What are the aesthetic characteristics of badness? Is repulsion the only reaction to the wickedness, mess and disorderliness characterizing it? Or can it, depending on particular conditions, generate fascination? How does it challenge the clinical practice?

One of our analyses deals with the many meanings and uses of the term, in the moral as well as in the aesthetic sphere, referring to the breaking of the rules in both fields.

Besides an initial interpretation of badness, related to something which our mind cannot contain or make sense of, we also consider it as a legitimate aesthetic value. It is then the sublime and tragic categories that allow us to grasp the fascination and awe, the difficulty of judgment and the pleasure, due to the excessiveness, the disproportion, and the playing on the edge of the norms.

We examined the roles that the category of badness, as well as those of the sublime and tragic, play vis-à-vis the category of madness, on both the patient's and the therapist's side, on the diagnostic front and on the therapeutic one. To this purpose, we referred to some clinical and artistic, narrative and pictorial examples.

This contribution provides a systematic review on recent developments in psychological interventions for bipolar disorder. The main focus of research to date has investigated the role of different psychotherapeutic approaches (cognitive behavioural therapy, family focused therapy, interpersonal and social rhythm therapy, psychoeducation) as an adjunct to pharmacotherapy for remission and relapse prevention. The review will assess efficacy and effectiveness of these interventions, their common ingredients, limitations and predictors of outcome. It will further explore the potential role of psychological interventions for primary prevention of bipolar disorders in high risk children and adolescents. Suggestions will be made for future work in these areas.

Suicide is well represented in the WHO mortality databases, providing the opportunity to study and discuss how ethno-genetic, cultural, religious, economical and political issues may influence suicide rates in different regions and countries. The problem is that all these factors act together and often with contrasting effect. Suicide rates in Europe vary widely - from about 30 per 100000 of population in Lithuania, Russian Federation, Belarus and Kazakhstan to about 1-2 per 100000 in Cyprus, Azerbaijan, Georgia, Armenia and Greece. It is possible to see from the map, that suicide rates diminish when moving from North to South and from East to West. This may be discussed within the so called “Finno-Ugrian hypothesis”. Gender is one of the issues most widely discussed in suicidal behavior. Across Europe males commit suicides 3-5 times more often than females. Dramatic changes in suicide rates on the post-soviet space are associated with male suicides, while female suicides remained almost unchanged. One explaination is a higher susceptibility of males to socio-economic stress while females seem to be more protected. There is a general rule that suicide rates go up with increasing age. In countries like Ukraine, suicide is significantly higher in rural than in urban areas. Other factors influencing suicides are seasonality, alcohol and substance abuse in the given population. Life-stress and its equivalents seem to be very important, as many other conditions (like cardiovascular and cerebrovascular diseases and accidents) have the same pattern as suicide when studying mortality rates across Europe.

Many European countries have a national suicide preventive programme. In June 2008, a new national programme for suicide prevention was approved by the Swedish Parliament in Sweden. One of the nine strategies in this programme is an assignment called ‘Lex Maria’ - to report all suicides that occur within or 28 days after contact with the healthcare system to The National Board of Health and Welfare (NBHW). Lex Maria guarantees that a systematic evaluation will always occur, providing opportunities to identify components which can be improved when treating suicidal patients. All Lex Maria reports are registered in a separate database at NBHW, allowing systematic analysis at a national level. The methodology used in this analysis will be presented, with examples of individual cases.

Analysis of all suicide cases, which occurred in Sweden in 2006 within the health care system, uncovered the following areas which should be improved when working with suicidal people:

• • Better routines for suicide risk assessment;

• • Better routines for documentation of suicide risk assessment and changes in patients mood;

• • Better routines for the transfer of information within the same unit;

• • Better communication between units to ensure correct transfer of information;

• • Better routines for collaboration between care givers to ensure a continuity of care.

Suicide, particularly in the case of current major depression, is quite common among patients who contact their GPs some weeks or months before their death. However, prior studies have shown that GP’s education, regarding the diagnosis and treatment of depressive disorders, can reduce suicide mortality in the given area served by trained GPs. The aim of our present study was to evaluate the effectiveness of a depression-management educational program for GPs in a region with a very high suicide rate (over 50 per 100.000) in Hungary. Twenty-eight GPs and their lead nurses, servicing 73,000 inhabitants in the region of Kiskunhalas, participated the 5-year educational program together with estabilishment of a Depression Outpatient Clinic and psychiatrist telephone consultation service. The annual suicide rate in the Kiskunhalas region decreased from 59.7/100.000 (5-year preintervention average) to 49.9/100.000. This decrease was significantly greater than both the county and whole Hungary (p=0.001 and p=0.001, respectively). However, the increase of antidepressant prescription was greater in the intervention region compared with both the county and whole Hungary and in women compared with men (p=0.02). There was no change in alcohol-related deaths or rate of unemployment in the intervention region during the whole study period (1996-2000 vs 2001 and 2005). The findings support earlier studies showing that continuous GP education on diagnosis and treatment of depression is an effective method of suicide prevention. The high importance of alcoholism in local suicides was unanticipated and not addressed, suggesting that optimal suicide prevention plans must also consider major local risk factors.

