Forensic psychiatric rehabilitation occupies a pivotal position between risk management, therapeutic intervention, and social reintegration. Individuals within forensic services who have learning disabilities and neurodevelopmental disorders (including autism spectrum disorder, ADHD, and developmental communication disorders) represent a particularly vulnerable and complex subgroup. They are overrepresented in secure settings, frequently misunderstood in the criminal justice process, and at heightened risk of prolonged admission, institutionalisation, and recidivism if rehabilitation pathways are not appropriately adapted to their cognitive and social profiles.

This presentation will examine the forensic aspects of psychiatric rehabilitation for this population, integrating clinical, ethical, and legal perspectives. It will explore how neurodevelopmental impairments affect offence pathways, including social naïvety, suggestibility, emotional dysregulation, rigidity of thinking, misinterpretation of social cues, and vulnerability to exploitation. The session will discuss how these factors influence mens rea, risk formulation, and responsivity to treatment, while emphasising that rehabilitation must move beyond containment toward meaningful skill acquisition and autonomy.

A central focus will be the development of structured, individualised rehabilitation plans that account for cognitive limitations, communication needs, and adaptive functioning deficits. Evidence-based interventions—including adapted cognitive behavioural approaches, offence-focused work tailored to intellectual ability, behavioural analysis, life-skills training, vocational preparation, and supported community transition—will be discussed. The importance of multidisciplinary collaboration, including forensic psychiatry, psychology, occupational therapy, speech and language therapy, social care, and legal professionals, will be highlighted as essential to safe and sustainable discharge planning.

The presentation will also address medico-legal considerations, including proportionality of restriction, the balance between public protection and therapeutic optimism, human rights frameworks, and the ethical imperative to avoid diagnostic overshadowing. Through illustrative case material, practical challenges such as treatment resistance, risk misinterpretation, and pathway bottlenecks will be examined, alongside strategies to enhance engagement and reduce long-term dependency on secure care.

The session aims to equip clinicians and service planners with a nuanced understanding of how forensic rehabilitation must be adapted for patients with learning disabilities and neurodevelopmental disorders, ultimately improving recovery trajectories, reducing reoffending risk, and supporting dignified reintegration into the community.

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Psychiatric hospitals, and forensic mental health settings face unique challenges in delivering empathic care. Society has wrestled with how to deal with offences perpetrated by the mentally unwell for centuries, and forensic psychiatry has ambiguous guiding principles. At times, the practitioner’s duty is to justice rather than the patient, and detached concern is required to balance competing ethical demands. Challenges are posed by working with patients for whom a lack of empathy can be an integral part of their mental disorder. Forensic mental health settings represent the last long stay environments in England. Lack of scrutiny, high levels of restrictive practice, and frequent violence and aggression, can lead to burnout and failures in compassionate care. Empathic engagement in central to the therapeutic endeavour in forensic settings, to achieve understanding and to enable positive change. This should be supported by reflective spaces, restorative practice, effective outcome measures, system-based approaches to learning and value-driven leadership.

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Psychiatric rehabilitation after trauma requires more than symptom reduction; it involves restoring functional capacity, autonomy, and social participation. Refugees and forcibly displaced individuals face a high burden of PTSD and complex stressors related to loss, disrupted identity, and integration challenges, which can hinder long-term recovery. In this talk, I will present clinical reflections from psychotherapeutic work with Ukrainian and Belarusian displaced patients conducted in a private outpatient setting in Poland. I will outline how Positive Psychotherapy can be applied as an evidence-informed, culturally adaptable, strengths-based approach to rehabilitation in PTSD, focusing on resource activation, meaning-making, reconstruction of identity, and rebuilding interpersonal functioning. Particular attention will be given to the therapeutic use of narratives: how patients’ personal stories, as well as carefully framed stories of other refugees, can enhance engagement, reduce shame and helplessness, and support post-traumatic growth—while maintaining boundaries and avoiding re-traumatisation. Practical tools will be shared that can be integrated into multidisciplinary rehabilitation pathways, complementing psychoeducation, peer support, and recovery-oriented care.

