactivity and impulsivity in children,adolescents and adults with ADHD. It is a non-stimulant drug, with noabuse potential. In a global multicenter study, children and adolescents(6 to 16 year old) who responded to an initial 12-week, open-label periodof treatment with atomoxetine, were randomized to continued atomoxetineor placebo for 9 months under double-blind conditions. Clinicalcharacteristics, including demographics, ADHD symptom severityand comorbidity, as well response to atomoxetine, were also analyzedon a country base in patients living in several European countries (Germany,France, Spain, Italy, Hungary, Poland, Norway and Sweden). Atotal of 416 patients completed acute atomoxetine treatment (out of604 enrolled) and were randomized. At end point, atomoxetine wassuperior to placebo in preventing relapse, defined as a return to 90% ofbaseline symptom severity. The proportion relapsing was 65 of 292(22.3%) for atomoxetine, and 47 of 124 (37.9%) for placebo (p=0.002).The proportion of patients with a 50% worsening in symptoms postrandomizationwas also lower on atomoxetine: 83 of 292 (28.4%) vs.59 of 124 (47.6%) for placebo (p

atypical antipsychotics are becoming part of the bipolar treatmentregimen. In this presentation, I will review results of clinical trialsevaluating the effects of atypical antipsychotic agents alone and incombination with antidepressants and/or mood stabilizers in thetreatment of acute mania. Differences in efficacy and tolerabilitybetween the available atypical antipsychotics will be reviewed andnewly released clinical data will be presented focusing on the treatmentof acutely ill inpatients with bipolar disorder.SAS11.3.LONG-TERM TREATMENT OF BIPOLAR DISORDER:IMPROVING OUTCOMESD.J. KupferDepartment of Psychiatry, University of Pittsburgh, PA, USABipolar disorder is a lifelong episodic condition characterized bymood swings between acute mania and depression. The long-termpharmacologic management of this disorder is complex. The objectivesof maintenance treatment are to stabilize the cyclic moodchanges associated with this disorder while at the same time managingtolerability and side-effect profiles to maximize general health andcompliance. Conventional antipsychotics have demonstrated efficacyfor acute mania but appear to have little role in the maintenance treatmentof bipolar disorder. The atypical antipsychotics, however, areincreasingly being used to control acute manic episodes, and emergingdata support their stabilizing and antidepressant properties. Someof the newer antipsychotics show particular promise as maintenancetherapy in bipolar disorder, and offer tolerability profiles superior toolder medications (e.g., minimal risk of treatment-emergentextrapyramidal symptoms and tardive dyskinesia). In this presentation,I will discuss ways to reduce the risk of recurrence and to promotequality of life over the long term in patients with bipolar disorder.Optimization of long-term treatment regimens and identificationof impediments to stability and compliance will be discussed. Recentdata regarding the efficacy, safety, and tolerability of atypical antipsychoticsas maintenance therapy in bipolar disorder will also be presented.SAS12.THE BOUNDARIES OF ANXIETY (Organized byAbbott)SAS12.1.ANXIETY AS A PSYCHOPATHOLOGICALPHENOMENONS. PallantiUniversity of Florence, ItalyAnxiety has a prominent position in the history of psychopathology.In fact, its evolutionary importance has been progressively documented,and it has been actually identified as one of the factors whichhave most significantly contributed to the evolution of the humanspecies, through its role in the processes of social attachment and riskavoidance. In recent years, the identification of cerebral pathwaysthrough positron emission tomography (PET) and magnetic resonanceimaging (MRI) studies carried out in experimental conditionsand during pharmacological treatment, as well as research concerningthe role of the amygdala have allowed more targeted hypotheses,which may be useful for the refinement of current diagnostic concepts.SAS12.2.NEUROBIOLOGICAL RATIONALE FORA SHORT- AND LONG-TERM TREATMENTOF ANXIETY DISORDERS WITH ANXIOLYTICSAND ANTIDEPRESSANTSG. BiggioUniversity of Cagliari, ItalyThe efficacy in reducing or eliminating the main symptoms of anxietydisorders and the almost complete absence of side effects have determinedin the last 40 years the extraordinary clinical success of benzodiazepines.The handiness of these drugs has also led to neglect formany years their ability to induce tolerance and physical and psychologicaldependence, associated to a reduction of the threshold of neuronalexcitability. Experimental research has demonstrated that ananxiety crisis is associated with the rapid reduction of the function ofGABAergic synapses and a parallel reduction of the threshold of neuronalexcitability, and with a high sensitivity to stress of monoaminergicneurons located in the frontal cortex and limbic areas. The previousadministration of a single dose of a benzodiazepine, through thefacilitation of the action of GABA on its receptors on monoaminergicneurons, produces a hyperpolarization of the neuronal membraneand a consequent increase of the threshold of neuronal excitability.An opposite phenomenon occurs instead after chronic administrationof a benzodiazepine. The latter treatment induces a reduction ofthe threshold of neuronal excitability, due to both functional modificationsat the membrane level and an effect on gene expression ofGABA receptors, which become less sensitive to GABA and benzodiazepines.Paradoxically, these effects are similar to those induced bychronic stress, which is characterized by the hyperexcitability ofmonoaminergic neurons associated to a reduced basal release. Thesedata have suggested that chronic treatment with benzodiazepinesdoes not represent anymore the treatment of choice for chronic anxietydisorders. On the contrary, the long-term therapy of choice forvarious anxiety disorders is the prolonged treatment with antidepressantsdrugs. The therapeutic action of these drugs becomes manifestafter some weeks and is associated to a positive effect on neuronaltrophism. Neuronal plasticity is enhanced, with positive consequenceson the neuronal responses to stressors and neuronal basalactivity. This action of antidepressants is mediated by the synthesis oftrophic factors, including the brain derived neurotrophic factor(BDNF), and consolidates with time, which suggests that a long-termtherapeutic protocol, contrary to the chronic use of benzodiazepines,may be decisive for the remission of symptoms and the prevention ofrecurrences.SAS12.3.THE THERAPEUTIC PLANNING IN ANXIETYDISORDERSE. Smeraldi, E. PolitiDepartment of Neuropsychiatric Sciences, Vita-Salute UniversityMedical School, Milan, ItalyAnxiety disorders are the most common psychiatric disorders.Approximately 1 out of 4 individuals in Italy reports a lifetime historyof at least one anxiety disorder. Comorbidity is also a significant problem,with approximately 75% of individuals with an anxiety disordermeeting criteria for at least one comorbid psychiatric condition.Despite these high prevalence rates, fewer than 30% of individualswho suffer from anxiety disorders seek treatment. Selective serotoninreuptake inhibitors (SSRIs) have emerged as the most favorable treatment,due to their safe and tolerable side-effect profile. Reversible362 World Psychiatry 3:S1 - October 2004

