The coexistence of depression and diabetes has serious implications for self care and long term outcomes. Fluoxetine a SSRI antidepressant has hypoglycemic anorectic effects and potentially cause weight loss proportional to the degree of inial obesity. We studied the prevalence and severity of depression and the impact of its treatment with Fluoxetine on weight and glycemic control in poorly controlled depressed type 2 diabetics in an outpatient clinic in Mosul.

Forty eight type 2 diabetic patients with depression from a total of 180 diabetics seen from Jan - Sep/2003 were treated with Fluoxetine 20-40 mg daily for 12 weeks.

The prevalence of depression in type 2 diabetics is (32.22%). A significant difference was found between the mean weight, meam FBG at inclusion and 12 weeks post Fluoxetine, P < 0.001. HbA1c results available only for 28 patients and showed significant drop from a mean value of 8.8% to 7.9% after 12 weeks, P < 0.001.

Depression is common in diabetics and should be treated, preferably with SSRIs. A high index of suspicion is needed and should be considered among the risks that contribute to poor control. The future diabetic management guidelines should include routine screening for and treatment, of depression. Further larger studies seem worthwhile.

The ethical reasons for being conversant with EBM can be divided into clinical and economic aspects, each of which has ethical aspects which will be discussed. These arguments are well known, and relatively non-controversial. But there are also strong ethical arguments for not practicing EBM all the time, and this paradox will also be discussed.

All medical procedures have both specific and non-specific effects: dummy medicines can relieve severe post-operative pain, and dummy operations can relieve both cardiac pain and epilepsy. In mental health, these effects are well known, albeit difficult to quantify. Our most potent weapon in doing so is the randomised controlled trial (RCT), and ethical aspects of such trials will be touched upon.

We are left with problems of mental disorders where the supposed beneficial effects of an active drug – we will give the example of anti-depressants – is entirely non-specific. What are the ethical aspects of prescribing potentially toxic drugs for conditions where they have no specific effect? This is a major problem in both specialist mental health care and above all, in general medical care – where the bulk of antidepressants and sedatives are prescribed. There are major ethical problems here, which will be discussed.

The great revolution of bioethics has been the incorporation of the principle of autonomy to the ethical model and parts from the assumption of recognizing human beings as autonomous beings. A paternalistic, authoritarian ethics has been substituted by ethics of autonomy.

Some specific requirements are needed so that an informed consent can be achieved: competence and ability of the patient to understand and willingness to decide.

The WPA has made different Declarations specifying Psychiatric Ethics. Art Therapy has developed a specific set of ethical standards. The role of art making in therapy poses unique ethical dilemmas and concerns for therapists such as:

Confidentiability: Art expressions must be recognized as confidential communications. Permission to display, exhibit, publish or share art expressions must be obtained from either the patient or in the case of a child, the parent or guard.

Ownership: The patient owns the art created in art therapy.

The artwork of the patient, especially the plastic artwork is used sometimes with artistic and commercial aims, which raises ethical and even legal problems.

There is a large background institutional or private exhibitions of the so-called psychopathological art.

The work created by the patient belongs to him and only the patient/author of the artwork can, in principle, decides over its use.

If the patient agrees to display of his art expression in any form the therapist must be careful to consider if this is in his best interest based on the context.

Recent decades have witnessed a significant increase in the use of complementary and alternative medicine (CAM). This includes an increased interest in, and use of, CAM in mental health, both as a primary source of treatment, and to treat side-effects of conventional medication. In the UK and elsewhere, much of CAM practice is unregulated, and the evidence base is under-developed. Many patients utilising CAMs do not disclose this to their doctors, raising risks of drug and other treatment interactions. Ethical issues associated with the use of CAM for mental health include: patient choice and consent for therapies of unknown efficacy, potential risks and benefits of CAM (including who evaluates these), and equity in terms of accessing treatments which are not generally provided as part of state-funded health services. Doctors have an ethical obligation to familiarise themselves with the range of CAM therapies their patients may be accessing and the evidence base for such treatments, both to facilitate informed decision-making on the part of their patients, and to help to minimise any potential for harm.