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Psychiatric rehabilitation remains a cornerstone of comprehensive mental healthcare, yet it continues to be relatively under-emphasised within mainstream service planning and clinical training. While prevention, crisis management, and acute symptom stabilisation are central to psychiatric practice, the longer-term processes that sustain recovery, reduce relapse, and promote meaningful reintegration into society often receive comparatively less attention. Without structured rehabilitation pathways, individuals with severe and enduring mental illness remain at high risk of repeated hospital admissions, social exclusion, unemployment, and functional decline.

This interactive workshop seeks to reposition psychiatric rehabilitation as a critical component of relapse prevention and long-term recovery. It will provide participants with a structured, evidence-based overview of rehabilitation models that aim not only to reduce symptom burden but also to restore autonomy, enhance functional capacity, and support personal recovery goals. Drawing on contemporary research and international service examples, we will examine how comprehensive rehabilitation programmes can improve clinical outcomes, reduce readmission rates, and enhance quality of life.

Through real-life case studies and clinical vignettes, participants will explore the practical application of key interventions, including cognitive behavioural therapy (CBT), life skills training, social skills development, vocational rehabilitation, and supported employment models such as Individual Placement and Support (IPS). We will examine how these interventions contribute to improved community tenure, greater occupational engagement, and strengthened self-efficacy. The session will emphasise the importance of multidisciplinary collaboration between psychiatrists, psychologists, occupational therapists, nurses, social workers, peer support workers, and community agencies. Particular focus will be placed on continuity of care, assertive outreach approaches, and coordinated transitions between inpatient and community services.

The workshop will also explore innovative developments in rehabilitation delivery. Emerging technologies such as mobile health applications for relapse monitoring, digital mood tracking, and telepsychiatry platforms offer promising opportunities to enhance engagement, accessibility, and long-term therapeutic continuity.

Importantly, the session will address gender-sensitive, trauma-informed, and culturally responsive rehabilitation models. Participants will reflect on how rehabilitation frameworks can be adapted to meet the needs of diverse populations, ensuring equitable access and personalised care. Consideration will also be given to recovery-oriented language, co-production with service users, and the integration of lived experience perspectives into service design.

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In the United Kingdom, forensic mental health services are funded under the National Health Service (NHS) and provide care in secure settings for individuals with complex mental health needs and involvement with the criminal justice system. While some services are delivered by private providers, this presentation focuses on NHS provision at Oxford Health NHS Foundation Trust.

Forensic services can feel highly supportive but are also risk-focused and restrictive. Unlike prison, where timeframes are often clearer, detention within forensic mental health services does not usually have a fixed end point, making it difficult for individuals to plan for the future and sustain progress. Extended stays within secure environments can contribute to institutionalisation effects, and individuals may experience dual stigma: stigma associated with mental ill health alongside stigma linked to past offending. Together, these factors can significantly impact identity, agency, and hope.

In response, empowerment is positioned as a core principle of recovery-oriented practice. A key component is the integration of peer support workers—individuals with lived experience of mental health services—who are employed to use that experience in a formal and recovery-focused way. Peer support within forensic settings is grounded in mutuality and relationship-building rather than clinical intervention, and can help challenge stigma, soften “us and them” dynamics, and strengthen personal agency.

Peer support is closely aligned with the Recovery College model, and this interrelationship is explored. Recovery Colleges provide structured educational opportunities for people detained within forensic mental health services, with opportunities to rebuild identities beyond illness- and offence-based narratives. Central is a progressive pathway of participation and empowerment, through which individuals may move from patient to student, from student to Expert by Experience tutor, and in some cases from Expert by Experience to active stakeholder within Recovery College leadership and development.

Recovery Colleges offer annual programmes of co-produced psychoeducational and recovery-focused courses that support individuals to develop skills, increase self-understanding, and consolidate recovery-oriented identities. Collaboration sits at the core of this approach, with service users, peer support workers, mental health professionals, and creative practitioners working together as equal partners in learning, delivery, and shared experience. This presentation reflects on how integrating peer support and Recovery College approaches within forensic mental health services can promote empowerment, shared ownership, and recovery-focused cultures within secure care.