monoamine oxidase inhibitors, tricyclic antidepressants, and cognitive-behavioraltherapy (CBT) are efficacious in the acute and longtermtreatment of any anxiety disorder. Little efficacy evidence existsfor nefazodone or reboxetine in anxiety disorder samples. Severalstudies of the serotonin norepinephrine reuptake inhibitors providepromising results. An extended-release formulation of venlafaxine(venlafaxine-XR) has demonstrated statistically superior responseand remission rates vs. placebo, good tolerability, and equivalent efficacyto SSRIs. Gabapentin has also been found effective. Pharmacologicalagents have also been successfully combined with CBT, andthis combination may offer distinct treatment advantages. Cognitivebehavioraltools and exposure-based practices may enhance pharmacotherapeuticoutcomes in the long term and facilitate relapse preventionefforts. In conclusion, SSRIs and CBT are considered firstlinetreatment for anxiety disorders. SSRIs are recommended insevere cases of anxiety disorders, in the presence of significant psychiatriccomorbidity. Clinical experience suggests that SSRI nonrespondersmay benefit from trials with additional SSRI agents or aswitch to a different class of medications. Partial responders may benefitfrom SSRI augmentation with CBT, gabapentin, reboxetine orvenlafaxine.SAS12.4.PANIC DISORDER WITH AND WITHOUTCOMORBIDITY: DATA ON EPIDEMIOLOGY,COURSE AND TREATMENT OUTCOMEE. Sacchetti, P. Valsecchi, S. BonomiUniversity of Brescia, ItalyThe lifetime prevalence of panic disorder with or without agoraphobiais 1.6-2.5%, whereas the 1 year prevalence is about 1%. Epidemiologicaland clinical studies report a frequent lifetime comorbidity ofpanic disorder with other anxiety disorders (social phobia 20-30%;specific phobia 10-20%; generalized anxiety disorder 25%; obsessivecompulsivedisorder 10-15%), as well as with mood disorders (majordepression 50-60%; bipolar disorder 20-25%), personality disorders(40-50%), substance abuse (20%) and physical diseases. The analysisof data from the Epidemiological Catchment Area (ECA) Study indicatesthat the lifetime comorbidity of panic attacks and depressivedisorders is eleven times higher than that expected by chance. Moreover,population studies suggest that the concomitance of depressionin patients with a diagnosis of panic disorder is strongly predictive offurther depressive episodes, panic attacks, other anxiety disordersand alcohol abuse. The personality disorders most frequentlyobserved in patients with panic disorder are those belonging to theanxious cluster: avoidant, obsessive-compulsive and dependent. Severalclinical and epidemiological studies report high rates of alcohol,cocaine and sedative abuse. Several physical diseases are frequentlyassociated with panic disorder: for instance, prospective studies haveshown that male subjects with high anxiety levels have a three foldincreased risk of fatal coronary events than the general population.Panic disorder per se has been found to be associated with a significantimpairment of physical and mental functioning and high rates ofwork dysfunction and economic dependence. Moreover, this disorderis often characterized by a chronic course with the persistence ofsymptoms in spite of treatment. Clinical studies show that although60-70% of patients have a positive response to treatment, only 30-40% recover, while 50% are partially symptomatic and 20% have astable symptomatology. The factors which have been most frequentlystudied as possible predictors of a less favourable response to treatmentare the severity of anxiety at onset, the presence of severe agoraphobia,the comorbidity with depression and personality disorders,the duration of the disorder and female sex. The comorbidity withdepression is associated with a more severe symptomatology, a worsecompliance to treatment and outcome, a higher incidence of suicidalattempts and substance abuse, more frequent physical complicationsand higher costs of assistance.SAS13.MAINTAINING GLOBAL PATIENT HEALTH IN THETREATMENT OF PSYCHIATRIC DISORDERS(Organized by Bristol-Myers Squibb/OtsukaPharmaceutical Co.)SAS13.1.PHARMACOLOGY OF ANTIPSYCHOTIC THERAPY:A NEW DIMENSION IN THE TREATMENT OFPSYCHOTIC DISORDERSM. Del ZompoDepartment of Neuroscience, University of Cagliari, ItalyThe dopamine hypothesis remains central to our understanding ofschizophrenia and current approaches to its treatment. Increaseddopamine activity in the mesolimbic pathway is thought to cause thepositive or psychotic symptoms of schizophrenia, while reduceddopamine neurotransmission in the mesocorticol pathway is believedto underlie negative symptoms and cognitive impairment. Both typicaland atypical antipsychotics act as antagonists at dopamine D 2receptors – the basis of their activity against positive symptoms – butdiffer in their efficacy against negative symptoms and liability forextrapyramidal side effects. This presentation will review differencesin the clinical profile of these agents in relation to their receptor bindingactivity, and will discuss latest thinking about the role of D 2receptoroccupancy and dissociation rates. Dopamine partial agonists representa new strategy for the management of schizophrenia. Theseagents can act as functional agonists in conditions of decreaseddopamine activity and as functional antagonists in conditions ofdopamine overactivity. They have the potential to control both positiveand negative symptoms of the disorder through their modulationof dopamine levels. This presentation will discuss the concept ofdopamine partial agonist activity with reference to the new antipsychoticaripiprazole. The activity of antipsychotic agents at otherreceptor types and the implications for clinical efficacy, safety and tolerabilitywill also be discussed.SAS13.2.OPTIMISING THE TREATMENT OF SCHIZOPHRENIAF. CañasDepartment of Psychiatry, Hospital Psiquiátrico, Madrid, SpainPatients with an acute episode of schizophrenia are often treated withantipsychotics to reduce disturbed behaviour in the short term, andwith continued maintenance treatment to prevent relapse. The introductionof atypical antipsychotic therapies for schizophrenia has ledto improvements over typical agents in both treatment efficacy andtolerability. In general, atypical antipsychotics show similar efficacyto typical agents against positive symptoms, but with greater effectagainst negative symptoms. Other important benefits of atypicalantipsychotics are their improved safety and tolerability profiles, particularlythe reduction of extrapyramidal symptoms. However, sideeffects with some treatments can still have a major impact on health,quality of life and compliance with antipsychotic therapy. Individualatypical agents may be associated with sedation, hyperprolacti-363

naemia, QT cprolongation, nausea, weight gain and orthostasis.Therefore, there remains an unmet need for additional well-toleratedantipsychotic agents. This presentation will discuss the relative risksand benefits associated with various treatments, including the newantipsychotic aripiprazole, and will present results of recent clinicaltrials of the efficacy and short-term safety of these agents.SAS13.3.THE NEXT GENERATION OF ANTIPSYCHOTICS:IMPROVED LONG-TERM PATIENT HEALTHS. KasperDepartment of General Psychiatry, University of Vienna, AustriaSchizophrenia and schizoaffective disorder are chronic conditions inwhich patients require long-term management to prevent relapse,improve health and promote effective re-integration into society. Thispresentation will review data from long-term clinical trials examiningthe effectiveness of current and next generation antipsychotics in preventingrelapse and providing long-term control of schizophreniasymptoms. The need for long-term therapy makes treatment safetyand tolerability a key factor in the overall effectiveness of antipsychoticmedication. Adverse events can impact on patient outcomethrough their effects both on treatment adherence and long-termpatient health. Although atypical antipsychotics offer improved treatmenttolerability over typical agents, some atypicals may be associatedwith distressing side effects, such as weight gain, that adverselyaffect patient outcome. The differing impact of the different atypicalantipsychotics, including the newest agent aripiprazole, on bodyweight, glucose and lipid levels will be reviewed. The implications ofthese findings for the long-term health of patients and the overalleffectiveness of these antipsychotic therapies will be discussed.SAS13.4.NEW THERAPEUTIC OPTIONSFOR THE TREATMENT OF BIPOLAR DISORDERA. YoungUniversity of Newcastle upon Tyne, UKBipolar disorder (BPD) is a chronic illness characterised by episodesof mania or potentially suicidal depression, sometimes requiring hospitalisation.Pharmacological treatment is often necessary to rapidlycontrol the acute stage of mania and for some months after recoveryto prevent relapse. Up to 50% of patients do not respond to currentlyavailable treatments, so effective treatment of BPD remains an unmetmedical need. Patients with BPD are often prescribed a combinationof agents such as lithium, valproate, carbamazepine, and lamotrigine,which may have limited therapeutic value and, in the case of lithium,potential toxic effects at therapeutic dosage. Recently, antipsychoticdrugs have been used to effectively manage the serious psychoticsymptoms of mania. However, typical antipsychotics are associatedwith adverse effects, particularly extrapyramidal symptoms, whichcan be particularly severe in patients with BPD. This has led to clinicaltrials investigating the use of newer, atypical antipsychotics inpatients with bipolar disorder. This presentation will provide anoverview of recent trial results for antipsychotics in acute mania anddiscuss new developments in drug therapy, including the introductionof the new antipsychotic aripiprazole, which may lead to future treatmentbenefits.SAS14.RAISING THE BAR IN THE TREATMENTOF PATIENTS WITH MOOD AND ANXIETYDISORDERS (Organized by Wyeth)SAS14.1.KEEPING PATIENTS HEALTHY: INCREASINGTHE CHANCES OF REMISSION AND PREVENTINGRELAPSE AND RECURRENCEF. BenazziUniversity of California at San Diego, USA and National HealthService, Forlì, ItalyMajor depressive disorder is a chronic illness. After recovering froman episode of depression, many patients experience recurrence within2 to 3 years. A patient whose recovery is incomplete, and who stillhas residual symptoms of depression, is more likely to have anotherepisode of depression. In addition, patients who respond to treatment(i.e., show at least a 50% improvement on the Hamilton Rating Scalefor Depression, HAM-D) but do not reach remission have poorersocial adjustment and miss more workdays. Remission, usuallydefined as a HAM-D score of 7 or less or absence or near-absence ofsymptoms, should be the goal of treatment. During remission apatient can recover gradually and maintain psychosocial function.Several obstacles hinder treatment to remission: inadequate durationof treatment, inadequate dosage, patient and physician satisfactionwith partial results, treatment discontinuation due to unpleasant sideeffects, failure to recognize residual symptoms, failure to recognizecomorbid disorders, and misdiagnosis. Once remission is reachedand a 6-month continuation period has been completed, treatmentmay be tapered. For patients at high risk for relapse, however, maintenancetherapy may be appropriate. Maintenance pharmacotherapyhas been demonstrated to be more efficacious than placebo in preventingrecurrences of depression in trials lasting several years.SAS14.2.INTERPRETING THE RESULTS OF CLINICAL TRIALSN. FreemantleUniversity of Birmingham, UKA wealth of information on the efficacy of newer antidepressants isavailable in published clinical trials. This presentation will focus onhow elements of the design of a clinical trial may affect the outcomeand can limit the potential for comparing results across trials. Trialsmay differ in sample size, duration, medication dosage, controls,patient populations included or excluded, endpoints, and outcomemeasures. In addition, differences in accounting for attrition over thecourse of the study may result in misleading estimates of efficacy. Statisticalmethods exist that enable researchers to combine the results ofmany comparable studies to achieve greater statistical power. Inmeta-analyses, results of similar studies are combined to permitdetection of differences in efficacy, which may be undetectable insmaller trials. If individual patient data are available from clinical trials,additional results may be gained, particularly for subgroups ofpatients. However, access to individual patient data is often hard toobtain. The results of relevant meta-analyses will be discussed.364 World Psychiatry 3:S1 - October 2004

