Avatar therapy is a digital therapy supported by a therapist in which voice hearers dialogue with a digital embodiment of their most distressing voice. Our previous randomised controlled trial of AVATAR therapy showed 6 sessions had a superior and substantial reduction in the severity of voices compared to that achieved by supportive counselling. Limitations included that the study was carried out in a single site, and six sessions limited what might be achieved by an extended approach to include a greater focus on individual biographical characteristics that had a bearing on the voice hearing experience . In the latest AVATR2 trial, we aimed to replicate these early results and deliver therapy by a wider workforce across several centres in the UK. We also tested the effectiveness of two forms of therapy -AVATAR Brief 6 sessions (AV-BRF) and AVATAR-Extended 12 sessions (AV-EXT). In this presentation I report the results of this clinical trial. We hypothesised that both forms of therapy alongside treatment as usual would be effective and superior to treatment as usual alone in reducing voice related distress (the primary outcome) at 16 and 28 weeks follow up. We found that both treatmetns did indeed reduce distress at 16 weeks and that this reduction was maintained at 28 weeks though was no longer statistically significant in compoariuson to treatment as usual at this point. The frequency of voices also reduced at both time points for AV-EXT that also achieved several other important outcomes in cluding enhanced wellbeing and reductions in delusional beliefs associated with the voice. There were no related serious adverse events. A health economic analysis was also carried out that also supports AV-EXT The next phase of the development of AVATAR therapy towards release for routine use is briefly described.

T. K. J. Craig Grant / Research support from: Research Grants Wellcome Trust; NIHR UK

Culture fundamentally influences human thinking, feeling and behaviour. The integration of cultural contexts into psychotherapeutic treatment is therefore essential, especially in light of the increasing diversity of our society. In addition, psychological stress following experiences of migration or flight requires special treatment expertise. Thus, intercultural psychotherapy is an essential approach in addressing mental health issues across diverse populations.

Life-threatening events, to which we feel helpless and at the mercy of, can inflict severe psychological trauma on us. If the event is too aversive, too horrific, and therefore cannot be autobiographically interwoven, fragments of memory are created that are not modified over time - like ordinary memories - but remain rigid, as if ‘frozen’. They are activated by triggers reminiscent of the original situation and then reappear, e.g. in the form of flashbacks. The high number of people with migration and refugee backgrounds with trauma-induced secondary disorders calls for culturally sensitive, trauma-focussed psychotherapies to close the enormous gap in care. Numerous psychotherapies are available for the treatment of trauma-related disorders, some of them have yet to be evaluated - or modified for the treatment of traumatised persons in the context of migration and flight in the case of those that have already been well evaluated. This presentation will give an overview on cultural and migration-related aspects of trauma-related disorders.

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Intercultural psychotherapy aims at an understanding of and translating between cultural differences which may be experienced between the psychotherapist and the client. This is especially important when considering that due to crisis, conflict and war, but also due to globalisation and increased mobility, an increased number of clients with a migration background seek to undergo psychotherapy. In this presentation, current literature on needs and challenges of intercultural psychotherapy is discussed with regard to an intersectionality framework and more specifically in the context of power and privileges. These frameworks provide a useful understanding of cultural competency and sensitivity in intercultural psychotherapy.

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Depression is widespread globally and is expected to be the leading cause of disability by 2030, according to the Global Burden of Disease study. Psychosocial factors, such as gender, life events, and migration experiences, increase the risk of depression, with migrants and asylum seekers showing particularly high depression rates. However, cultural differences and social background of individuals are often not adequately addressed in medical settings, which lead to misdiagnoses and mismanagement. Language and cultural barriers may complicate communication of subjective experiences, which consitute a critical part of the expression of symptomatology in depression. Depressed patients may have challenges in verbal expression of their symptoms and distress may be communicated through somatic symtoms, or what might be called as “organ language” or “somatic idiom”, especially in the context of migration. Indeed, somatization is closely linked to the experience of migration stress and can be a form of cultural adaptation. Moreover, the degree of somatization in migrants is found to be related to their level of integration into the host culture. Therefore, the diagnosis and management of depression in the intercultural context can be challenging, as somatic complaints may obscure the recognition of underlying psychological distress. This can delay the seeking of psychiatric help, as patients are often reluctant to attribute their symptoms to psychological causes. Fear of stigma, or perceiving the patient as overly-dependent or attention-seeking might hinder processes of treatment and care. Existing treatment modalities with highest level of evidence, such as CBT, should be culturally adapted. Cultural adaptations involve modifying language, metaphors, and treatment goals to resonate with the patient’s cultural context. While there is some evidence on the positive impact of culturally-adapted interventions including CBT, more research is needed to refine these approaches and address gaps in the literature. Psychotherapy in the intercultural context requires both cultural competence and time for dialogue.