P. Neckar Employee of: Employee of: Employee of Oxford Health NHS Foundation trust, N. Boxall Employee of: Employee of Oxford Health NHS Foundation trust

Despite progress in psychiatric treatment, unmet needs remain a persistent and structural problem in recovery and rehabilitation. These needs—such as social inclusion, autonomy, meaningful participation, housing, employment, and identity reconstruction—cannot be adequately addressed solely within health care systems. When recovery is framed primarily as a clinical responsibility, unmet needs risk being medicalised, individualised, and ultimately left unresolved.

This presentation adopts a critical, recovery-oriented perspective to argue that the dominance of health service–centred models actively contributes to the persistence of unmet needs. While mental health services are essential, many recovery needs emerge within social, political, and economic contexts that lie beyond the reach of clinical interventions. Institutional rehabilitation models may unintentionally reinforce dependency and marginalisation by overlooking structural determinants of recovery.

Drawing on trauma-informed and psychosocial frameworks, the presentation highlights the role of mental health nursing as both a clinical and advocacy practice. Addressing unmet needs requires cross-sectoral responsibility, community engagement, and a shift from service-led recovery to socially embedded, rights-based recovery approaches.

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Major depressive disorder (MDD) and suicidal behavior are characterized by rapid emotional and behavioral changes that are often missed by standard, episodic clinical assessments. Digital psychiatry offers tools to observe these dynamics over time, supporting earlier detection of clinical worsening and more timely intervention.

This presentation draws on clinical research using ecological momentary assessment (EMA) and passive smartphone monitoring in patients with depression and suicidal behavior. We show how real-time emotion tracking—capturing affective intensity, variability, and reactivity—provides clinically meaningful information that complements routine symptom scales and suicide risk evaluations. Passive behavioral indicators allow ongoing monitoring of vulnerability with minimal patient burden.

We also discuss approaches for integrating longitudinal emotional and behavioral data to identify individual patterns associated with relapse and escalation of suicidal risk, with an emphasis on clinical interpretability and usability. We will address practical considerations for implementation in routine care and future directions toward more personalized, continuous, and proactive management of MDD and suicidality.

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The global landscape of mental health is defined by a profound paradox: while clinical understanding and therapeutic modalities have reached unprecedented levels of sophistication, the actual ability for a person to access care remains obstructed. This crisis has evolved into a rapidly growing epidemic, with mental health conditions now soaring past one billion people worldwide (WHO, 2025).

As a result, mental health is now a leading cause of disability globally (Benefit Representatives of America, 2023). Systemic failures in follow-up care contribute to mortality risk, as worsening symptoms during extensive wait periods increase readmission rates (Pederson et al., 2016). By quantifying these invisible obstacles, the Mental Health Access Burden Index (MHABI) moves focus from clinical symptoms to structural barriers, humanizing data to ensure no patient is “lost in transition.”

The objective outlines the development and implementation of the Mental Health Access Burden Index (MHABI), a composite measurement framework created to quantify the multidimensional burden resulting from delays in accessing mental health care across institutional, individual, and organizational levels.

The MHABI (0–100) is an algorithmic framework synthesizing Clinical Burden (Wait Time/DALYs), Economic Impact (Missed Work/School), and Crisis Risk (ER/Suicide history). Results are categorized via a Burden Score Reference Scale: Low (0-39), Moderate (40-69), High Critical (70-85), and Critical (86-100). The provisionally patented methodology introduces a paradigm shift from linear sorting (the “Deli Counter” model) to Burden-Based Stratification across four risk tiers. It employs Diagnostic Sub-Scores to identify why a score is high and Risk Amplification Logic, a conditional multiplier that elevates the composite score when high-risk indicators co-occur, reflecting real-world clinical complexity.

Simulated scenarios show MHABI identifies patients “waiting in line” who require immediate intervention. It addresses the “Deli Counter” blind spot where Patient A (low acuity) and Patient B (high-risk/unemployed) are treated identically due to a “False Equivalence” in wait-time metrics. Prompt, score-prioritized access reduces symptom severity and duration by up to 87%. This targeted approach preserves socioeconomic stability, functional independence, and alleviates clinician cognitive load.

The MHABI bridges the gap between the clinical science of the brain and the social determinants of the community. By quantifying the invisible obstacles to care, this framework ensures that psychiatric treatment is prioritized as a fundamental human right.