SAS14.3.THE IMPORTANCE OF RECOGNIZINGAND TREATING THE PHYSICAL SYMPTOMSOF DEPRESSION AND MOOD DISORDERSP. BlierInstitute of Mental Health Research, University of Ottawa,Ontario, CanadaDepression is both underdiagnosed and undertreated. Among theobstacles to recognition and treatment is the difficulty of diagnosingpatients who present with primarily physical symptoms. Manypatients with depression present with numerous vague physical complaints,prompting a search for a medical cause. Yet the more physicalsymptoms they describe, the more likely they are to have depression.The symptoms most likely to be associated with depression are sleepdisturbances, fatigue, musculoskeletal complaints, back pain, andshortness of breath. The relationship between pain and depression iscomplex and bidirectional. Depression may lower the pain thresholdand interfere with coping. Alternatively, pain may precipitate depressionin vulnerable patients. It has been hypothesized that there maybe an underlying neuronal connection between pain and depressionbecause both serotonin and norepinephrine have been implicated inthe pathogenesis of depression and in the perception of pain. This hasprompted study of the use of dual-acting antidepressants, thoseaffecting both the serotonin and norepinephrine systems, for patientswhose depression is marked by physical symptoms.SAS14.4.THE IMPACT OF COMORBIDITY AND TREATMENTOF DEPRESSION AND ANXIETYP. AlexanderBrown University, Providence, OH, USAMany studies have found that patients with depression often havesymptoms of anxiety. Depressed patients exhibiting these symptomstend to be more severely depressed and to have more psychosocialimpairment. They respond to treatment more slowly and are morelikely to commit suicide. The extent of comorbid anxiety disordershas been estimated to be about 50%, with the most common beingpanic disorder, generalized anxiety disorder, and social phobia. Arecent study examining the full range of Axis I disorders found that72% of the depressed patients had a concurrent disorder. Additionalpatients had Axis I disorders in partial remission or clinically significantbut subthreshold symptoms of Axis I disorders. Patients withconcurrent depression and anxiety disorders are more likely to haveoccupational dysfunction than patients with depression alone. AWorld Health Organization (WHO) study found that primary carephysicians were more likely to recognize depression when it isaccompanied by an anxiety disorder. But even when it was recognized,only half of the patients received pharmacotherapy. Therapeuticapproaches include benzodiazepines, azapirones, and antidepressants,alone or in combination, as well as cognitive behavioral therapyand interpersonal therapy. A number of studies have comparedthese treatment approaches and will be discussed during this presentation.365

INDEX OF AUTHORSAbbey S.E. 59Abdel Azim R.S. 137, 191Abdelrahman A. 109Abdollahian E. 223, 295Abe Y. 337Abou-Gharbia N. 217Abou-Saleh M. 171Abraham K. 282Abutaseh S. 154Accorrà D. 337Ackenheil M. 19, 84, 85, 270Acuña G. 307Adenzato C. 300Adeyemi J.D. 339Adlaf E. 172Adrianzen C. 199Adzievski B.V. 228Adzievski V. 283Agee M. 187Aguado-Mañas J.A. 295, 343Aguiar W. 331Ahmadi J. 305, 306, 308Ahmadi M. 305Ahmadi N. 305, 306Ahmed S. 202, 214Ahmed M.M. 60Ahn Y.M. 167Aiello G. 292Aiello M.G. 292Aili H. 327Akhmedova K. 104Akinci Yilmaz F. 172Akiskal H.S. 20, 86, 102Alaka K.J. 202Alari F. 279Albani M. 274Albert U. 28, 159, 253, 285Alcaz S. 306Alemán Neyra L. 107Alessandra M. 225Alessandrini M. 224Alevizos V. 82, 114Alexander P. 365Alexandropoulos K. 338, 349Alfano B. 79, 203, 204Algrain V. 289Ali S.A. 69Ali B.S. 193Alish Y. 181Allebeck P. 173Allen A. 296, 297Allen L. 12Allende P. 39Allingham B. 200Almqvist F. 142Alonso M. 235Alseikiene Z. 273Al-Sharbati M.M. 187Altamura M. 79, 204Altamura A.C. 33, 127, 177, 183, 184, 360Altenberg B. 192Álvarez E. 200Amann B. 203Amati A. 292Amato A.G. 23Amering M. 242Amini M.R. 223Amminger P. 75Ammon M. 164Amodio P. 315Anagnostopoulos D. 82, 114, 341Ancajas J. 176Ancilletta B. 361Andersen H.F. 261Andersen S. 249Andersen E.W. 282Anderson V. 75Andre C. 275Andreasen N.C. 7, 91, 92Andreazza A.C. 237Andreetto U. 313Andreoli A. 101, 140, 158Andreoli S.B. 311, 337Andrés S. 267Andrews G. 171Andrezina R. 244Angeli E. 332Angelone S. 202, 232, 239Angermeyer M.C. 122, 182Annoni G. 85Anselmetti S. 163, 182, 232, 264Antonucci N. 204Antun F.T. 120, 135Antuono P. 309Anwald B. 205Apter J.T. 56Apter A. 174Apter-Danon G. 177Apud J.A. 34Aragão R.M. 304Arango C. 358Arango Davila C. 199Arata A. 293, 294Araya M. 109Arboleda-Florez J. 27, 70, 72, 78Arcel L.T. 93367