The European Alliance Against Depression (EAAD) is a 4-level, community-based intervention programme to improve the care of depressed patients and prevent suicidality in Europe (1). Effects of this intervention concept have been evaluated in the intervention regions concerning the number of suicidal acts as primary outcome (2) but also concerning several other aspects, such as changes in attitudes towards depression in the general population, prescription rates of antidepressants or media coverage. Results provide first evidence that this intervention concept is highly cost-efficient. The European Commission listed EAAD as a ‘best practice’ model in its Green Paper (European Commission 2005).

This presentation will give a brief overview of comparison of DSMIV and ICD10 classification systems for mental and behavioural disorders. It will summarise what work was carried out in developing these systems in terms of their cross-cultural validity and reliability. It will also review the subsequent research into the validity and reliability of these systems. Finally some of the relevant approaches and methods would be discussed in relation to the issue of cross-cultural validity and reliability of diagnostic classification

Psychiatric and psychological testing are used extensively in both clinical and research contexts, with the goal of providing an objective indication of the construct being measured. At the same time, it has long been recognized that there is no such thing as a culture free or even fair test, to the extent that cultural bias-the constant and systematic statistical error due not to chance but to ethnic group membership-can seriously undermine the validity of a psychological or psychiatric test. The very construct being measured may not have a culturally compatible equivalent, or, relatedly, the behavior sampled in a given item or combination of items may not be associated with the construct in question in the same way across all cultures. In addition the means by which the behavior is sampled-the instrument construction, the sorts of questions or their structure, for example-can vary in familiarity across cultures. Finally, the individual items themselves may be poorly or ambiguously translated, may be predicated on specific cutlural norms, or, indeed, the meaning of the item can vary cross-culturally. Finally, sampling bias pertains to the representativeness of the sample, however, this is all the more complex given that constructs such as “race”, “ethnic group” and so forth are often poorly defined and ambiguous, and thus who is and who is not included in a given group may further undermine the validity of the test. Despite these difficulties, concrete steps can be taken to increase the cultural validity of the test used.

For a long time it was assumed that depressive disorders were a classic western problem specific to industrial states. However, the World Bank discovered in a study as early as 1993 that depression in Third World countries was already fifth on the list of illnesses which comprise the largest contribution to the Global Burden of Disease. Affective and behavioural disorders as well as somatic complaints represent the three central categories of symptoms in depression. In western cultures an affective disorder is seen as the main characteristic of a depression, whereas in other cultures different symptoms can be in the foreground. The increase in supraregional communication and cooperation as well as the worldwide increase in immigrant populations demand that cultural aspects are considered in the diagnosis and treatment of depression. Physicians need to consider the cultural background of their patients in order to achieve an optimal therapy. If the sociocultural aspects, which cannot always be fully appreciated, of a culturally sensitive diagnosis are not taken into consideration, this can lead to an artificial prevalence of the disorder by making false diagnoses. In order to minimize these mistakes, the guideline for judging cultural influencing factors should be used to complete the diagnosis.

Not only the development of culturally adequate therapy concepts and institutions, but also the expansion of knowledge about the psychopathology and epidemiolgy of psychic disorders, e. g. of depression in immigrant groups and the examination of their use of treatment facilities, are the goals of cross-cultural psychiatry and psychotherapy.

In an ongoing attempt to improve efficacy of electroconvulsive therapy (ECT) while minimizing side-effects, both different electrode placements and stimulus parameters have been studied. It has been shown that the traditional bitemporal electrode placement and modern techniques such as bifrontal and unilateral ECT are efficacious, depending on the stimulus used. Modern ECT-devices deliver a square wave brief pulse stimulus. An unresolved issue in the use of brief pulse stimulation concerns the optimal pulse width. It has been suggested that the use of a stimulus with an ultra brief (UB) pulse width, i.e. 0.3 ms, is substantially more efficient in seizure induction, thus needing less energy, and producing less cognitive side-effects than standard pulse width (i.e. 0.5-2 ms) stimulation. There has been a concern, however, of lower antidepressant efficacy of UB ECT, with patients needing additional treatment sessions. Moreover, it has been suggested that the diminished antidepressive efficacy is encountered solely with the combination of an ultra-brief pulse width and bilateral electrode placement, as compared to unilateral UB ECT or standard pulse ECT. In a randomized trial, the antidepressive efficacy and cognitive side-effects of bifrontal and right unilateral UB ECT were compared. It was shown that, using an ultra-brief pulse width, BF ECT is as efficacious as UL ECT, although patients receiving UL ECT achieved response/remission-criteria after a smaller number of treatments. In both treatment conditions there was an improvement of cognitive function, both during and after the treatment course.

