The EPA has undergone substantial structural changes in the last few years. It currently consists of 2 councils, the council of the individual members as well as the Council of the representatives of the National Psychiatric Associations. The aims of this presentation are to highlight ongoing projects of the Council of the NPAs on one side and raise important questions for the future as to how the EPA can develop and what role the NPAs will play in European Psychiatry in general.

The Council consists of 34 Society/Association members from 30 European countries, representing 77,000 psychiatrists. The mission of the Council of NPAs is to support the general mission of the EPA and promote the highest possible quality of professionals, training and services for psychiatric patient care throughout Europe. Its aim is to initiate programs for working groups, prepare guidance papers on different relevant subjects to psychiatry and psychiatrists and furthermore, to support scientific symposia.

The aim of this symposium is to initiate a fruitful discussion on timely topics central as well as to EPA as to European psychiatry in general.

The Great Depression that hit the economies of most countries in the world since 2008 has had a particular impact in Europe. Among his most notable consequences are rising unemployment, debt, housing instability, impoverishment, and increased social inequalities. All these factors have a negative impact on the mental health of the population, and in fact, numerous studies confirm increased rates of depression, anxiety, stress, addictive behaviours, suicide, and deterioration of family relationships in many European countries. Coinciding with these events, austerity policies have led to a limitation of social and health resources available to a population affected by the crisis, just when these resources were most needed. However, History has taught us that times of crisis are also times of opportunities. The Great Depression and its aftermath may represent an opportunity to change the way healthcare planning on mental health is performed as well as the implementation and management of psychiatric services. It is timely to address long-postponed issues such as the coordination of health and social services, the culmination of the transition from hospital-based care to community care, the provision of psychiatric care in the context of Primary Care, the evaluation of services from the perspective of cost-effectiveness, the training of psychiatrists to meet the needs of a population that not only wants or needs a purely psychopharmacological care, or the fight against stigma. These elements will be addressed in this presentation, taking into account the availability of data to support an evidence-based mental health planning across Europe.

Parental psychopathology is a known risk factor of psychological and behavioral difficulties in the offspring, however several questions regarding the nature of this relationship are yet unanswered. First, it is not clear whether the timing of parental psychopathology is relevant and particularly whether pregnancy is a period of particular vulnerability. Second, the age when the relationship between parental psychopathology and children's behavior can be observed is not yet determined. Third, the association between parental psychopathology and children's outcomes is heterogeneous, and may vary with other factors including family socioeconomic position. Based on data from the French EDEN cohort study (2000 mother-child pairs followed from pregnancy onwards, since 2004-2006), this presentation will examine the longitudinal association between maternal depression and tobacco use and children's temperament (assessed by the EAS scale at age 18 months) and psychological difficulties (assessed by the SDQ at age 3 and 5 years), as well as the moderating role of familial socioeconomic factors. Findings show that maternal tobacco use in pregnancy as well as maternal depression in pregnancy or persistent over time are associated with children's difficult temperament and behavioral difficulties (particularly symptoms of hyperactivity and inattention). Associations between maternal addictive behaviors and depression and children's outcomes may be stronger in case of family socioeconomic difficulties. These results highlight the importance of tobacco use in pregnancy and depressive symptoms that may be of subclinical level with regard to children's behavioral outcomes. The intergenerational transmission of psychopathology may be heightened in case of socioeconomic difficulties.

Youth with high callous-unemotional traits (CU) are at risk for early-onset and persistent conduct problems. Research suggests that there may be different developmental pathways to CU (genetic/constitutional vs environmental), and that the absence or presence of co-occurring internalizing problems is a key marker. However, it is unclear whether such a distinction is valid. Intermediate phenotypes such as DNA methylation, an epigenetic modification regulating gene expression, may help to clarify etiological pathways. This is the first study to examine prospective inter-relationships between environmental risk (prenatal/postnatal) and

DNA methylation (birth, age 7 and 9) in the prediction of CU (age 13), for youth low vs high in internalizing problems. We focused on DNA methylation in the vicinity of the oxytocin receptor (OXTR) gene as it has been previously implicated in CU. Participants were 84 youth with early-onset and persistent conduct problems drawn from the Avon Longitudinal Study of Parents and Children.