Archibald D.G. 217, 218, 219, 250Ardissone G.C. 307Ariño B. 14Aristides M. 295Arnone R. 342Arolt V. 268, 270Arosio B. 85Artioli P. 22, 268, 310, 335Aschauer H.N. 266Ascoli M. 94Ashley K. 145Askar M.A.A. 60Asnis G. 279Assunção S. 199, 235Atala J. 313, 314Atallah A.N. 337Atger I. 65Atkinson L. 172Autonell J. 238Avantaggiato J. 340Avino C. 23Avramova V. 254Awad A.G. 58Awadallah N. 318Aydemir O. 270Aydin N. 205, 228Azim S.A. 60, 69Ba G. 241, 285Babaee M. 308Babayan N.G. 277Babinkostova Z. 283, 336Baca E. 236Badalyan M.G. 277Bader A. 222Báez R. 235Baghai T.C. 270Baiardi F. 271, 272Bailer U. 266Bailey R. 156Bailey S. 129Baldini-Rossi N. 149Baldwin D.S. 8Ball D. 303, 344Ballageer T. 170Ballerini A. 152Bandelow B. 31, 43Banerjee K.R. 171, 173, 178Bangs M. 296Barahona Ruiz E. 342Barale F. 300Baranzini F. 244Barbaresi W.J. 296Barbato A. 157Barbini B. 263, 264Barbui C. 196Barcellos J.F. 336Bareggi S.R. 216Bari M.A. 214Barnow S. 193Baron D. 52, 98Baroni A. 317Baroni S. 159Barraco A. 255Barratt E.S. 50, 153, 154Barriguete J.A. 65Barros M.B.A. 42Barroso M.D. 335Barrowclough C. 33Bartoli A. 241Barton G. 280Basangwa D. 105Basile V.S. 21, 205Bassetti R. 33, 127, 177, 360Bassi M. 140, 147Bastiani A. 337Basu S. 194Battas O. 232Batzar E. 220Bauer M. 350Baumann A.E. 242Baykova E.S. 335Beauverie P. 199, 200Bechi M. 163, 202, 232, 239Bechter K. 229Becker T. 196, 182Bedogni F. 215Beersma D.G.M. 274Beezhold J. 116, 137Beitchman J. 172Belaise C. 44Belesioti B. 301Belfort E. 98, 106, 108, 120, 135Belger M. 198Belhadj A. 253, 299Bellivier F. 90Bellodi L. 158, 175Bellomo A. 79, 215, 348Belmonte-de-Abreu P.S. 237Beltikova K.B. 278Ben Zineb S. 76, 110Benabarre A. 252Benassi S. 206Benattia I. 258Benazzi F. 102, 247, 364Bencivenga R. 63Benedetti F. 263, 264, 265, 266, 280Benedetti M.M. 340Benedetti V. 31Beneke M. 207Benes F.M. 128368 World Psychiatry 3:S1 - October 2004

Benko L. 301Ben-Nahum Z. 181, 260Bennegadi R. 95Benoit M. 127Bensason D. 209Benti R. 238Benyakar M. 73, 74Beraldo, S. 216Berardinello E. 315Berg P.H. 214Berganza C.E. 27, 47, 60Berger G. 298Berger M. 178Berger P. 44Berger R. 69Bergesio C. 285Bergstrom R.F. 214Beria Z. 343Bernal M. 122Bernardi F. 55Bernasconi A. 263, 265, 280Bernstein H. 24Bernstein I.H. 177Berretta S. 128Berrettoni P.A. 186Berry S. 212Bersani A. 175Bersani G. 189, 253Bertelli M. 87, 331, 332Bertelsen A. 169Bertha E.A. 242Berti A. 254, 326Berti Ceroni G. 322Bertini N. 103Bertolino A. 79, 204, 315Bertolote J.M. 41, 83, 96Besharat M.A. 329Bestini E. 332Bethani H. 341Betti L. 159Bevc I. 256Bhanji N.H. 199Bianchi A. 248Bianchi L. 182Bianchin G.L. 294Biederman J. 27, 39, 296, 360Biedka L. 347Bielli A. 285Bielski R.J. 260Biggio G. 139, 362Biggs M. 24Billiard M. 16Bindman J. 196Biondi M. 65Birchwood M. 146Birger M. 181, 259, 260Bisello W. 316Bjarnadottir S. 78Bjersér S. 173Black S.E. 21Blackburn J. 298Blanch J. 266, 256, 274, 313, 314Blaser R. 170Blasi G. 79Blay S.L. 245, 311, 307Blier P. 365Bloch S. 6, 26Block T. 316Blonde L. 217, 350Blotta M.G. 248Boato P. 337Bobes J. 89, 202Bockholt H. 91Bockting C.L.H. 176Bodnar D. 52Bøgesø K.P. 261Boget T. 241Bogetto F. 28, 159, 163, 188, 253, 285Boghi A. 291Bogojevic G. 285Boidi G. 186Bokhan N.A. 308, 309Bokszanska A. 96Bolino F. 231, 234, 235, 328Bollorino F. 96Bomarsi S. 326Bomba J. 110Bomfim C.S.A. 330Bonaviri G. 230Bondy B. 270Bonevski D. 283, 285Bonfiglio M. 313, 337Bonomi S. 363Booster G. 255Borenstein D.B. 30Borgeat F. 234Bosco H. 42Bossie C. 211, 212Botbol M. 65, 88Botega N.J. 42, 288Boter H. 119Bouden A. 253, 299Bouhours P. 208, 211, 250, 262, 263Boukanovskaya T.I. 172Bouras N. 40, 96Bowden C. 247Bowers L. 124Bowie C.R. 221Boyer P. 357Bradac G.B. 291369

Braendle D. 209Bræstrup C. 261Braeunig P. 262Brambilla F. 63, 292Bräunig P. 117Bravo-Ortiz M.F. 235Breier A. 214Breier P. 112Breitembach A. 336Bressi C. 101, 313, 337Brewer W. 75Briazgounov I.P. 299Brickman A. 74, 80Briggs S. 249, 262Brigidi B. 318Brink J. 22, 333Brion N. 143Brocco C. 143Brooks W. 92Broome M.R. 61Brown E. 334Brownell K.D. 290Brownlie E. 172Brunello N. 137, 351Bruno A. 176, 227, 237,298, 326, 328Bucci P. 98, 148, 229, 280, 281, 291Buchsbaum M.S. 74, 80, 148, 149Buitelaar J.K. 38, 187Buizza C. 243Bulanov V.S. 225Bulucz J. 242Burger H. 227Bürgin D. 170Bürgy M. 69Burke R. 128Burmeister J. 164Burnand Y. 101Burns A. 3Burns M. 332Burns T. 23, 174, 180Burridge J. 295Burt T. 259, 260Burti L. 173, 178, 196Buse J. 201Bushnell J. 171Busnello E.A. 243Bussé D. 192, 314, 343Bustillo J. 92Butorin G. 300Butorina N. 301Buysse D. 354Bymaster F. 215, 297Byne W. 80Cabaj R. 145Caballero L. 115Cacciani P. 358Cacciola M. 252Caci E. 127Cadlovski G. 228, 336Caffo E. 15Caforio G. 79, 204Cailhol L. 101Calabrese J. 247, 249, 252Calarge C. 7Calati R. 335Calcagni M.L. 329Callegari C. 244, 319Callicott J.H. 79Calligaris C. 239Calovska-Samardjiska V. 348Caltagirone C. 230Camardese G. 83Camarena-Robles E. 106,107Cambria R. 176, 227, 237, 298, 326, 328Cameron S. 297Cammeo C. 215Cammino S. 175Campagnola N. 331Campanella D. 287, 316Campbell L. 63Campbell W.G. 303Campigli M. 331Campolo D. 176, 298Campos F. 319Campos R. 17Camus V. 42, 54Cañas F. 202, 363Canashiro S. 337Cancro R. 25Canez V.F.M. 336Canive J.M. 80Cantone D. 302Canuso C. 249, 250, 262, 263Caparevic Z. 302Capasso A. 228Caperna S. 319Caracci G. 74,87Carano A. 287, 316Caras S. 14Carbonell C. 54Carcione A. 347Cardini L. 332Carli V. 83Carlson C. 201, 215Carmi A. 26,72Carmosino G. 271, 272Carniello F. 330Caroff S.N. 117Carolei A. 186Caroppo E. 328, 344370 World Psychiatry 3:S1 - October 2004

