Health is considered a right in the Spanish constitution and is financed through a very strict tax system. Health care covers 100% of the population and 100% of the needs, including even illegal immigrants.

The main problem of Spanish Health Care is that it has been transferred to the 17 different Autonomous Communities existing in Spain (regions with high administrative and political autonomy) which are the providers. In order to offer better services (and have more chances to be reelected) the autonomous communities have in the years before the crisis overspent circa 30% of their budget every year in health care, education and other services. The present economic crisis is forcing to better management and more standardization of the system having on the other hand significantly reduced the budget allocated to health care. There is more control on the expenses and no room for overspending via loans. At present there is no agreement on a common portfolio of services yet. There are also limitations such as charging for prescription and the reduction of the number of facilities and professionals.

Particularly for patients with mental disorders, the bioethical principles respect for the patient's autonomy and beneficence often come into conflict.

On the one hand, physicians have the legal and ethical duty to treat patients only with their informed consent. On the other hand, physicians have the duty to help patients. Many patients with severe mental or neurological disorders cannot give valid consent since their ability for autonomous decision making is temporarily reduced. In some cases, (compulsory) treatment might be the only way to restore the mental capabilities underlying autonomous decision making. To hold back treatment by referring solely to the autonomy principle runs the risk of acute or chronic health damage for patients. Furthermore, this position is based on a narrow understanding of respect for the patient's autonomy, which overlooks the duty to enhance or restore the disease-limited capability for autonomy, if possible.

An example for a narrow understanding of autonomy is the Special Report on Torture in Psychiatry by Juan Méndez (United Nations Special Rapporteur on Torture).

Positions which exclusively emphasize autonomy tend to overlook the right for adequate help.

Ethical dilemmas cannot simply be solved by prohibiting involuntary treatment in psychiatry without exception. Rather a solution has to consist of respect of the patient's autonomous will (possibly formulated in a psychiatric advance directive), effective help to restore reduced capabilities for autonomy, and beneficence.

Impaired episodic memory (EM) has been reported in schizophrenia. Intact EM requires that contextual features be bound to the content of the event, a mechanism called contextual binding (CB). It is proposed that binding errors during the encoding process are responsible for EM impairments in schizophrenia. The hippocampal formation is considered the central element for CB, it is hypothesized that the synaptic disorganization described in this condition results in such a deficit. The main goals of these studies were to investigate the neurofunctioning, neuroanatomy and neurofunctional connectivity of the hippocampus while performing a task that used CB mechanisms. Spatial relational processing is part of CB and is rooted in the hippocampal region. Visuospatial navigation (wayfinding task), was used as a probe to activate the hippocampus and its associated regions in a group of patients with schizophrenia (n=21) and matched healthy controls (n=23). During the wayfinding task individuals with schizophrenia found landmarks less frequently, made more errors and took more time to complete the task. fMRI result indicated that the patient group had a hypofunctioning of the posterior part of the hippocampus while performing the wayfinding task. VBM results indicated that controls had significantly more hippocampal GM than patients and poor performances at the wayfinding task was associated with decreased right hippocampal GM for the overall group. Connectivity results indicated that patient's hippocampus recruited alternate pathways and regions to guide and help them complete the wayfinding task. Structural and functional differences in the hippocampus might explain the connectivity differences and CB deficit in schizophrenia.

Digital health technologies may improve the management of individuals with mental health disorders by targeting important barriers to effective care. For patients with schizophrenia, for example, addressing:

• • The challenge of dealing with individual variation in treatment response. No specific tools are available to facilitate the delivery of truly patient-centric care. Predictors of an individual's side effects or treatment efficacy are not available, patients’ views on care are often not recorded, clinical state between appointments cannot be easily assessed, precise symptoms and side effects experiences are not captured in a reliable way and physical health is often neglected.

• • The challenge of effectively accessing and utilizing the vast amounts of evidence-based information to direct patient management at the point-of-care. Valuable evidence-based information, including guidelines and systematic reviews, is not used to guide care because there is too much information to assimilate, it is inaccessible at the point-of-care and it is difficult to personalize to any individual patient.

Optimal Medicine will present findings related to use of a web-based clinical decision support software system which enables clinicians to deliver individualised, evidence-based treatment at the point of care including:

• • Delivery of context-specific personalized decision support through a workflow driven interface

• • Interactive visualisation and monitoring of longitudinal status

• • Side effect risk profiling based on an individual's unique and evolving characteristics

• • Symptom and side effect rapid evaluation and monitoring using a hierarchical data selection

• • Integrated remote-monitoring technologies (iTunes app) for use between clinical contacts at times of particular vulnerability, such as discharge from hospital.