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Background: Substance-induced psychosis is an acute psychotic condition occurring after substance use, where the psychotic symptoms are alleviated with abstinence. Some of those diagnosed with substance-induced psychosis later develop schizophrenia, and this transition occurs most often for psychosis induced by cannabis. This talk will present results from a register-based study investigating transition rates. The results will be discussed together with other factors that together question the validity of the diagnostic entity of “cannabis-induced psychosis” Method: In our study, we used data from National Patient Register in Norway from 2010 to 2015 to estimate the cumulative hazard for transition from any substance-induced psychosis (F1x.5) and cannabis-induced psychosis (F12.5) to schizophrenia spectrum disorder (F20, F22 and F23). Results: The six-year cumulative hazard for transition from substance-induced psychosis to schizophrenia was 27.6% (25.6-29.7) for any SIP, and highest for those with cannabis-induced psychosis, 36% (95% CI 31.4-41.0). Conclusion: Cannabis-induced psychosis constitutes a significant risk for later schizophrenia. This raises a question of whether the initial diagnosis of CIP was correct, or whether these may have been cases of a development of primary psychosis concealed by cannabis use. Further, the term “cannabis-induced psychosis” places a major explanatory emphasis on the substance use, ignoring other potential contributing factors such as vulnerability including genetic disposition for psychosis.

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Problematic cannabis use is prevalent among individuals with first-episode psychosis (FEP), with 35.6% meeting criteria for comorbid cannabis use disorder (CUD) (1). Cannabis use is associated with poorer FEP outcomes, including higher psychosis relapse risk (2). However, evidence on effective pharmacological treatments and long-term outcomes for FEP+CUD remains limited.

To evaluate outcomes of FEP with comorbid CUD and assess the real-world effectiveness of antipsychotic treatments in this population.

This study analyzed a Swedish nationwide cohort using longitudinal register data (2006–2021). The sample included 1,820 patients with FEP+CUD (84.7% male, mean age 26.8 years). Outcomes included hospitalizations for psychotic relapse, any psychiatric disorder, or substance use disorder (SUD). Associations between antipsychotic use and outcomes were assessed using within-individual Cox regression models. Mortality rates were compared across FEP+CUD (n=2,154, mean age 25.0 years), cannabis-induced psychosis (CIP, n=1,263, mean age 25.0), and FEP without SUD (n=17,589, mean age 27.4), adjusting for age, sex, education, other SUDs, and disability pension status.

Over a mean follow-up of 6.13 years, 76% of participants were hospitalized for psychiatric diagnoses, 63% for SUD, and 61% for psychotic relapse. Antipsychotic use was associated with a 33% reduction in psychotic relapse risk. Clozapine and long-acting injectable (LAI) formulations of risperidone, aripiprazole, and paliperidone showed the greatest efficacy in relapse prevention. Clozapine reduced SUD-related hospitalizations by 86%. Within 10 years, 7.8% of FEP+CUD and 5.2% of CIP patients died, compared to 3.4% of FEP without SUD (adjusted odds ratio [aOR] 2.61, 95% CI 2.19–3.13, and aOR 1.67, 95% CI 1.28–2.17). Suicide was the leading cause of death in all groups, with higher rates in FEP+CUD (aOR 1.94, 95% CI 1.49–2.52) and CIP (aOR 1.70, 95% CI 1.21–2.37) compared to FEP without SUD.