Carozzi A. 285Carpiniello B. 252Carrà G. 100, 300Carranza F. 191Carreras E. 313, 314Carson W. 202, 216, 217, 218, 219, 246, 250, 251Carta M.G. 121, 122, 252Carter J. 67Carucci C. 286Carusi F. 162Caruso N. 287Carvalho A.M. 322Carvalho M.C.L. 275Casacchia M. 230, 235, 294, 328Casarosa E. 55Casarotto S. 75Casas N. 324Case M. 201, 249, 262Casey D. 217Casper R. 176Cassano G.B. 18, 29, 79, 203, 204, 257, 352Castagnini A.C. 169Castaldo E. 63, 291Castiglioni F. 241Castra R. 319Castro R.P.G.N. 289Catalán R. 241, 256, 266, 267, 314Catalano M. 310Catanesi R. 166Catapano F. 159, 301, 302, 317Cattaneo C. 337Cattaneo E. 184Catty J. 174Cavallaro R. 163, 182, 202, 204, 206, 213, 222, 232, 239, 264,326, 355Cavalletto L. 315Cavazzoni P. 201, 214, 252Cavedini P. 158Cavolina P. 361Cavrini G. 174Cazzullo C.L. 84, 85Cecchetto C. 330Cedeño I. 229Cedro C. 227, 237Cella S. 292Ceregato A. 253Ceresa M. 241Cerretini M. 336Cerveri G. 238, 321Chai Y.-G. 305Chang H.-L. 213Charismas D. 285Charman T. 15Chatton A. 304Chaudhry N. 275Chaudhry H. 157Chemello L. 315Chen C.-K. 213Chen F. 261Chen K. 246Chen R. 219Chen Y. 127Chenivesse P. 143Cheung H.K. 118Chiarenza G.A. 75Chidiac Obegi N. 54Chiles J.A. 160Chiu E. 42Chiu H. 321Cho H.C. 304Choi I.-G. 304, 305Choi S.J. 207Chouinard G. 199, 200Chourbaji S. 175Christian B.T. 80Christodoulou C. 338Christodoulou G.N. 82, 114, 151, 152, 322Chumy M.T. 325Chung Y.-C. 233Cialdella P. 217Ciampelli M. 279Ciancaglini P. 186Cianflone D. 222Ciappi F. 312Cibin M. 307Cicconetti A. 316Cifuentes M. 300Cigala Fulgosi M. 263, 264Cigliano M. 301, 317Cipollone I. 294Ciraulo D.A. 124Cirera E. 313, 314Cirillo F. 329Cirillo G. 291Cislo P. 217Citrome L. 200, 201Citron A. 332Civiero M. 330Cizza G. 267Claassen D. 95Clark V. 91Clarke D. 297Clemens J.W. 257Clerici M. 85, 100Cocchi F. 163, 204, 206, 222, 232Cochand P. 162Cochennec M.F. 101Coelho C. 60Cohen C. 330, 343Cohen S. 301371

Coleman P.G. 53Collazo C.R. 73, 74Colligan R.C. 296Collins G.R. 130, 131Colom F. 33Colombo C. 263, 264, 265, 266, 280Colotto A. 227Comes M. 252Conde M. 324, 335Condeza M.I. 300Coneva A. 336Connolly S. 202Connor K. 265, 282Conrad R. 188Contreras V. 145Cooper-Kazzaz R. 56Copello A. 23Corcos M. 65Cordoba R.N. 108Cordovana V. 225Corea S. 332Corlito G. 336Cornelius J.R. 24Corral M.R. 52Correale J. 130Corrieri U. 336Corruble E. 263Cortese L. 176, 227, 237, 298, 328Corya S. 248, 249, 262Coryell W. 279Cosci F. 279Cossetta E. 340Costa E. 127, 128, 206, 324, 331Costello H. 96Cotellessa C. 316Cotrufo P. 292, 301Cottrell S. 295Coulthard M. 186Cournos F. 74, 118Courtet P. 90Cowley A. 96Cox J. 48Craig T. 180Craven M. 112, 113Crawford M. 239Creed F. 12, 275Cremato F. 292Cremonese C. 331, 336Cristofalo D. 196Cronkite R.C. 255Croquette Krokar M. 304Crosby R. 67Crosby R.D. 290Crow S. 67Csémy L. 190Csendes A. 294Csukly G. 243Cullberg J. 168Cullen L. 273Cummins A. 338Cuomo C. 83, 164Cupillari M. 225Curci P. 234Curi de Souza R. 331Curtin K. 308, 323, 324Curtis V. 210, 354Cywinski J. 274da Silva Filho J.F. 331Dailianis K. 269, 321Daini S. 294, 329, 336Dalben I. 304Dalben I.S. 271Dalery J. 232Daley D.C. 24Dallaspezia S. 280Dalle Luche R. 132Dalmotto M. 312Dalsaev M. 317Dalsaeva R. 317D’amato T. 232D’Amico G. 326Damsa C. 136Dan I. 255D’Andia F. 312Daneluzzo E. 204Dangellia A. 345D’Angelo R. 50Daniel D. 218, 220Daniore-Quierci R. 115Dannlowski U. 268D’Antonio E. 224Danyelan A. 136Danyte G. 243d’Aquino G. 342D’Arrigo C. 252Darwish M. 282Darwish A.K. 174Das B. 34David A.S. 37Davidson J. 265, 282Davidson M. 162, 355Davis J. 127, 128De Berardinis M. 80De Berardis D. 287, 316de Bertolini C. 313De Candia M. 79, 204De Fazio P. 292De Felice M. 223de Feo S. 326De Fidio D. 313372 World Psychiatry 3:S1 - October 2004

de Flores T. 314De Giacomo P. 144De Giorgi A. 215, 315, 348de Girolamo G. 114, 131, 148, 174, 179, 335De Hert M. 118, 183, 199de Jonge S. 270De Luca V. 205De Luca M. 143De Mari M. 133De Masi R. 292De Mattia G. 223de Miranda Ramos A.A. 331De Nayer A. 199De Pablo J. 274de Patoul A. 183De Queiroz V. 257, 124De Risio S. 83, 163, 164, 276, 294, 329, 336, 349De Ronchi D. 268, 310De Rosa C. 23, 145De Rosa M. 228De Toni E. 315de Zwaan M. 290DeBattista A. 176Deberdt W. 215DeCory H. 297DeDoncker P. 245, 246Degli Esposti E. 271, 272Degrandi A. 241Degtyaryova T.D. 299Dehbozorgi G. 308Dein S. 52Dekker J. 177Del Debbio A. 248Del Mastro A. 228Del Papa B. 343Del Zompo M. 363Delgado M. 168Delius-Stute H. 310dell’Agnello G. 296, 297Dello Russo G. 189Dell’Osso B. 159, 216Dell’Osso L. 248Denis F. 250D’Ercole A. 344Detke H. 247, 248, 249Detke M.J. 255, 257Deus P. 230Deveci A. 270Devouche E. 177Di Benedetto R. 281, 292Di Caprio E.L. 17Di Carlo G. 344Di Genova A. 162Di Giacinto F. 287Di Giovambattista E. 328Di Maria G. 328, 344Di Matteo D. 287di Michele F. 230Di Michele V. 230, 231, 234, 235, 328Di Munzio W. 342Di Rosa A.E. 173Di Rosa E. 173Di Sciascio G. 315Diallina M. 286, 338, 349Dias R.S. 271Diaz E. 294Diaz-Comas L. 229Díaz-Martínez A. 12Dickinson P. 187Dierks T. 97, 98, 195Dikeos D.G. 38, 66Diligenski V. 302Dimalta S. 204Dimic S. 83Dimopoulou E. 348Dinan T. 350Dindo L. 279D’Innella P. 254Dittmann R.W. 213Diurni M. 244Djordjevic H. 317, 320Dobrescu I. 226Doherty F. 233Dolbeault S. 64Dolz M. 238Domagalska E. 347Domenici E. 35Domocos A.M. 276, 311Domocos D.C. 276, 311Donda P. 255Donges U. 268Döpfner M. 27Dorado R. 324, 355Dossenbach M. 235Doueiri M.S. 206Dougherty D.M. 50, 124, 125, 154Douki S. 76, 110Douzenis A.I. 244Dowe G. 185Drábková H. 190Drago F. 161Drake R.E. 36Dressing H. 123Drosataki K. 338D’Souza D. 257D’Souza R. 259, 260Dubois A.-M. 54Duddu V. 256Dudeck M. 193Duffy D. 308, 323, 324373