For youth with low internalizing problems (46%), we found that (i) OXTR methylation at birth associated with higher CU (age 13) as well as decreased experience of victimization during childhood (birth–age 9), (ii) higher prenatal parental risks (maternal psychopathology, criminal behaviors, substance use) associated with higher OXTR methylation at birth and (iii) OXTR methylation levels were more stable across time (birth–age 9). In contrast, for youth with high internalizing problems, CU were associated with prenatal risks of an interpersonal nature (that is, intimate partner violence, family conflict) but not OXTR methylation. Findings support the existence of distinct developmental pathways to CU.

To evaluate whether different evolutive profiles of depressive symptoms exist from pregnancy to 2-years postpartum, and whether early postnatal depressive symptoms (PNDS) predicted child developmental outcome independently of later maternal depressive symptoms, we studied data issued from a french prospective, longitudinal study, MATQUID (Quid of Maternity). Up to 598 mothers and children were followed-up from pregnancy to 2 years, with repeated measures of PNDS (Edinburgh Postnatal Depression Scale-EPDS; Center for Epidemiologic Studies Depression Scale-CESD) and of the children development (Bayley Scales II). Semiparametric mixture models have identified 4 distinct trajectories of maternal depressive symptoms (never depressed; depressed only during the postnatal period; depressed throughout the follow-up period; highly depressed throughout the follow-up period). Associations between 6 week PNDS, subsequent depressive symptoms and child development were evaluated with multilevel modelling techniques. Children of mothers with 6 week PNDS were significantly more likely than children of non- symptomatic mothers to have poor cognitive outcome, association reduced to trend level when adjusted for later maternal depressive symptoms. The main limitation of the MATQUID cohort is the low level of risk for PNDS, so these results cannot be extrapolated to all types of populations. Nevertheless, different subtypes of evolutionary profiles of PNDS have been found and the effects of early PNDS on infant development seem to be at least partly explained by subsequent depressive symptoms. These results emphasize the absolute necessity of using integrative models, both in research and in clinical practice, incorporating the evolution of parental mental health and the children development.

Physical growth is considered one of the most important indicators of child health. Stunting caused by undernutrition is indirectly responsible for more than half of deaths among young children globally and can have adverse developmental repercussions. Until recently, research on risk factors for suboptimal growth has focused primarily on micronutrient deficiencies and child illness, with little attention paid to potential social predictors such as maternal mental health. The current presentation summarizes the 1) results of a child health study from Brazil showing an association between maternal depressive symptoms and stunting in children under two years of age, 2) similar findings from a systematic review and meta-analysis that pooled results from seventeen studies in eleven low- and middle- income countries, 3) results from a longitudinal US representative sample that found maternal depressive symptoms at nine months postpartum related to an increased odds of a child being <10% in height-for-age at ages four and five, and 4) a discussion of potential mechanisms that could explain these associations. We will compare our results and discuss them in the context of other findings examining growth trajectories. Our results suggest that maternal depression and depressive symptoms during infancy can impact physical growth in early childhood in a variety of settings, both developed and developing countries. Prevention, early detection and treatment of maternal depressive symptoms during the first year postpartum may prevent stature deficits in later childhood.

Several lines of evidence suggest that individualsliving in inner cities of industrialized countries suffer from an increasedburden of mental distress, and this may be specifically pronounced amongminorities. We investigated individual levels of mental distress in individualswith and without minority statues in an inner city district of Berlin. We foundassociations with poverty in the neighbourhood (as measured by the percentageof inhabitants receiving public welfare) above and beyond the effects of localethnic composition and individual differences in income and education. Wefurthermore observed that this effect of local poverty on mental health is morepronounced in subjects with versus without minority Status. Our observationssuggest that the high level of mental distress in subjects with minority statusliving in inner cities is associated with economic effects within the local neighbourhood, beyond the effects of individual resources, emphasizing the need for targetedinterventions.