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Despite strong evidence for its effectiveness, psychotherapy remains insufficiently accessible across many European health systems, resulting in substantial treatment gaps and persistent unmet mental health needs. This presentation examines the current landscape of psychotherapy service provision in Europe, with a particular focus on the mismatch between population-level mental health needs and available psychotherapeutic care.

Drawing on comparative data and system-level observations, the talk will outline key structural and organizational factors contributing to treatment gaps, including workforce shortages, uneven geographic distribution of services, long waiting times, limited public reimbursement, and fragmentation between primary care, specialist services, and community-based care. Special attention will be given to vulnerable populations, for whom barriers to access further exacerbate existing health inequalities.

The presentation will also explore the clinical, public health, and societal consequences of unmet psychotherapeutic needs, including symptom chronicity, increased use of emergency and inpatient services, reduced functional outcomes, and broader economic costs. By situating these findings within a public mental health framework, the talk highlights how insufficient access to psychotherapy undermines both individual recovery and system sustainability.

In conclusion, the presentation emphasizes the need for coordinated policy, workforce development, and service-level strategies to reduce treatment gaps and improve equitable access to psychotherapy across Europe, contributing to higher-quality mental health care and expanded horizons for prevention and early intervention.

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Evidence indicates that therapist-guided digital interventions, particularly internet-delivered cognitive behavioral therapy and videoconferencing-based psychotherapy, can achieve clinical outcomes comparable to in-person treatment for common mental disorders such as depression and anxiety when applied to appropriately selected patients. Key clinical opportunities include improved access to care, flexibility in treatment delivery, support for stepped and blended care models, and enhanced symptom monitoring between sessions. Emerging technologies such as virtual reality and just-in-time adaptive interventions may further augment established therapeutic techniques. Besides, digital psychotherapies have the potential to narrow the treatment gap during disasters.

At the same time, clinically relevant limitations must be acknowledged. Engagement and adherence remain inconsistent, especially in unguided interventions, with high dropout rates reported in routine care. Digital formats may limit clinicians’ ability to assess acute risk, comorbidity, and subtle clinical cues, and many digital interventions exclude patients with high clinical complexity. Additional concerns include data privacy, variable evidence quality, unclear liability, and insufficient regulatory oversight. For those with limited internet access and a lack of privacy, digital psychotherapies become unsustainable. That causes a gap between practice and theory.

Digital psychotherapies should therefore be understood as complementary tools rather than replacements for face-to-face care. Their effective clinical use requires careful patient selection, ongoing human oversight, and integration within well-governed mental health care systems.

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Sexuality is a complex aspect of human functioning, including gender identity, roles, sexual orientation, pleasure, intimacy and reproduction. In the past decades, the view of sexuality in persons with ASD has developed from being „asexual” to experiencing intense romantic and sexual needs. During the development of sexuality, persons with ASD are often without adequate education, as parents often feel incompetent to educate their children. Also, specific sensory sensitivity alters the modality of sexual contact in persons with ASD. General self-awareness in ASD is lower, and it is an important aspect of sexuality. There is increasing evidence of specifics in sexuality and sexual orientation in persons with ASD, with non-heterosexual orientation being significantly more prevalent than in the general population, especially in females with autism. Gender dysphoria is present in higher prevalence in persons with ASD than in the general population. Individuals with ASD have higher prevalence of mental health problems, especially if they are a part of sexual and gender minorities. This case-based presentation aims to emphasize the importance of sexuality in ASD, an often disregarded subject in this population.

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Autistic individuals face unique challenges across multiple domains of sexual and gender health that are often overlooked in clinical practice and education. This presentation will address four key areas: the significant gaps in sex education for autistic people, relationship difficulties and social-communication barriers that impact intimate partnerships, patterns of sexual orientation diversity in autism spectrum conditions, and the intersection of autism with transgender and gender-diverse identities.

Research indicates that autistic people receive inadequate or inaccessible sex education, often delivered in formats that don’t account for different learning styles or communication needs. Relationship challenges are common, stemming from difficulties with social reciprocity, sensory sensitivities, and navigating unwritten social rules in dating and intimacy. Studies show higher rates of diverse sexual orientations as well as gender dysphoria in autistic populations and due to social barriers and limited access to appropriate medical care and sexual education, this translates into higher rates of mental disorders and an increased risk of suicide.