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Kornetova E.G. 238Korpinen E. 142Korzenev A.V. 283Kosel M. 25Kostic D. 219Kostic M. 283, 285, 336Kostic N. 302Kotler M. 77, 181, 182, 259, 260Kotsi K. 269Koumaris V. 293Koutras V. 290, 302, 306Kovacs G. 77Kovess V. 121Kozumplik O. 255Kramer L. 124, 125Kramer L.A. 154Krasanakis S. 286Krasnov V. 81, 105Kratochvil C. 296Krautgartner M. 99Krch F.D. 190Kriketos A.D. 63Kröber H.-L. 181Krsteska R. 311Krüger S. 117, 262Kryzhanovskaya L. 201Kucukalic A. 151Küey L. 48, 113, 114, 141, 152Kühn K.-U. 22Kujawa M. 217, 218, 250Kujundziska M. 285Kuleshova N.A. 238Kulke C. 146Kungel M. 218Kuperman J. 320Kupfer D.J. 8, 31, 354, 357, 362Kupriyanova I.E. 335Kurimay T. 62Kurtz D. 214Kurz M. 197Kurzthaler I. 197Kusters J. 209Kwok H. 40Kyprianos S. 286, 307, 319, 320, 321La Malfa G.P. 87, 331, 332La Rovere R. 316La Torre D. 176, 227, 237, 252, 298, 326, 328Laan E. 13Laan W. 227Labbane R. 233, 283Lacerenza R. 83, 164, 276Lacey J.H. 190Lachaux B. 199, 200Lacorte-Pi T.M. 312Lahaye M. 209Lai C. 294, 329, 336Lalee-Mentzel J. 268Lam S. 218Lam W. 259, 260Lambert H. 186Lambertenghi Deliliers G. 313Lancaster K. 67Landau J. 144Lang T. 240Lange R. 273, 333Lapidus R. 56Larmour P. 326Larsen M.B. 261Las Casas R. 322Lasser R. 211, 212Lassi S. 87, 331, 332Latas M. 285Latif M.A. 209, 210Latorre V. 79Lattuada E. 206Lau S. 181Lauriello J. 92Lauronen E. 169Lavie L. 16Lavie P. 16Lazaratou H. 341Lazzaretto L. 196le Grange D. 67Le Nestour-Crevillé A. 177Leaderer M. 219, 200Leavey G. 53Leboyer M. 90Lecic-Tosevski D. 83, 112, 151Lee J.-S. 305Lee K. 242Lee K.-J. 233Lee K.M. 288, 304Lee K.Y. 167Lee M.A. 205Lee S.M. 288Lee Y. 230Leese M. 179, 196Leff J. 9Legnani E. 202Lehrer D.S. 80Lehtinen V. 121Leisch F. 266Lejava G. 306Lenroot R. 91, 92Lenzi A. 343Leocani L. 97León C. 312Lerer B. 56Leufkens H. 236, 272Leung S.K. 118380 World Psychiatry 3:S1 - October 2004

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Mancuso F. 196, 292, 329Mandel F.S. 220Mandelli L. 268, 335Mandiberg J. 23Manenti S. 313, 321, 337Mangano C. 225Mangano V. 225Mangelli L. 44Maniadaki K. 298Mann K.F. 24, 46Mann S. 325Mann S.C. 117Mannix S. 295Manor I. 38Manos G. 218, 219Manoussakis C. 337Mantani T. 62, 313Mantas C. 269Manuseva N. 228, 348Manzanares J. 139Manzone M.L. 215Manzotti P. 340Marangelli G. 342Maratos A. 239Marazziti D. 159Marcel E. 143Marchiori E. 133Marcus R. 218, 251, 250Margari F. 312Margis R. 336Marine S. 56Marinelli S. 328Marini M. 347Marinoni A. 186Marinoni M. 279Marinov P. 346Mariotti A. 248Mark L. 309Markantonaki M. 286, 338, 349Markov A.A. 335Markowitz J.C. 281Marola V. 328Marotta G. 238Marques S. 322Marques Filho A.B. 289Marquez E.M. 201, 202, 214Marquez M. 238Marrella G. 196Marseglia R. 223Marsh D.A. 154Marshall E.J. 303Martin A. 209, 259Martin R. 333Martín J.L.R. 200Martindale B. 97Martínez C. 200Martínez E. 314Martinez M. 324Martínez-Calvo A. 17, 38, 247Martino G. 173Martinotti G. 328Marusic A. 90Maruta T. 201, 270, 318Masala I. 159Masegoza M. 324, 355Masellis M. 21, 159, 205, 317Masetti S. 285Masheb R.M. 290Masi G. 103, 296, 361Masilovich D. 128Massa R. 268Massana G. 274, 344Massei G.J. 248Mastroianni F. 312Matarazzo R. 312Mateescu L. 226Matejic J. 316Matera V. 287Materazzi M.A. 80,81Mathias C.W. 154Mathis D. 117Matorin A.A. 156Matsui T. 283Mattay V. 341 79Mattsson M. 168Matza L. 295Mauri M.C. 216, 238, 321Mavreas V. 269Maximova N.M. 277, 278Mayberg H. 149Mayer A. 112Mazza M. 163, 196, 230, 235, 276, 349Mazzi F. 132, 286, 335Mazzi G. 330McAllister P. 77McBride M. 199, 235McClelland R. 130McDonell M. 185, 297McFarlane A.C. 2McFarlane W. 61McFarlane W.R. 125McGlashan T.H. 327McGorry P. 1, 58, 75McHugh S. 233McIlroy F. 260McIntyre J. 78McIntyre R.S. 361McKeown E. 165McLean T. 196McManus M. 326382 World Psychiatry 3:S1 - October 2004

McNair B. 278McQuade R. 217, 219, 251Meares R. 50Medda P. 257Medina Amor J.L. 73, 77Medori R. 208, 249, 250Meduri M. 173, 176, 227, 237, 298, 326, 328Mehler-Wex C. 213Mehnert A. 64, 212Mehra M. 245, 246Meijer W.E.E. 272Mellino M. 340Mellsop G. 30, 47, 324Meltzer H.Y. 21, 205Menardi A. 336Mencacci C. 163, 238, 321, 351Mendel S. 320Mendlewicz J. 35,126Menezes M. 331Menezes R.S. 194, 243, 336Meng H. 170Menke R. 160Mercuriali E. 330Mergl R. 203Merlotti E. 148, 213, 229, 280, 281, 291Meyer W. 319Mezghani L. 299Mezzetti M. 312Mezzich J.E. 5, 48, 59Micciolo R. 114, 179Micev V. 348Miceva E. 228, 283Miceva-Velickoska E. 348Michaelovsky E. 174Michel E. 127Michelson D. 296, 297Michopoulos A. 301Miettunen J. 11, 169Migliardi G. 252Mihai A. 1,116Mihajlov A.N. 299Mik H. 172Mikeladze D. 306Milano W. 228Milea S. 299Milia P. 295, 325Miljkovic S. 317, 320Millepiedi S. 103, 361Miller A.L. 160Miller G.A. 80Miller I. 61Milner K.-L. 63Milton D. 296Minamikawa N. 284Miniati M. 343Minns M. 128Minshew N.J. 15Mirabella F. 347Miraglia del Giudice E. 291Miranda-Sivelo A. 295, 343Misawa H. 222, 226, 231Misionzhnik E.Y. 278Mitchell C.P. 127Mitchell J. 67Mitchell M. 214, 290Mitelman S. 74, 80Mitish M.D. 299Mitjanas T. 256, 266, 287Miyagi F. 222, 226, 231Miyaoka H. 227, 228, 278Miyasaka L.S. 337Modai I. 95, 32Moeller F.G. 50, 124, 125, 154Moeller O. 270Moeller F.G. 124, 154Mohagheghzadeh M. 306, 308Mohareri F. 223Mohl A. 210Mohs R.C. 202Möller H.-J. 18, 49, 127, 207, 210, 270Molteni R. 215Monahan J. 123Monari M. 338Monje M.C. 248Monks S. 308, 323, 324Monteiro M. 45Monteleone P. 63, 291Montgomery S.A. 260Montresor C. 184Montt D. 294Moos R.H. 255Morando D. 293Mordini E. 130Moreno A. 167Moreno R.A. 271Moretti P. 185Morey L.C. 327Moring J. 169Morosini P. 131, 132, 197, 335, 347Morrell C. 146Mortara P. 291Mortensen E.L. 50Mosca A. 85Moscarelli M. 30Mota M. 60Motamed F. 306Moussaoui D. 109, 232Mrad M.F. 283383