Clozapine and LAI formulations of second-generation antipsychotics (excluding olanzapine) or oral aripiprazole effectively prevent hospitalizations in FEP+CUD. Targeted efforts are needed to reduce premature mortality, particularly from suicide, in FEP patients with comorbid cannabis use disorder or cannabis-induced psychosis.

1. Hunt GE, et al. Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990–2017: Systematic review and meta-analysis. Drug Alcohol Depend. 2018;191:234–258.

2. Bowtell M, et al. Clinical and demographic predictors of continuing remission or relapse following discontinuation of antipsychotic medication after a first episode of psychosis: A systematic review. Schizophr Res. 2018;197:9–18.

S. Niemelä Consultant of: Recordati, Shire-Takeda, Speakers bureau of: Dne Pharma, Lundbeck, Recordati, Shire-Takeda

Introduction

Cannabis-induced psychosis (CIP) is often assumed to resolve with sustained abstinence, although recent studies report adverse long-term outcomes, such as a high risk of diagnostic transition to schizophrenia. Cannabis is also known to increase relapse rate in individuals with psychotic disorders in general, and there is a lack of knowledge on optimal treatment of this patient group.

In this presentation, data on incidence and mortality associated with CIP, and real-world effectiveness of antipsychotics in relapse prevention in persons with CIP will be presented.

Nationwide Scandinavian registers were utilized to identify persons with first-time CIP (ICD-10 F12.5) during the years 2000-2021. Incidence and mortality of CIP were investigated with Danish, Norwegian and Swedish register-based data, and antipsychotic use with Swedish data. Annual incidence rates of CIP per 100 000 persons were calculated. For mortality study, incident cases of CIP were matched by age- and gender with comparison persons without substance-induced psychosis and hazard ratios (HRs) were calculated for all-cause and cause-specific mortality. Association between use of specific antipsychotics (oral vs. long-acting injectable, LAI, forms) and risk of hospitalization due to any psychosis relapse was investigated in within-individual design where each person acted as his/her own control to minimize selection bias, analyzed with stratified Cox models.

The incidence rate of CIP increased in time in all Scandinavian countries and was the highest in Denmark throughout the study years (rate in 2016 5.6, vs. 3.0 in Norway and 2.7 in Sweden). CIP was associated with an increased risk of mortality, risk estimates (HRs) ranging from 6.6 in Denmark, to 7.6 in Sweden, and 9.0 in Norway, compared with general population controls. In within-individual models, antipsychotic use was associated with a decreased risk of hospitalization due to psychosis relapse, with an adjusted HR of 0.75 (95% Confidence Interval 0.67-0.84), compared with time periods when the same individuals did not use antipsychotics.

Incidence of cannabis-induced psychosis is increasing in Scandinavian countries, and it is associated with significant mortality risk. Antipsychotics are effective treatments in preventing psychosis relapses also in individuals with CIP.

H. Taipale Grant / Research support from: Janssen, Speakers bureau of: Gedeon Richter, Janssen, Lundbeck, Otsuka

I will present data from a range of Danish studies on both cannabis-induced psychosis and Danish epidemiological studies on the association between cannabis and psychotic disorders such as schizophrenia. A deeper understanding of these associations is important. If the consistent association that we have observed for many decades is indeed causal, then cannabis is perhaps the single most important preventable risk factor for schizophrenia that we have identified to date. The development over time of the population attributable risk fraction, gender differences, and other novel areas will be covered in the presentation.

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Psychosocial interventions play a role in recovery and in the patient’s journey. Recovery is individual and so needs individual responses from the mental health services with individual goals set. Different interventions will be useful at different stages and, of course, they only “work” for some people. Three main strategies are often referred to – reducing symptoms, reducing barriers to recovery, and extending and maintaining recovery to achieve some stable and acceptable (to the patient) optimal level of functioning. Psychosocial intervention strategies are beneficial for each of these, and they are often thought of as independent, but they are inter-related with one type of therapy leading to reductions in the need for other therapies. Even though many of these strategies are included in guidelines, the process of considering which one to start with is a choice. We need to work out how that choice is made.