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Sexual health in neurodevelopmental disorders remains understudied. Women and transgender/gender diverse (TGD) adults with ADHD may face elevated risks of sexual dysfunction and interpersonal violence, alongside gender-specific barriers to care. Evidence also suggests higher ADHD symptom burden in TGD populations, yet little is known about sexuality and relationship safety in these groups.

Using preliminary findings from the International Survey on Experiences, Health, and Barriers in Women with ADHD, the objectives are to:

1. (1) Describe gender identity, sexual orientation, and relationship characteristics in women/TGD respondents with ADHD.

2. (2) Estimate self-reported sexual problems and interpersonal conflict (including intimate partner violence, IPV), and explore associations with ADHD context.

Cross-sectional, descriptive analysis of an international online survey (Dutch/English) targeting women ≥18 years with self-reported ADHD symptoms or a formal ADHD diagnosis. Recruitment: social media, patient organisations, newsletters, research networks. Outcomes included demographics, sexual/romantic orientation (multi-select), relationship status, partner ADHD, and conflict tactics/IPV items. Analyses summarised distributions using valid-percent denominators, with explicit reporting of missing data due to optional items.

Nearly 6,000 respondents completed the survey (N=5,893). Most were assigned female at birth (n=4,114). Respondents reported diverse sexual and romantic orientations, with around two-thirds identifying as straight and over one-third as bisexual, pansexual, queer, asexual, or other minority orientations. Two in five were married, and a notable proportion reported partners with ADHD.

Although only 1% reported a diagnosed sexual disorder, this was likely underestimated due to nonresponse. Reports of relationship conflict were concerning: 15% disclosed partners insisting on sex without force, and 2.6% reported forced sex at some point. Very few endorsed perpetration themselves.

These preliminary findings highlight substantial diversity in sexual orientation, frequent partnerships where ADHD is present, and notable rates of sexual coercion and forced sex among women/TGD adults with ADHD. The low rate of diagnosed sexual disorders likely reflects underreporting. Findings underscore the need for clinicians to integrate sexuality and relationship safety into ADHD assessment and care.

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The relationship between neurodivergence and gender diversity is an actively growing research interest, where many research findings suggest a stronger association than that is observed in the general population. The issue has been more extensively studied with regard to the autism spectrum features, compared to attention deficit and hyperactivity. Yet, there are some prevalence studies suggesting a higher rates of ADHD in trans and gender diverse individuals. Recent research in the mental health and clinical implication of the presence of autistic features in trans and gender diverse people indicate a major contribution of the level of executive functions in the excessive mental health burden they experience, compared to other trans and gender diverse individuals, both with respect to their experience with the minority stress and their progress in gender-affirmation. Trans and gender diverse individuals with ADHD may share a similar difficulty, though with varying severity. Furthermore, ADHD may complicate the access to the potential sources of resilience, including social support, especially if it is not recognized and managed early in life. Finally, the clinical presentation of ADHD may render the access to and execution gender-affirming health services for the individual. This may be related to the failure of the individual to follow the requirements of the assessment in the clinic; but also, sometimes more importantly, the clinician’s and social relation’s failure to confide in the authenticity of expressed identity. Mental health care professional should be familiar with the increased burden of this intersection for the individual and have the means to assist the individual in both domains concurrently.

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Access to parenthood for patients suffering from bipolar disorder is a public health issue that must be addressed through prevention.

The preconception period is the most appropriate time to define shared prevention plans that address both the adjustment of psychotropic treatments and the most appropriate obstetric, pediatric, and psychiatric care pathways for the mother and baby.

When a patient consults while already pregnant, time constraints mean that strategies must be adapted, particularly in terms of in terms of obstetric and pediatric care.

This presentation will address the main approaches to the use of psychotropic drugs during the perinatal period, as well as the organization of coordinated and graduated integrated care pathways for mothers and newborns during the perinatal period.

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Very little research to date has been conducted to investigate mother-infant relationship and infant development in women with a history of bipolar disorder or affective psychosis.