Mrazek D.A. 296Mucci A. 37, 75, 79, 98, 103, 148, 195, 196, 203, 204, 229, 280, 281,291, 292, 329Mueller D.J. 205Mueller M. 24, 333Mueller T.J. 97Muffatti R. 215Muhammed-Moussa S. 56Mukherjee J. 216Mukhopadhyay N. 201Mulert C. 203Müller D.R. 195Müller N. 85Müller-Pollard C. 303Müller-Spahn F. 45Mullins P. 92Munawar M. 275Mundo E. 33, 127, 177, 183, 184Mundt C. 69, 153Munir F. 318Munizza C. 157Munk-Jørgensen P. 169Munno D. 291Muñoz M. 235Muñoz M.M. 147Muramatsu K. 278Muramatsu Y. 278Murray S. 219, 220Musalek M. 68, 142Muscatello M.R.A. 176, 227, 237, 252, 298,326, 328Musgnung J. 258, 282Myers T. 67Na C. 230Naber D. 207, 210Nacarino Alcorta B. 342Nacef F. 76, 110Nadelson C.C. 39Nagao K. 284Nagata T. 31Nahshoni E. 174Najjar D. 188Nakagawa D. 337Nakajima G. 165Nakajima S. 269Nakane M. 201Nakano M. 270, 318Naneishvili G.B. 104, 343Nappi G. 79, 204Napreyenko A.K. 316Narayana P.A. 50, 124, 125, 154Nardini M. 79, 81, 204, 315, 348Nascivera N. 302Nassar L.E. 124Naud S. 318Naugle R. 274Navarrette G. 334Navarro M. 166Nawka P. 121Naylor M.R. 318, 339Neeleman J. 227Nelubova T. 104Neubauera H.A. 261Neuhold A. 298Neumeier K. 270Neumer S.-P. 267Neverauskas J. 273Neviani V. 300Newcomer J. 216Newcorn J. 296Newman M.E. 56Ng F.S. 118Ng L.L. 311Ng V. 303Ngaradoume K. 336Ng-Tse T. 194Niaz U. 89Nicoara O. 276Nicolaou A. 301Nieddu G. 295, 325Nielsen J. 188Nijman H. 236, 323Niklewski G. 242Nikolaev E. 348Nimatoudis I. 224, 254Nivoli A. 295, 325Nivoli G.C. 295, 325Nivoli L.F. 295, 325Njenga F. 105Nkowane M. 37Nobuo K. 283Nofzinger E. 354Nolen W. 236, 245, 272Nombela Arrieta M. 342Nordén T. 173Nordfjord W. 78Norman R. 170, 196Norris Jr K.T.Norzuraida Z. 315Nosé M. 196Nöthen M.M. 185Notman M.T. 39Novick D. 198Novotni A. 111, 283, 285Núñez E. 107Nyman J. 67Obot I. 45Ochiai M. 222, 226Ochoa S. 238O’Connor K. 24384 World Psychiatry 3:S1 - October 2004

Octavio I. 218Oggionni C. 337Oh K.S. 288Oh Y.H. 288Ohlraun S. 185Okamura H. 313Okasha A. 5, 46Okasha T. 12, 81, 96, 109Olatawura M. 113O’Leary D.S. 7Olfson M. 202Olgiati P. 195, 247, 254Olié J.P. 217Oliveira G.S. 336Oliveira M.L. 318Olivier J.C. 95Olivieri S. 343Olmsted M. 67Olonade P.O. 339Olson D.P. 124O’Neill F.A. 233O’Neill H. 345Opjordsmoen S. 68, 210Orford J. 23Orlandini A. 89Orso L. 335Orsucci F. 163, 276, 349Ortiz Lucas P. 342Ortolan M. 315Orwid M. 347Oskarsson H. 78, 267, 303Osorio Suárez R. 342Østerskov M. 94Othmani S. 253Otsuka K. 337Otte C. 303Owen M.J. 34Owens D. 41Owens J. 186Oz F. 172Özer S. 284Özmen E. 284Ozols I. 278Ozono S. 62, 313Ozturk I. 205Öztürk Ö 222, 277, 292Pacetti M. 252Pacheco Palha A. 60Pacilli A. 287Pacitti F. 189Padoani W. 347Paes E. 315Pagano M. 327Pagliarulo E. 285Pagnin D. 257Paiola A.A. 289Pajonk F.G. 208, 209Palego L. 159Palesch Y. 333Palla A. 248Palladino F. 301, 302Pallanti S. 31, 149, 151, 351, 362Palli A. 146Palmieri G. 94Palombo E. 286Palomo T. 139Palsson S.P. 78Palumbo G. 347Pan Y. 270Panagoulias E. 269, 321, 348Pandolfo G. 227, 237, 326Pans M. 218Pantelis C. 75Panzarino P. 144Papa S. 79Papadopoulos P. 321, 348Paparrigopoulos T. 66Papazacharias A. 215, 348Papeschi L.L. 286Papini B. 182, 202, 239Paplos K.G. 322Pappa S. 269Pappapietro K. 294Paragoni S. 271Parameshvara Deva M. 51Parellada E. 210Park J.I. 167Parlato G. 349Parnas J. 169, 170, 188, 194, 195Parramon G. 266Patel N. 194Paterno O. 196Paton J. 43Patti M.F. 326Paula T.H. 311Pavan C. 315Pavan L. 336, 347Pavlovic E. 232Paykel E.S. 353Payne V. 265Pedata L.T. 69Pederson K. 290Peitl A. 232Pejkovska S. 285Pejoska-Gerazova V. 283Pejuskovic B. 83Peloso P.F. 102, 165Pelusi L. 287, 316Peluso E.T.P. 245, 307, 311Penadés R. 241, 256, 266, 267, 287385

Penna L. 316Perani D. 158Perchatkina O.E. 290Percival C. 275Pereira M.G. 146Pereira M.S. 336Pérez V. 200Pérez-Iñigo J.L. 73, 74, 77Pérez-Rial S. 139Pérez Lo Presti A. 235Peri J.-M. 314, 327Perini G.I. 315Perna G. 175Perris F. 159, 301Perrone L. 291Persegani C. 286Pertosa M. 294Perugi G. 103Petitjean F. 217Petito A. 215, 315, 348Petrella C. 228Petreski D. 283Petrides G. 24Petruccelli F. 69Petruccelli I. 69Petruzzella V. 79Petruzzelli M.G. 312Peuskens H. 183Peuskens J. 118, 183, 199Pfuhlmann B. 133Pham M. 154Philipp M. 207Phillips G.A. 214Phillips L. 75Piat M. 341Picardi A. 114, 179, 328, 344Picci R.L. 102Piccinini G. 337Piccinni A. 248, 344Piegari G. 196, 281, 329Pienaar F. 188Pieroni M. 222Pierri G. 102, 312Pierri M. 330Pietrini P. 8Pigato G. 336Pilecki M. 293Pilla G. 238Pincini P. 234Pinder R. 55Pine D. 279Pini S. 29, 257Pino R. 296, 297Pioli R. 197, 241, 243Pirfo E. 166, 224, 228, 312Pirola R. 216Pirovano A. 310Pirrotta R. 101Pisapia A. 342Piselli M. 185Pita-Alcorta C. 229Pitzer M. 213Placidi G. 331Plamadeala T. 332Plenge P. 261Ploeger B. 205Ploia C. 310Pluchino N. 55Podea D. 284Pogarell O. 203Poggi E. 343Polazarevska M. 336, 348Poldrugo F. 100Policante F. 293Polidori G. 132, 335Politi E. 204, 362Pollero D. 340Pollice R. 328Pomini V. 234Pomm R. 320Pompili M. 191Ponath G. 270Ponteri M. 241, 243Pontes A. 271Pontiggia A. 263, 265, 280Pope Jr. H.G.Popoli M. 35Porcellana M. 101, 313, 337Porcelli P. 189Porter J. 308Porter Miller T. 297Portwich P. 345Potenza M.N. 150Potkin S.G. 21, 251Pouncey C. 47, 60Pournaghash-Tehrani S. 325Povlsen U.J. 94Poznyak V. 36, 45Prelipceanu D. 185Preti A. 86Preuss U. 170Price J.S. 86Price J. 144Priebe S. 151, 185Priesch M. 266Prieto J. 313, 314Priftis F. 286, 307, 319, 320, 321Prikyrl R. 80Propping P. 185Prost R. 309386 World Psychiatry 3:S1 - October 2004