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Effective approaches exist to prevent and treat mental illness and to promote mental health but most people who could benefit from evidence-based interventions (policies, programmes, and individual-level practices or services) do not receive them. Too often, research produces interventions and implementation strategies that are difficult to scale owing to misalignment with the political, cultural, policy, system, community, provider, and individual realities of real-world settings. The Lancet Psychiatry Commission on Transforming Mental Health Implementation Research considers strategies for changing how research is done to produce more actionable evidence. It examines how to integrate research and real-world implementation; centre equity in mental health intervention and implementation research; apply a complexity science lens to mental health research; expand designs beyond the randomised clinical trial; and value transdisciplinarity across endeavours. Most mental health implementation research has been done in high-income countries but the Commission’s recommendations incorporate research from low-income and middle-income countries and call for strategies to expand mental health implementation research globally.

J. Marsh Employee of: Elsevier

Mood disorders (MD) have been consistently associated with alterations in the immune system. Evidence suggests a condition of systemic low-grade inflammation with abnormally decreased adaptive, increased innate immunity, and with higher levels of circulating cytokines, higher macrophage/monocyte inflammatory activation patterns, and higher neutrophils to lymphocyte counts. A dynamic pattern of premature immunosenescence and partial T cell defect starting early in adolescence, involving a reduction of naïve T cells and an expansion of memory and senescent T cells, parallels lifetime recurrence of illness episodes, worsening outcomes and fostering chronicity. Consistent systematic reviews and meta-analyses affirm that COVID-19 survivors show persistent psychopathology and neurocognitive impairment, with clinical significant depressive psychopathology being reported in around 31% of patients. Psychopathological features are the same observed in MD, along the same gradient of severity, and including a typically melancholic cognitive vulnerability. Neurocognitive impairment could possibly separate from depression in the long term, but not in the first year after infection, and it is largely overlapping with persistent cognitive deficits described in MD. We will discuss pathogenetic mechanisms shared by both, MD and post-COVID depression, with a specific emphasis on: (i) spread disruption of white matter microstructure, reduced grey matter volumes in anterior cingulate cortex, and abnormal functional connectivity in the cortico-limbic circuitries; (ii) abnormal cell trafficking across the blood brain barrier, essential for brain maintenance and repair in healthy conditions; (iii) altered immuno-inflammatory setpoints as observed in the peripheral blood, known to parallel white and grey matter abnormalities in the brain, and recently shown to disrupt neurovascular coupling and spontaneous neural activity. We suggest that post viral depression provides an invaluable model illness for the study of immune-inflammatory mechanisms involved in the pathogenesis of mood disorders, to identify new targets for treatment, with the aim of restoring mental health and brain homeostasis.

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Sleep is not something that occurs in isolation—it is embedded in a context. These contexts include biological, psychological and social factors, as well as a range of environmental considerations.

Throughout Europe psychologists engage in research and practice and collaborate with colleagues from allied professions such as psychiatry and those with lived experience on the topic of sleep.

Insights are gathered from throughout the network of the European Federation of Psychologists’ Associations (EFPA). Individual examples and emergent themes are identified from a wide range of contexts including:

The role of sleep in European policy

Sleep in times of crisis

Community-oriented approaches to supporting healthy sleep patterns

The role of sleep and rest in the workplace

How concern over topics like climate change affects sleep

Competency around sleep in practitioner training and standards

The implications of digitalisation on sleep

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In this talk, Dr. Arnardottir will summarize the main findings of the SLEEP REVOLUTION, an EU Horizon 2020 Research and Innovation Programme no. 965417. The project is an inter-disciplinary and international research and development project with 39 partner institutions and companies in Europe and Australia. SLEEP REVOLUTION aims to introduce an approach based on machine learning to assess sleep apnea severity and treatment needs as well as the use of digital health technology to measure sleep and health (app, cognitive testing, consumer sleep technology and clinically validated sleep technology for home use). Through these technological solutions , the project brings together researchers, patients and healthcare professionals to provide beyond the current state-of-the-art diagnosis and optimal treatment for sleep disorders. The approach of this project can be used as a model for other disease assessment and follow-up.