A neuroinflammatory process has been discussed in the literature in schizophrenia. Some immune-related genes have been reported to be increased in serum and post-mortem brain tissue of schizophrenia patients, whereas other studies cannot confirm these results. These controversies may be related to the selection of genes or the material under investigation as well as antipsychotic treatment.

In our genome-wide microarray study (Illumina) we have investigated the left superior temporal cortex and left anterior cingulate cortex in 10 patients with schizophrenia and 10 healthy controls. In a second Laser Capture Microdissection study we dissected pyramidal cells from hippocampus CA4 and performed genome-wide microarrays (Affymetrix).

In the superior temporal cortex and anterior cingulate cortex we found a downregulation of a large group of immune-related genes and could confirm these alterations by quantitative real-time PCR. In the pyramidal neurons of the hippocampus we also found immune-related genes to be downregulated, along with alterations in transcription factors and acetylcholine receptors.

Downregulation of immune-related genes in the brain of schizophrenia patients may occur in several brain regions and may be related to diagnosis or antipsychotic treatment. In contrast to findings in the blood, down-regulated immune-related genes in the brain are related to disturbances in synaptic transmission and plasticity, for example alterations of NMDA receptor mediated plasticity and free radicals.

The question of the cause of these findings, like an immune-deficiency or inflammation processes during neuronal development cannot be answered in post-mortem studies of elderly, chronic schizophrenia patients, which received antipsychotics for decades.

Increased incidence rates of psychotic disorder have been consistently observed in immigrants with significant variability across ethnic groups. These findings have been attributed to cross-cultural biases, i.e. misinterpretation of culturally appropriate ideas leading to an overestimation of these disorders among ethnic minorities. Another alternative explanation constitutes the selection hypothesis positing that the increased rate is due to selective migration of predisposed people. We will present two studies that aimed at testing these hypotheses by examining (a) whether risk factors for psychosis are more prevalent among future emigrants, and (b) whether psychotic symptoms differ in severity and nature according to ethnic group. The first study was conducted among a cohort of 50 087 conscripts who were assessed at age 18 on cannabis use, IQ, psychiatric diagnosis, social adjustment, history of trauma and urbanicity of place of upbringing. Through data linkage we examined whether these exposures predicted emigration out of Sweden. The second study included 301 first episode psychosis (FEP) patients within a defined catchment area in Montreal, Canada. Patients were administered scales for the assessment of positive and negative symptoms, as well as general psychopathology. Symptom scores of the reference group were compared to those of patients with different ethnic backgrounds. The results of these studies will be discussed in light of candidate explanations for the increased risk of psychotic disorder among immigrants. Future avenues using data from the EUropean Gene-Environment Interaction (EU-GEI) project will be proposed.

The Nordic countries are highly developed welfare states with a long tradition of egalitarian health and welfare policies. The Nordic welfare model is based on tax-funded public services and a high level of social protection. Improvements in mental health and mental health services have been on the agenda in these countries during recent decades. Mental health services have undergone a thorough reform, from an emphasis on psychiatric institutional care to the current emphasis on out-patient care and social participation. The reduction in numbers of hospital beds for psychiatric patients, especially for those with long-term disorders, has been met by an increase of psychiatric treatment in primary care and by growth in housing institutions provided by social care. In spite of the reforms, there is still a considerable life expectancy gap between people with mental disorders and the rest of the population.

A core element of Nordic mental health policies is a focus on mental health promotion, preventive actions and social inclusion. Acknowledging that determinants of mental health often lie in non-health domains such as social and family policies, labor policies and education policies, the Health in All Policies approach has been developed. Health in All Policies is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. In Europe, different models and best practices have been developed to secure that public policies across sectors systematically takes into account the mental health implications of decisions and avoids harmful mental health impacts. This includes effective safeguards to protect policies from distortion by commercial and vested interests and influence. Especially in times of economic hardship, nonhealth policies may have a decisive impact on populations’ health including mental health.

Accumulating evidence supports the view that deregulation of the immune system represents an important vulnerability factor for mood disorders and that this may be a common pathophysiological mechanism that underlies the development and progression of these disorders, at least in a subset of patients. Furthermore, mood disorders are also often accompanied by chronic medical conditions related to immune dysfunction such as autoimmune diseases, diabetes and atherosclerosis. The reviewed data suggest that if immune biomarkers exist for such immune abnormality they may be found in raised macrophage/monocyte inflammatory activation patterns (monocytosis, high inflammatory gene expression, raised GRβ/GRα ratio, and high levels of pro- and anti-inflammatory monocyte/macrophage derived cytokines in serum/plasma). This activation of the inflammatory response system may be suggestive for microglia activation as these cells are the macrophages of the brain, although evidence from human studies is still lacking. However, animal models of mood disorders suggest that such monocyte/microglia activation could be seen as the result of a combination of genetic predisposition and environmental factors. It has been proposed that the abnormal immune activation state of these cells is reached after an aberrant development/maturation from precursors. In the case of microglia, this in turn may lead to impaired neuronal development. This developmental/maturation abnormality may render the cells more vulnerable to subsequent stressors such as inflammatory stimuli thereby leading to increased incidence of mood disorders.