The efficacy of electroconvulsive therapy (ECT) is widely recognized and indications are well defined for acute treatments. Surprisingly, the use of continuation and maintenance ECT (M-ECT) is uncommon after acute remission. This is partly because of the scarcity of scientific evidence. Indications are poorly defined and the practice is based on case reports and small open studies. Recent data suggest that M-ECT is a viable treatment option in severe affective and psychotic illnesses, especially in recurring, drug-resistant or medically compromised patients who suffer toxic effects with psychotropics.

Studies regarding the duration and frequency of treatment sessions are laking. The time interval between sessions and duration of treatment vary according to clinical requirements, and should be individualized. The length of treatment and deciding when to stop it are still uncertain. Controversial data about the relation between the frequency of sessions and diagnostic is found. An inverse relation between good prognostic factors for each patient and the frequency of M-ECT was described. During continuation and maintenance ECT, seizure threshold increases until a plateau not being clear when the plateau is reached and if it depends on other treatment variables.

The risk of cognitive dysfunction following M-ECT is one major concern. A transient memory and attention dysfunction are described after acute ECT. Recent studies seem to suggest that M-ECT is cognitively safe.

Electroconvulsive therapy (ECT) is a very effective treatment in severe psychiatric disorders. One of the main drawbacks of ECT is the high and early relapse rate in the absence of post- ECT treatment. After a successful ECT- course, pre- ECT pharmacotherapy is often continued. There is, however, no evidence that proves this strategy effective. The research on post- ECT treatments is limited, but promising. The available studies show that relapse rates can be decreased from more than 80% to 40% or less using either imipramine (1), the combination of lithium and nortriptyline (2) or continuation- ECT (3). The question whether or not starting antidepressants during the course of ECT ca further decrease relapse rates remains unanswered. Preliminary data show that starting antidepressants medication during the ECT course has no impact on post- ECT relapse. There is an urgent need for further research on treatment strategies to decrease the unacceptable high relapse rates after recovery from ECT.

During recent years magnetic (MRI) studies have pointed to a reduction in hippocampal volume in patients with severe depression. Volumetric changes reflect the actual number of days that individuals have been depressed (1). These findings have heightened interest in studying hippocampal structure and function in experimental animals, especially during and after electroconvulsive seizures -the most powerful of antidepressant therapies (2). Both before and after 2000, with the earliest report on hippocampal neurogenesis following seizures, findings of gliogenesis and synaptogenesis have been reported (3). During the last decade further studies of neurotropic factors have supported ideas of the role of neuroplasticity related to ECT in humans (4). All antidepressant medications, but not antipsychotics, have a similar, but weaker effect on hippocampal neurogenesis. We hypothesize that an induction of neurotropic factors leading to hippocampal neurogenesis may play a major role for the action of ECT (5).

Cognitive deficits are increasingly recognized as key features of schizophrenia, important determinants of poor psychosocial outcome and targets for treatment strategies. The huge literature on the topic made it clear that cognitive impairment is present in the majority of subjects with schizophrenia, is not an epiphenomenon of symptoms, is a risk factor for psychotic disorders and seems to contribute to poor functional outcome more than symptoms. However, relationships of cognitive impairment with symptoms, drug treatment and duration of untreated psychosis remain controversial and studies involving large cohorts of first episode schizophrenia patients are highly needed to address these topics adequately. The European First Episode Schizophrenia Trial collected demographic, clinical, psychosocial and cognitive baseline data in 498 first episode patients with schizophrenia, schizophreniform or schizoaffective disorder, with minimal or no prior exposure to antipsychotics, and in 220 healthy subjects, comparable with patients for age, sex, race and education level of parents. Z scores of the examined cognitive abilities (number of standard deviations below the comparison group means) ranged from -0.88 to -1.73. No association was found between the duration of untreated psychosis and cognitive impairment. Psychopathological dimensions were weakly correlated with cognitive impairment both at baseline evaluation and after six months of treatment.

According to EUFEST findings, cognitive impairment in patients with first-episode schizophrenia is moderate/severe, has no association with the duration of untreated psychosis, involves several domains of cognition, and is largely independent from psychopathology.