E. Arnardóttir Consultant of: Medical Advisory Board for Philips (Feb 2022-Feb 2024) and Lille (Sept 2024), Speakers bureau of: Nox Medical, ResMed, Jazz Pharmaceuticals, Linde Healthcare, Apnimed, Wink Sleep, Vistor (NovoNordisk)

Sleep is essential for physical, brain (including mental) and societal health. Sleep-wake disorders are confirmed as independent risk factors and/or modulators of several neurological (such as stroke, dementia, and parkinsonism), psychiatric (depression) and other (arterial hypertension, diabetes, oncological) disorders. According to the Cost Of Illness in Neurology in Europe (COIN-EU) Study, 1.7 trillion euros cost is estimated for neurological disorders, of which 25.45% is dedicated for sleep disorders. In this talk both the socioeconomic burden of sleep disorders, and possible sleep-based interventions for improving brain and physical health, will be discussed.

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Brain health impacts everyone, in Europe and beyond. Whether it is the continued quest for cures and treatment for those living with brain conditions or the protection and fostering of healthy brains for our future generations, the challenges are unprecedented. To elevate brain health on the national, EU, and international policy agendas while making the most of existing initiatives, the European Brain Council (EBC) kicked off the No Health Without Brain Health campaign in the European Parliament during the 2024 Brain Awareness Week ahead of the 2024 European Elections.

This campaign is structured around two priority policy asks: the creation of a European Parliament Intergroup on Brain Health and Research and increased support to the creation of EU and National Brain plans. One year after the official kick-off, the campaign demonstrated that, when united, the brain community can reach a significant number of policymakers and make its voice heard to drive tangible policy changes.

The presentation “No Health Without Brain Health: Prioritising Brain Health in the European Union to Leave No One Behind” in this joint workshop will showcase success stories, address challenges and share good practices in EU-wide brain health initiatives. It will highlight the importance of collaboration and breaking down silos in preparing for the brain-healthy transition of our societies. Additionally, it will address the burden of brain disorders, neurological and mental alike, in a comprehensive and collaborative manner.

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Mental health is an integral and essential component of health. An important implication of this definition is that mental health is more than just the absence of mental disorders or disabilities. Brain health can be defined as a life-long dynamic state of cognitive, emotional and motor domains underpinned by physiological processes. Exercise is a good model, since training the body improves Brain and Mental Health. Pathophysiological research and biomarkers are required.

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The latest revision of the International Classification of Diseases, ICD-11, was first issued by the World Health Organization in 2022 and a comprehensive account of mental and behavioural disorders, the Clinical Descriptions and Diagnostic Requirements (CDDR) was published in 2024. Within mental disorders is a new section “Disorders due to Substance Use and Addictive Behaviours”, which sets out the diagnostic requirements for, and distinctions between, the accepted range of conditions related to psychoactive substance use and behaviours such as gambling and online (video-) gaming.

Considerable changes have been made to ICD-11 compared with its predecessor ICD-10, originally published in 1992. The process leading to ICD-11 began in 2005 and a work group for substance disorders was convened in 2010, and for addictive behaviours in 2014. Certain key considerations guided the development of the new section, which had to serve both public health and preventive and clinical diagnostic needs. These were:

1. - the importance for reporting a wide range of psychoactive substances for monitoring and prevention, which led to the expansion to 14 categories;

2. - the need on public health and also clinical grounds for having a spectrum of severity of substance use, which could be defined precisely in line with the evidence base;

3. - the recognition of the high-level psychometric performance of key diagnoses in ICD-10 including substance dependence; and:

4. - compatibility with the available data on the neurobiology and cognitive processes underlying addictive disorders.