Ethical concerns are of a growing importance not only in clinical practice and research, but also in publication process. Every presentation of scientific data should content clear statement disclosing any possible conflicts of interests (e.g., relationship of a researcher to pharmaceutical industry). Redundant publication such as publishing the results of the same trial in several journals under different titles is regarded unethical, as well as “salami slicing”, which is in fact step-by-step publication of partial results of a study (e.g., separately results in males and females, young and elderly etc.) just in order to increase publication output. All of co-authors must provide publisher with their written consent to avoid blind authorship. Only person significantly participating in the concept, design, drafting and reviewing of the study is eligible as an author. Others should be properly acknowledged. Fabrication of data, falsification, plagiarism and other frauds still occur in the scientific literature, although they are beyond any ethical limits.

Historical exclusion of personality disorders from the medical paradigm is reflected on the existence of the DSM-IV axis II for personality disorders. Personality disorders are perceived as substrates of vulnerability for axis I mental disorders such as depression, bipolar, anxiety or psychotic syndromes. A psychobiological perspective of this model of personality disorders is based on the study of genetic predispositions, of biological bases of personality traits and of the relationship of both with environmental precipitants.

Another psychobiological view of personality disorders is needed as a consequence of clinical evidence in borderline personality disorder (BPD). Most of the diagnostic criteria for this disorder are symptoms rather than traits and seem to be associated to several pathophysiological abnormalities. Serotonin dysregulation and glucocorticoid receptor dysfunctions among other biochemical findings have been reported in BPD. According to these biological findings, BPD could be included in a similar psychobiological framework than the axis I mental disorders.

Abstract not available at the time of printing.

During decades abstinence has been the only major treatment goal in addiction treatment; the efficacy of addiction clinics in general and treatment programs in particular usually has been evaluated with the aid of abstinence rates: the higher the number of abstainers, the better the treatment program. But for many of the patients suffering from addiction abstinence is not a very attractive treatment goal, for some of them not even an unattainable one. For many of our patients abstinence means weakness, handicap, stigmatization, a feeling of restraint, declining, inhibition, not being accepted, suppression, tension, being ill, social withdrawal, no fun, no relaxation anymore, isolation, etc.. In any case the term abstinence is strongly connected with abstention from, loosening of and distance to something. In this way a quite unattractive form of the nothing becomes the final goal of addiction treatment. Among others, this could be considered as one of the reasons of poor patient adherence in abstinence-oriented treatment programs. A way-out of this highly unsatisfactory situation for both, the patients as well as the therapists, could be a change of paradigms to abstinence-supported treatment. In abstinence-supported programs, abstinence is no longer the final goal but one of the important steps in order to reach other treatment goals according to an autonomous and mostly joyful life: on the basis of dimensional diagnostics, which are in contrast to classical categorical diagnostics not disease-oriented but phenomenology-, pathogenesis- and process-oriented, the patient and the therapist plan in dialogue accessible treatment goals according to the patient's deficiencies and resources; in this perspective abstinence is not the final aim but offers the patient a chance for transformation.

Naltrexone (NTX), an opioid antagonist, blocks intrinsic properties of substances that act on the mu, kappa and delta opioid receptor sites by competitive occupation. It is ascertained that alcohol acts on the opioid receptor sites. By blocking these sites, NTX prevents the reinforcing effects of alcohol consumption. Recent reviews of the effectiveness of NTX in the treatment of alcohol dependence agree that: a) NTX is effective in the treatment of alcohol dependence, especially with regard to the primary outcome parameter, i.e. relapse into heavy or uncontrolled drinking; b) NTX compliance probably is pivotal for successful alcohol treatment; c) There is some evidence that the combination of NTX and CBT (cognitive-behavioural oriented program) is somewhat more effective than NTX combined with supportive therapy; d) Also, there is some evidence that NTX can be of benefit to subgroups of alcoholics characterized by dual diagnosis, Type-II alcoholism or subjects with low level of clinical depression and alcohol dependence severity. Several strategies and hypothesis have been brought up in the literature, in which NTX compliance is subject of debate. Results of a current research about strategies to improve the effectiveness of NTX suggest that interventions aimed at enhancing medication adherence were more efficacy than strategies to increase the likelihood of taking NTX (“pill-count”).