Prot K. 347Pshenichnih I. 288Pugner K.M. 216Puig I.-J. 81Puig O. 241, 256, 266, 287, 327Pulido R. 338Purdon S.E. 202Quarantelli M. 79, 203, 204Quartesan R. 185Quercioli L. 31Quinn D. 297Quinn P. 332Quinti E. 294Raballo A. 231, 234Rabinowitz J. 212Raboch J. 111, 120, 135Racagni G. 35, 215, 350Rachidi L. 232Racu A. 332Radaelli D. 264Rafanelli C. 19Rafrafi R. 233Raharinivo S. 166Rahman A. 256Raicevic-Sibinovic S. 320Raistrick D. 23Rajkumar S. 82Ramacciotti C. 63Ramakrishnan A.G. 273Ramos V. 254Ramos Moreira L. 331Rapuano A. 238Rasgon N. 184Rassmussen K. 24Ratcliffe M. 198Raucci A. 223Raucci G. 223Ravassi C. 255Raveendran V. 300Ravindranath B. 197Ray S. 216Razzoli E. 313Re E. 342Read J. 168, 191, 240Rechtman R. 95Redzic V. 99Reed L.J. 303Reed M. 245, 246Regardie K. 219Regeer E.J. 245Regini C. 358Reilly E.L. 50, 154Reines E.H. 261Reis A. 134Reisz D. 339Reitz B. 316Rejas J. 202Reminajes A. 145Remschmidt H. 213Rendall M. 208Renshaw P.F. 50, 124, 125Resch F. 170Rettenbacher M.A. 197, 222Rettig K. 310Retz W. 27Reynaert C. 289Reynaud M. 24Reynolds C. 354Reznik I. 181, 182, 259, 260Riba M.B. 156Ribeiro C.S. 288Richard R. 100Richter K. 242Ridder S. 175Riec˘ansky I. 271Riedel M. 85Riedel-Heller S.G. 122Riera L. 218Riesenberg R. 214Rietschel M. 185Rigatelli M. 17, 94, 163, 286, 338Riglietta M. 223Rihmer Z. 20Rioseco P. 334Ripke B. 146Risser R. 247, 248, 249Riva M.A. 215Robert P.H. 127Roberts N. 322Robinson J. 200Robinson R.L. 255Robison L.M. 264Robson J. 255Roca M. 115, 236Rocca P. 163, 188Rocha A.B. 330Rocha R. 336Rock S.L. 202Roder V. 195, 327Rodgers M. 185Rodrigues Jardim S. 331Rodríguez A. 256Rodríguez-Artalejo F. 200Rodriguez-Menendez V. 206Rodríguez-Palanca A. 73, 77Roerig J.L. 290Rogowska J. 124Röhricht F. 185Rollin L. 251Romeo E. 230387

Romero S. 266, 335Roncaglia I. 248Roncone R. 230, 235, 294Rondón M. 39, 88Ronning G.F. 191Rosado L. 355Rose G. 339Roselli-Cruz A. 322Rosenbaum J.F. 257Rosenheck R. 57, 126, 183Rösler M. 27Rossano F. 159, 317Rossattini M. 206Rossi A. 79, 162, 163, 203, 204, 223, 255Rossi G. 197, 243Rossi N. 338Rössler W. 70Rotella F. 279Rothermundt M. 270Rotkiewicz A. 309Roukas D.K. 226Rousaud A. 274, 314Rouse E.D. 124Rovira M. 313, 314Rowe W. 298Rowland L. 92Roy A. 89, 205Roybal D. 255Roychowdhury S.M. 214Rozanov V. 320Rózsa S. 242Ruberto A. 191Rucci P. 29Rudnitsky V.A. 316Ruggeri G. 344Ruggeri M. 148Ruggerini C. 300Ruhrmann S. 207, 208Ruini C. 19Ruiz I. 199Ruiz P. 51, 93, 120, 134, 155Rummans T. 24Ruocco E. 317Rupnow M.F.T. 249, 263Rusche S. 181Rush A.J. 24, 25, 177Russell I. 23Russell J. 63Russell J.M. 257Russo A. 225Russo M. 183, 184Russo P. 271, 272Rutledge E. 344, 345Rutten F.F.H. 187, 245Ryan C. 61Sacchetti E. 85, 209, 211, 358, 363Sachs G. 247, 250Sackeim H. 25Sacristán M. 200Sadler J.Z. 61Sæbye D. 188Saeki T. 62, 313Saha H. 193Sahin Ö 228Saijo Y. 269Sakkas D. 338Salamero M. 241, 256, 266, 287, 312Saldivia S. 334Saleem P.T. 210Salerno R.B. 316Salerno R.M. 287Sales S. 291Salini G. 287, 316Salize H.J. 123Salkovskis P. 4, 6Salloum I.M. 24, 48Salomone G. 342Salvacion A.A. 127Salvador M. 237Salvador-Carulla L. 40, 80, 97, 158Salvadori D. 33, 183Salvini R. 332Samardziska V. 228Sambataro F. 204Samokhvalov A.V. 289Samolis S. 272Samuel S. 274San Miguel R. 343San Miguel Cuellar R. 295Sanches A.F. 304Sánchez C. 261, 265Sánchez N. 312Sanchez R. 250, 251Sanchez-Moreno J. 247, 252Sandman M. 197Sanislow C.A. 327Sanseverino B. 228Santini A. 177Santisteban E. 324, 335Santonastaso P. 63Santone G. 114, 179Santoro A. 266Sanzovo S. 294Saoud M. 232Saraceno B. 13Saragoni S. 272Sarasola A. 17Sarchiapone M. 83Sargolzaee M.R. 136Sartorio E. 264388 World Psychiatry 3:S1 - October 2004

Sartorius N. 1, 356Sasaki S. 269Sata F. 269Sato M. 201, 270, 318Savenko Y.S. 289Savenkov O. 299Saveska A. 283, 336Saxena S. 5, 37, 82Sayed H.Y. 69Saz P. 17Sbardella A. 337Scapati F. 166Scarabino T. 79Scarone S. 215Schaffner K.F. 46, 6Schall U. 176Schatzberg A. 56, 350Scheen A. 183, 199Scheff T. 180Schellong J. 146Schene A. 176, 196Scherer M. 240Schiavi E. 248Schilling G. 188Schlaepfer T.E. 25Schlamp D. 213Schlögelhofer M. 266Schlund M.W. 175Schmauss M. 207Schmolke M. 82, 164Schneider J. 341Schöepping C.M. 336Schoevers R. 265Scholten D. 170Schön W. 228Schooler N. 1Schosser A. 266Schreiner A. 207, 208, 209, 210, 250,262, 310Schreiner V. 229Schrittwieserv U. 298Schuenck Guilande A. 331Schulman J. 25Schulpen T.W.J. 187Schulte P. 182, 189, 271Schulte-Markwort M. 213Schulz E. 213Schulze B. 70Schütz G. 175Schützwohl M. 151Schwalen S. 310Schwarz M. 85Sclar D.A. 264Scott J. 57Scott M. 345Scudellari P. 322Scuticchio D. 87, 332Sean P.T. 199, 200Searles J. 339Sechter D. 217Secnik K. 295Seebohm P. 57Segagni Lusignani G. 300Segura-Garcia C. 63, 292Selten J.P. 227Semenzin M. 347Semerari A. 150Semeraro R. 312Semke A.V. 238, 346Semke V.A. 335Semke V.Y. 319, 335Senatore I. 132Sénon J.L. 290Sepede G. 287, 316Sergeyeva S.A. 308, 309Serretti A. 22, 195, 247, 268, 310, 335Sessa F. 331Sethuraman G. 214Severino L. 254Seyringer M.E. 240Sgaragli G. 336Shadrin V.N. 346Shamrey V.K. 283Sharaby N. 318Sharfstein S.S. 30Sharif M. 188Sharma R.P. 127Sharma V. 338Sharpe M. 11Shea M.T. 327Shen H. 247Sher L. 174Sherry K.F. 155Shidao A. 284Shiels C. 340, 341Shihabuddin L. 80Shin D.H. 304Shin H.D. 305Shin S.-E. 242Shingler K. 91Shinkai T. 205Shinkevich N.V. 335Shirakawa I. 337Shlapnikov N. 181, 260Shmukler A.B. 104Short R. 185Shumlyansky V. 104Shustin V.A. 283Siannis F. 322Siapati S. 301389

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