Objectives: The current study (Biaggi et al. J Affect Disord 2021; Biaggi et al. Psychol Med 2023; Biaggi et al. J Affect Disord 2024) aimed to investigate the quality of the mother-infant relationship and the development of the infants born to women with a history of bipolar disorder, schizoaffective disorder or previous postpartum psychosis (PP). Potential predictors of mother-infant interaction quality were also investigated.

103 women (and their offspring) were included in the study, 43 with a history of bipolar disorder, schizoaffective disorder or previous postpartum psychosis, and 60 with no current/previous mental illness or family history of PP. Women were recruited during pregnancy and followed up with their offspring until 12 months postpartum.

Mother–infant relationship was assessed using the MAAS in pregnancy, the MPAS and the CARE-Index at 8 weeks and 12 months postpartum. Infant development was investigated using the Bayley-III at 12 months postpartum.

Compared to healthy controls, women with a history of bipolar disorder or affective psychosis had less synchronous mother–infant interactions, a more negative affective experience towards their infants at both 8 weeks and 12 months postpartum and had infants with less optimal cognitive, language, motor and socio-emotional development at 12 months postpartum. Maternal ability to recognize emotions, particularly fear and infant social-interactive behaviour were significant predictors for mother-infant interaction quality.

These results suggest that a history of bipolar disorder or affective psychosis could represent a risk factor for the mother-infant relationship and the infant development during the perinatal period, suggesting the need of early monitoring and the development of interventions, where necessary. Preventive interventions aimed at improving maternal ability to recognize emotions and infant social-interactive behaviour may be helpful to support the quality of the mother-infant interaction and potentially also the infant long-term development.

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The postpartum period represents one of the highest-risk phases for relapse in women with bipolar disorder, with a markedly increased vulnerability to depressive episodes, mania, mixed states, and postpartum psychosis. Rapid biological changes after childbirth, combined with sleep deprivation, stress, and psychosocial demands, can destabilize even previously well-controlled patients. Effective postpartum management therefore requires proactive, individualized planning that integrates pharmacological relapse prevention with psychosocial interventions and family-centred care.

This presentation provides practical, evidence-based guidance for everyday clinical practice in postpartum bipolar disorder. Pharmacotherapy remains a cornerstone of relapse prevention. Lithium is among the most effective options, particularly for preventing severe postpartum mood episodes; however, careful monitoring is essential due to postpartum physiological changes affecting fluid balance and renal clearance. Other mood-stabilizing strategies may include lamotrigine and second-generation antipsychotics, selected according to prior response, symptom profile, and tolerability. Treatment decisions must also address breastfeeding-related concerns. Shared decision-making is crucial, balancing the benefits of breastfeeding with maternal stability, infant safety, and the risk associated with sleep loss. In acute episodes with psychotic symptoms or severe agitation, rapid stabilization and safety planning—including consideration of hospitalization and, when indicated, electroconvulsive therapy—may be lifesaving.

Alongside medication, psychosocial interventions are essential and should not be considered optional. Psychoeducation focused on relapse signatures, early warning signs, and adherence support improves insight and timely help-seeking. Sleep protection is a key preventive strategy, requiring structured plans for night-time support and realistic expectations around infant care. Interpersonal and social rhythm approaches may help restore daily routines and reduce mood instability, while cognitive-behavioural techniques can support coping with anxiety, guilt, and intrusive thoughts. Partner and family involvement is often critical for monitoring symptoms, reducing burden, and strengthening protective factors. Special attention should be given to the parent–infant relationship, as mood episodes may impair bonding and parenting confidence; supportive interventions can promote recovery and healthier developmental outcomes.

Overall, integrated postpartum care combining pharmacotherapy with psychosocial and family-based strategies can reduce relapse risk, improve maternal functioning, and support safe, meaningful early motherhood for women living with bipolar disorder.

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Based on the 2023 Ambassador study on schizophrenia, conducted among 454 psychiatrists and trainees from 35 European countries using six clinical vignettes (cases A–F), we aimed to explore therapeutic approaches across different phases and clinical situations, while assessing adherence to guidelines.