Rates of severe mental disorders such as schizophrenia substantially increased among migrants to Western European countries, particularly when living in a neighbourhood in which they can receive little social support. We assessed rates of self-rated mental health problems as well as individual and neighbourhood factors such as income and joblessness. Furthermore, the evaluated intercultural openness of the mental health system in the inner city of Berlin. We found that beyond individual factors, neighbourhood poverty substantially contributes to increased rates of self-reported mental health problems in the inner city of Berlin. Mental health institutions are often not geared towards the needs of migrants, with a substantial number of hospitals, policlinics, general practices and consultation offices reporting a need for guidelines, education as well as financial support for translators.

With increasing globalisation, the migration of people is being affected by migration of resources as well Individuals have multiple cultural identities and will need careful assessments. Cultures play a significant role in the way in which mental illnesses of all kind present. These are strongly influenced by the type of cultures individuals come from and settle down. Acculturation affects the mode of presentation. Potential impact of culture on therapeutic alliance – whether in drug management or in psychotherapy will be described in relation to managing migrant patients who have specific needs. Cultures determine and affect patterns of child-rearing as well as cognitive development of individuals and their world view. When ill, culture determines how individuals and their families explain what has gone wrong and how emotional distress is expressed. It is critical that clinicians are aware of the role culture plays not only in defining these experiences and clinicians should take this into account in the process of developing therapeutic interventions and strategies which will be culturally acceptable and accessible. Cultural factors also play a major role in therapeutic engagement and alliance, in psychopharmacological interventions as well as in delivery of specific psychotherapies. It is likely that prevalence of various psychotic disorders will vary, as will pathways into care and patterns of help-seeking.

Present day Psychiatric nosology allows for three syndromes of psychopathological sadness segregated by intensity and stability of symptoms as well as vegetative and premorbid particularities. Yet it is mostly a matter of seeing the advancement of the disorder (duration and presence of polarity) rather the particularity of the episode that roots the possibility of a diagnosis. We propose an exegesis of the various psychopathological studies contributions that might help segregating phenomenological particularities of each episode. Ultimately we aim shed light on the differences that were ground to the nosology so that increased clarity is reached for diagnosis and research.

From a phenomenological point of view, all addictions lead to the final collapse of the Dasein structure (the constitution of the Being-at-the-world-with-others). Subsequent to having travelled down many different psychopathological pathways, many addicts remain without the spatial-temporal 'here and now” dimension. This makes it impossible for them to stay in a space-with-others and to project themselves in time. The result of this time/space cleavage is emptiness. It is very difficult to treat this existential situation, which is characterized by patients frequently dropping out of conventional treatment, the loss of the being-at-the-world structure, boredom, emptiness, dread, anger, lack of meaning, loneliness, and isolation. In this paper Dasein Group-Analysis (an original interpretation and application of Binswanger's Dasein-Analysis) is proposed and discussed. Unlike Dasein-Analysis, this approach applies phenomenology beyond the classic pair of analyst and patient, to a group of people made up of doctors and patients, in which everyone is simply a human being at the world.

Cultures play a major role in identifying abnormality, allowing idioms of distress, expression of distress and help-seeking. It is critical that clinicians are aware of differences between disease and illness. Patients are interested in illnesses which cannot be easily classified whereas doctors are interested in diseases which often can be diagnosed easily and classified. For the first time DSM-IV introduced an awareness and understanding of cultural factors thereby signaling recognition of their role and value in diagnostic assessment and treatment planning. Clinical experience since their introduction has revealed that there is a heterogeneity in the way they are used and without doubt researchers, clinicians and administrators use them in different ways. An open ended way of exploring the impact of cultural factors can lead to an understanding of the cultural factors so that patient's cultural identities can be taken into account without clinician stereotyping. Family and carers’ perceptions are equally important and they may also contribute to cultural understanding. Classification of culturally influenced diseases can add a further complicated dimension in understanding the role diagnosis can play and culturally sensitive interventions. In addition culturally bound syndromes need a fuller detailed discussion. Thus training guidelines for clinicians and researchers need to be developed separately. Supplementary categories may need to be developed for special populations such as children and adolescents, the elderly, and immigrants, asylum seekers and refugees. Thus clear cultural assessments may lead to better classifcations.