Previous attempts to identify predictors for the treatment response in alcoholism have mainly concentrated on social and personality variables. Project MATCH was such an attempt which finally failed. The same holds true for similar attempts in pharmacotherapy. Therefore, we set out for a large oligocentre trial “Project PREDICT”. 432 patients are randomly assigned to treatment with acamprosate, naltrexone or placebo. At baseline patients are assessed with a battery of interviews, questionnaires and biological examinations (e.g. genetics). Specific emphasis is put on patients' individual pathways into relapse. It is determined whether relapse drinking respresented a positive reinforcer (“reward craving”) or a negative reinforcer (“relief craving”). This is assessed with questionnaires, the startle reflex and fMRI. We hypothesize, that patients who are a priori identified as “positive reinforcers” better respond to naltrexone. Negative reinforcers should benefit most from acamprosate.

All patients have been included by now. Preliminary analyses suggest that it seems indeed possible to distinguish between the two craving types. The equivalent of positive reinforcement in the startle reflex correlates with fMRI responses to cues with a positive valence of about 0.7. These methods might offer a platform for a targeted pharmacotherapy in alcoholism.

Prenatal exposure to severe famine has been associated with an increased risk of schizophrenia and affective disorders. We studied the morbidity risk for addiction in persons being exposed to famine during gestation in the Dutch hunger winter of 1944-45 in a case control study. For each trimester of gestation the birth ratio of patients and inhabitants prenatal exposed to the famine was compared to the ratio of patients and inhabitants born in the same period in the subsequent year. Our findings indicate that the first trimester gestational exposure to the famine period significantly increased the probability of developing addiction in later life in male individuals (OR=1,62; 1,18 - 2,74; p<0.01). In addition to the time and gender specific effects on the vulnerability for schizophrenia and affective spectrum disorder during gestation a similar effect seems to exist for addiction disorders as another indication for the disastrous influence of severe malnutrition on brain development and maturation.

In this paper I distinguish between two claims. 1) That subjects or selves are constituted by narratives. 2) That narratives play an essential and irreducible role in capturing subjectivity. I will argue that whilst the reduction of selves to narratives - in claim 1 - fails, claim 2 helps highlight the essential role of normativity in characterising subjects' mental lives. But the irreducibility of normativity places principled limits on the range of phenomena on which psychiatry can aim to shed light.

Subjectivity is an essential part of psychiatry, often forgotten in daily clinical work, despite the remarkable demonstrations done by the German school of phenomenology in the 20th century concerning this aspect of our specialty.

As a matter of fact perception of internal and external time, social space, relationship to pleasure and religion are essentially linked to culture. One of the most important determinants of culture is economy, which is itself largely determined by geography and history of the region.

The author will present the intertwine existing between these variables, and its impact on the clinical picture and the subjective interpretation of the patient, taking depression as a model for this theoretical construction.

Evidence Based Medicine and Psychiatry has had a (controversial) success in the last years. Narrative Based Medicine and Psychiatry has emerged subsequently as a complementary (not an alternative) movement. The object of this presentation is the following question: To what extent are these movements something new for medical science? Or, to what extent are they simply the current expression of an age-old tradition in the history of medicine and psychiatry? Our objective here is to review a series of possible (and scantily commented) historical antecedents, not so much of Evidence- and Narrative- Based Medicine and Psychiatry in themselves, as of the scientific aspirations and the human needs that are behind them.

This paper is included in the Research Project Ref. HUM2005-02105/FISO, Ministerio de Educación y Ciencia (Ministry of Education and Science), Madrid, Spain.