Our findings showed moderate to high agreement among European psychiatrists on pharmacological treatment for first-episode psychosis, cognitive and negative symptoms, prodromal symptoms, and pregnancy, with only moderate adherence to guidelines. Treatment preferences were similar for antipsychotic-induced metabolic side effects and treatment resistance, but guideline adherence in these areas was partial. Non-pharmacological interventions—such as psychotherapy, recovery-oriented care, cognitive remediation, and physical exercise—were generally underused, with exceptions for psychoeducation, lifestyle recommendations, and cognitive behavioral therapy in the prodromal phase.

These results highlight a gap between research evidence, guidelines, and real-world practice. Clinicians’ expertise and experience are key to shaping future guidelines in form of clinical consensus, particularly where practice diverges from recommendations.

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Treatment-resistant schizophrenia (TRS) is a common clinical problem, up to 30% of patients show little or no response to treatment. The most comprehensive definition of TRS was coined by the Treatment Response and Resistance in Psychosis (TRRIP) working group. First step in the management of TRS is to rule out pseudoresistance, i.e., failure to respond from different reasons (non-adherence, poor metabolizers, incorrect diagnosis, comorbidity, insufficient dosage or duration of trial, masking side effects). There is a general agreement among various treatment guidelines, the drug of choice for TRS is clozapine. Recent meta-analyses, systematic reviews, and individual meta-analyses cast doubts on clozapine superiority, suggesting that other antipsychotics (e.g., olanzapine, clozapine) may as effective as clozapine. However, it should be noted that in many RCTs clozapine was underdosed; numerous studies where clozapine arm was not blinded were excluded from analyses, severely resistant patients were not included, and finally, clozapine was significantly superior to comparator drugs when disregarding RCTs sponsored by the manufacturer of the comparator. Patients who do not respond or do not tolerate clozapine (“ultra-resistant schizophrenia”) may benefit from clozapine augmentation. Data indicate that clozapine can be effectively combined with ECT, mirtazapine, or memantine for overall symptoms, with ECT for positive symptoms, memantine, duloxetine, or mirtazapine for negative symptoms. Real-world data from Finnish and Swedish national registers showed that the dose of an augmenting agent is important (standard doses of SSRIs and SNRIs, medium doses of aripiprazole). Non-pharmacological therapeutic options for TRS, in monotherapy or as clozapine augmentation, include neurostimulatory methods (ECT, rTMS, tDCS), psychotherapy for specific symptoms (CBT), physical activity for negative symptoms, or more experimental (DBS, virtual reality).

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As a young doctor, it is challenging to decide when coercion or forceful measures are necessary, as well as when the use of force follows the principle of “less harm”. This is because there are a wide spectrum of opinions, criteria,ethical questions, moral values, and laws which one must consider, and which can be difficult to understand and balance without a great amount of prior experience.

Every medicine has primary effects and side effects, and every intervention has potentially positive benefits and negative implications. As psychiatric doctors we have the obligation to not do harm, a moral duty to help others, and a lawful compulsion to use the minimum harmful measure when needed. The decision to use coercion is complicated to navigate as a young doctor in training with potentially limited experience in making such morally and legally complex decisions. We are forced to make fast decisions when an acute situation arises, where we must grapple with many considerations, including: external input and pressure, internal ethical questions about what is right and wrong, utilitarian questions about what is the best and least harmful measure to take to help our patients, unintended consequences of our decisions for the patients recovery and wellbeing and the safety of ourselves and colleagues, and the possible lawful implications of the actions and measures taken.

Furthermore, young doctors face pressure from colleagues and care personnel. Thus, when making treatment decisions, one must consider not only their own opinion, but that of potentially more senior colleagues whose ideas, methods, and approaches to the concept of “less harm” may be different. The path of educating ourselves and finding our own criteria and methods of work is long and complicated, which can lead young doctors to feel as though they are ”walking in a jungle” of uncertainty, confusion, frustration, fear and contradiction. This especially challenging when deciding on cases involving coercion and force.

This talk is based largely on personal experiences as well as screening among young doctors both within and outside of psychiatry using both personal and group interviews and surveys. Results will be contextualized with existing academic studies on the topic of coercion in psychiatry.

The aim of this talk is to present the different challenges a young doctor faces while working in a psychiatric institution, opening a debate about the concept of “less harm” in the context of an acute situation, exploring the uncertainties and ethical values that a young doctor faces on a daily basis whilst performing their job and discuss different proposals about how to reduce the amount of coercive messures.

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