Four central substance use diagnoses feature in ICD-11. They are, in order of severity, (i) hazardous substance use, (ii) episode of harmful use, (iii) harmful (pattern of) substance use, and (iv) substance dependence. When there is any form of unhealthy use, one of these four conditions should be diagnosed. In addition, there are many substance-induced disorders, including intoxication, withdrawal, substance-induced delirium, substance-induced mental disorders, and substance-induced neurocognitive disorders. In separate sections are the physical disorders related to substance use. There are currently two diagnoses available for specific behavioural conditions, namely gambling disorder and gaming disorder, together with the health risk factors of hazardous gambling and hazardous gaming. The presentation will include some of the empirical data that support the election of these diagnoses which form the basis for monitoring and healthcare provision in WHO (UN) member countries.

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In the ICD-11 the number of drug categories as “headers” for the substance related morbidity chapters has doubled. Furthermore, the ICD-11 has rationalized the number of criteria for substance dependence from six to three, but in the process in fact the threshold for receiving a diagnosis of substance dependence has been reduced substantially. Lastly, the ICD-11 has increased substantially the number of drug induced comorbidities. The former “substance induced psychosis” has now been joined by substance induced depression, anxiety disorder and even OCD for some drugs. This talk will raise some questions regarding the functionality of these changes.

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Background and relevance

Addictive behaviours have for the first time been included within the addiction spectrum. The transition to ICD-11 is a critical step in advancing mental health and addiction medicine.

The implementation of ICD-11 is expected to improve Health Records, facilitate Better Treatment, reduce Stigma, and enhance Public Health Surveillance.Testing the practical implications of these changes is key to ensure preparedness and smooth and effective implementation.

We conducted a comprehensive evaluation to assess the practical implications of these changes in Switzerland, determining the ease of implementation in clinical and public health settings.

Assessment consisted in:

Gathering Feedback through collecting insights from health professionals to identify potential challenges and areas for improvement.

Informing Training Needs by identifying the training requirements for health professionals to effectively use the new system.

The field testing involved multiple components: online survey, focus groups, expert reviews, key informant interviews, and a consensus conference.

The testinginvolved 64 health professionals and covered diverse professional backgrounds and geographical locations). Respondents had a median of 15.25 years of experience in addiction medicine, 75% of them were Clinicians and 25% were Public Health Professionals.

Key findings of the diffrernt survey components included: High approval rates for the utility (89%), feasibility (92%) and ease of use (86%) of the ICD-11.

Strong support (90%) for the inclusion of Addictive behaviors, particularly Gaming disorder and Gambling disorder, In contrast, the broader clinical spectrum of Gaming disorder (hazardous gaming and harmful gaming) received limited support (5%).

The national consensus conference concluded that ICD-11 is mainly perceived to have a positive impact on Swiss health records, to enable better documentation of emerging health conditions, and to reduce stigma. Divergent views were represented and expressed their acceptance or reluctance towards including addictive behaviours.

Careful transition and preparedness at the national level, training health professionals along with effective communication to public audience, were reported to be essential to mitigate risks of stigma and over-pathologizing addictive behaviours.

The implementation of ICD-11 in Switzerland is anticipated to enhance the understanding of the societal and economic impacts of new categories such as Gaming disorder. The field-testing data collected from a wide variety of experts and care professionals underscores the need for investment in training, communication, and preparedness to ensure a smooth transition and maximize the benefits of the new classification system.

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Psychiatry faces numerous challenges that significantly affect mental health of people in Europe, from climate change, wars, migration, pandemics, to rapid advance of artificial intelligence. Among the most pressing issues are deteriorating mental health of children and adolescents and the lack of trained professionals. At the same time, progress in neuroscientific research contributes to the development of new effective treatments, e.g., monoclonal antibodies for Alzheimer’s disease; repurposing of drugs for psychiatric disorders, such as GLP-1 agonists, showed potential in treatment of alcohol addiction. There is also a renewed interest in psychedelics, recent studies verified their therapeutic efficacy in treatment of several mental disorders. Neurostimulation methods (rTMS, tDSC) are recognized non-pharmacological interventions; utilization of new technologies (AI, virtual reality, mobile apps, etc.) can help us in treatment and prevention of mental disorders.

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