Genetics and neurobiology of anxiety and depression

Major Depressive Disorder, and related anxiety disorders, are familial conditions whose mechanisms are largely undiscovered. Approached to dissecting their heterogeneity and better understanding their mechanisms include better phenotypic measurement, prospective longitudinal assessment and the use of large population-based cohorts. We demonstrate using data from a prospective cohort study (The Bipolar Family Study) of people at high genetic risk of mood disorder, the functional, structural and connectivity imaging changes associated with the later development of depression. In addition, we use a novel genetically-informed approach to the study of genome-wide association data that utilises the correlation between cognitive, personality and other phenotypic measures of depression – to aid gene discovery in the disorder.

Major depression is associated with abnormal self-processing (i.e self criticism, rumination) characterized by increased activity in cortical midline structures.

Among these structures the Medial Prefrontal Cortex (MPFC) has focused research attention.

Connected with several cortical and sub-cortical structures, the MPFC activity may predict clinical outcome of depressed patients treated with antidepressant. We have recently showed that the level of activity of MPFC before treatment predict clinical remission at 24 weeks in patients receiving antidepressant.

Moreover the level of MPFC activity was not affected by antidepressant, suggesting that this region may constitute a trait marker of major depression.

Recent data emphasize that impaired self processing and MPFC may be observed in subjects with genetic vulnerability for affective disorders.

Thus we will present data showing that subjects with the short allele S of the 5-HTTLPR promoter gene have increased activity of MPFC during self processing. Consistent with gene x environment interaction hypothesis, the degree of Amygdala activity in S careers was modulated by exposure to life stress events and self processing.

Moreover we will discuss the relationships between self-esteem, social stress and the changes in MPFC activity related to exposure to social threat.

Overall our talk will emphasize the role of MPFC in the pathophysiology of depression and the multiple determinants (genetic, environmental exposure, social context) of its impairment in affective disorders.

Clinical interviews are typically used in the assessment psychosis and related clinical symptoms. However, these measures are limited by recall bias and averaging, and thus important information is lost. Ambulatory real-time monitoring devices have the advantage of providing detailed and sensitive information about symptoms. This can provide valuable information about change and fluctuations in symptoms across time. Suicide represents a substantial problem in psychiatry, but little is known about the immediate triggers of suicidal ideation. Psychological theory suggests that the instability, in addition to the intensity, of depressed mood may be an important risk factor for the development of suicidal ideation. Mobile phone-based assessments may allow for a more accurate measure of suicidality and mood across time. In this presentation, a new smart phone software application (ClinTouch) for the assessment of psychotic and related symptoms will be described. Research investigating the feasibility, acceptability, and limitations of mobile-phone based assessment will be discussed in relation to people with psychosis. Mobile phone-based research investigating the short-term predictors of thoughts about self-injury will also be considered. The talk will finish with an outline of how mobile-based assessments could be applied in clinical settings.

The type of data collected in ESM/EMA studies are usually referred to as nested data. For example, if participants provide data every day for two weeks, this would be described as ‘days nested within participants” and would be called a two level data set. Similarly, if participants provided multiple observations each day for two weeks this would be described as ‘observations nested within days nested within participants” and would be called a three level data set.

Such data cannot be analyzed using OLS multiple regression (e.g., the data provided each day by each participant is a unit of analysis) because such analyses assume that observations are independent, and they are not. Moreover, although some OLS analyses may take such dependencies into account, they fall short in other ways, e.g., they do not model error properly.

Analyzing such data structures requires the use of specific techniques that are referred to as multilevel modeling. In such analyses, relationships at all levels of analysis are modeled simultaneously. For example, in a two level model (days nested within persons), we could model within-person relationships between stress and symptom expression, and then model the between-person differences in the strength of these within-person relationships. Who reacts more strongly to stress, who reacts less strongly? Within- and between-person measures can be continuous or categorical, and they can be combined, and temporal dynamics at either level of analysis can be examined to reveal mechanisms underlying symptom expression.