The evolution of the Romanian Health System during the last twenty years was marked by the transition from an overly centralized system to a social, self-financing system, facing many economic and administrative problems. Between the congestion of issues that plagued the new system, and the authorities’ slow response to these issues, a bottleneck has been produced, which is currently preventing the health system from providing appropriate services to any of its affiliates.

The current crisis arose as a result of perpetuating a reactive instead of a proactive attitude toward the challenges of the health reform -- meaning that all problems were only acknowledged and considered after they had occurred, instead of being anticipated and planned for in advance. At the time that the reform was being implemented, profound changes were also occurring in Romania in domains other than health (such as government, education etc.), and it was not taken into consideration how these systems would interfere with each other. Problems quickly surfaced due to the state of general transition and the insufficiently planned division of resources among many, often unstable, networks. When faced with this, the decision-makers traded planning and analysis for post-hoc responding to the incoming problems, an attitude which over time has led to a loss of perspective, and a distorted view of the current needs and functions of the health system.

Starting with the year 1999, the health reform process has led to the rapid development of medical services in both public and private sectors. The general public became increasingly informed with regard to their options and available technologies, the demand for health services increased and the supply diversified. In the context of these rapid legislative, economic and social changes, absent a solid strategy to control and stabilize the swift development, the typical difficulties associated with the start of any reform slowly spiraled out of control, becoming harder and harder to contain.

The quick pace at which the health system developed modified the profile of the main players: health professionals were able to perform better, but at the same time bureaucracy and restrictions increased. Patients received better care and subsequently demanded more services, but at the same time the financiers became less able to accurately predict the medical services needed, and the cost of these services became harder to control. A general state of dissatisfaction emerged as a consequence, which the current institutional health system is not prepared to handle.

The proposed reform, if properly implemented, creates exciting opportunities: it promotes public-private partnerships in Romania, provides a better framework to inform the population about available medical services and health insurance options, and increases the involvement of the community in broad interest health issues. However, with the global economic crisis and escalating costs, the lack of vision and consistency on the part of the decision-makers and the lack of confidence on the part of the population when it comes to reform processes could pose a threat to the success of the new health law. To avoid that, it is necessary to have a clear understanding of the current structure and needs of the health system, and tailor the measures of the reform to fit and fulfill these needs.

It requires the development of coherent health strategy, aimed to create concrete and feasible objectives and to ensure protection against both threatening diseases and financial risks. Any desirable implementation strategy that would exploit the strengths and guard against the weaknesses of the proposed law should include measures such as standardizing the health system to the highest possible extent, resizing and reconfiguring it based on integrated health care services, and stimulating private health insurance as a complementary alternative for financing health services.

Cognitive impairments have a high prevalence in schizophrenia, and are important determinants of functional outcome and treatment responsiveness. They are well-documented in chronic schizophrenia patients but are already apparent before the onset of the disorder and are predictive of transition to psychosis. Cognitive Remediation approaches have proved to be effective in enhancing cognitive functions and functional outcome in multi-episode schizophrenia patients. Recent studies suggest that younger people with an early course of illness are even more likely to benefit from these interventions. Therefore, Cognitive Remediation approaches may be especially appropriate for early intervention in psychosis. However, there is still a paucity of studies that evaluated Cognitive Remediation in early psychosis patients and in those symptomatically at-risk for psychosis. Moreover, several approaches are summarized under the umbrella term Cognitive Remediation. Consequently, they differ in content, setting, and practical application. Therefore, it remains rather unclear which type of therapy works best for the specific treatment needs of these patients. Against this background, this presentation will summarize and critically discuss current CRT approaches and their efficacy in early psychosis and in at-risk mental states with regard to cognitions, symptom levels, and functional outcome. Furthermore, we will present novel treatments and study designs specifically developed for early intervention in psychosis.

In his presentation, Bert Johnson, president of EUFAMI, will speak about the needs and rights of people directly by mental illness from the perspective of the family. He will discuss, amongst a number of issues, the optimal balance between the promotion of the rights of the individual to full citizenship and the issue of social protection. Bert will highlight what he sees as some of the implications for those who are affected by mental illness when their individual citizenship rights are curtailed or taken away. Also, he will enunciate EUFAMI strong held view that the rights of any individual as set out in the UN Charter must always remain sacred and that legislation, at both national, European and international level must always have this as their core principle. Bert will also speak about some of the work EUFAMI and its members are undertaking which is related to the subject matter.