Prävalenz der Komorbidität Psychose und Sucht

Systematische Literaturübersicht der Wirksamkeit von Acamprosat, Naltrexon, Disulfiram und Nalmefen zur Trinkmengenreduktion und Aufrechterhaltung der Abstinenz bei Alkoholabhängigkeit

Das Ziel der vorliegenden Übersichtsarbeit ist die systematische Darstellung der aktuellen Evidenz zur Wirksamkeit von Acamprosat, Naltrexon, Disulfiram und Nalmefen für die Aufrechterhaltung der Abstinenz oder Trinkmengenreduktion bei alkoholabhängigen Patient:innen. Bezogen auf den Zeitraum 2005 bis 2020 wurden insgesamt 27 Studien identifiziert, die alle Einschlusskriterien (u. a. RCT, mind. 8 Wochen Behandlungsdauer) erfüllten. Es wurden überwiegend Hinweise zur Wirksamkeit von Nalmefen gefunden. Acamprosat war nicht (zusätzlich) wirksam. Naltrexon trug in kombinierten Interventionen einen zusätzlichen Nutzen bei, dies galt jedoch nicht für die Mehrzahl der Studien. Disulfiram war nicht wirksam darin, einen zusätzlichen Nutzen zur Erhaltung der Abstinenz beizutragen, im Vergleich zu Topiramat, einem Antikonvulsivum, jedoch effektiver. Die Ergebnisse stehen nicht im Einklang mit dem bisher bekannten Forschungsstand, der Acamprosat, Naltrexon und Nalmefen als überwiegend effektiv und sicher einstuft und Disulfiram als mäßig wirksam. Der pharmakologische Interventionsbedarf sollte bei Bestehen alkoholbezogener Probleme exploriert und ggf. erwogen werden, damit diesbezüglich Vorbehalte abgebaut und ein umfassendes und zugleich individuelles Behandlungsangebot geschaffen wird. Hinsichtlich der Trinkmengenreduktion sollten Aspekte der Schadensminderung als Behandlungsziel berücksichtigt werden.

The Outcome of Structured Education in Adults With Type 2 Diabetes Mellitus and Substance Use Disorder: A Literature Review

OBJECTIVE

Structured diabetes education for patients is a cornerstone of therapy; it empowers the patients by giving them appropriate tools for the self-management of the illness. The objective of this work was to determine how substance use disorder influences the outcome of structured diabetes education in patients with type 2 diabetes mellitus, and whether patients with substance use disorder are less likely to benefit because of their addiction issues.

METHODS

Only clinical trials involving substance use, which were randomized, in the context of type 2 diabetes mellitus were included.

RESULTS

Literature was only available for alcohol use disorder, and there were no studies available on any other recreational substance use disorders and its effects on structured diabetes education. Out of 3 relevant studies, in the context of alcohol use disorder, 2 studies identified alcohol use by the patients as a limiting factor in receiving structured diabetes education. One study did not show any impact of alcohol on structured diabetes education.

CONCLUSIONS

More high-quality randomized controlled trials with better sample sizes are required to say with confidence if alcohol use affects the patient's ability to participate in structured educational programs for type 2 diabetes mellitus management.

Motivational changes of cannabis use prior to and during the course of schizophrenia

BACKGROUND AND OBJECTIVES

We investigated subjective reasons/motivation for cannabis use in patients with schizophrenia (n = 51) compared to otherwise healthy cannabis users (n = 109). Moreover, we explored possible changes in the motivational patterns of both groups over time.

METHODS

A questionnaire was developed with six dimensions of motivations to use cannabis: affect regulation, relaxation, habit, structuring everyday life, creativity, and sociability. Participants filled out the instrument regarding their present and initial use of cannabis.

RESULTS

At the time of onset of consumption, groups only differed significantly in habit with higher ratings for patients with schizophrenia and cannabis use (SCH+CAN group) and in sociability with higher ratings for otherwise healthy users (CAN group). In respect of present use, the motivation to consume cannabis was significantly higher for affect regulation and structuring everyday life in the SCH+CAN group and for relaxation and sociability in the CAN group. With reference to time-based variations, the SCH+CAN group reported increased relevance of structuring everyday life over time. Furthermore, the CAN group reported increased importance of habit over time, whereas the SCH+CAN patients showed decreased ratings of habit over time.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Our findings must be considered preliminary because of the retrospective nature of the assessment. Nevertheless, the present study provides an indication of the time-dependent variation of cannabis-use motivation in schizophrenia, which may provide a better understanding of the functions of cannabis use within the population. Results argue for specific motivational based interventions for the group of schizophrenia patients with regular cannabis use. (Am J Addict 2017;26:122-128).

Effect of criminal justice mandate on drug treatment completion in women

BACKGROUND

Drug and alcohol abuse among women is a growing problem in the United States. Drug treatment is an effective way to manage the psychological, biological, financial, and social cost of drug abuse. Prior research has identified criminal justice referrals or coercion as a predictor of treatment completion among men but questions remain about the same effect in women.

OBJECTIVES

This study uses the Treatment Episodes Datasets Discharge 2006-2008 (TEDS-D) to explore the association between coercion and treatment completion among women.

METHODS

Analysis compared primary treatment episodes of coerced women to those who entered treatment voluntarily. A logistic model of the odds of treatment success was performed controlling for race/ethnicity, age, education, employment, primary substance of abuse, number of substances reported at admission, referral source, treatment setting, and treatment duration.

RESULTS

582 671 primary treatment episodes were analyzed comparing women with coercion referrals (n = 196 660) to those who entered treatment voluntarily (n = 390 054). Results of multivariable logistic modeling showed that coerced women had better odds of completion or transfer than women who entered voluntarily. However, this association was modified by treatment setting with better odds in ambulatory (OR = 1.49 [1.47, 1.51]) than in inpatient (OR = 1.06 [1.03, 1.10]) and worst outcomes in detoxification (OR = 0.89 [0.84, 0.96]).

CONCLUSION

These results dispute the broad effectiveness of legal mandates across all drug treatment settings among women. They show the need for further recognition of female-specific characteristics that can affect motivation and treatment success to better inform healthcare and judicial policies on drug treatment services for women.

Craving in patients with schizophrenia and cannabis use disorders

OBJECTIVE

Cannabis use is widespread among patients with schizophrenia despite its negative impact on the course of the disease. Craving is a considerable predictor for relapse in people with substance use disorders. Our investigation aimed to gain insight into the intensity and dimensions of cravings in patients with schizophrenia and cannabis use disorders (CUDs), compared with otherwise healthy people with CUDs (control subjects).

METHOD

We examined 51 patients with schizophrenia and CUDs and 51 control subjects by means of the Cannabis-Craving Screening questionnaire.

RESULTS

We found greater overall intensity of craving and greater relief craving in patients with schizophrenia and CUDs. Reward craving was greater in the CUDs group. Relief craving was associated with symptoms of schizophrenia in patients with schizophrenia and CUDs.

CONCLUSION

Our findings are in line with the view that aspects of self-medication or affect regulation may account (at least in part) for cannabis use in people with schizophrenia. A better understanding of the dimensions of craving may help to improve targeted therapeutic interventions that aim to reduce drug consumption in this difficult-to-treat patient group.

The impact of alcohol dependence on social brain function

The impact of alcoholism (ALC) or alcohol dependence on the neural mechanisms underlying cognitive and affective empathy (i.e. the different routes to understanding other people's minds) in schizophrenic patients and non-schizophrenic subjects is still poorly understood. We therefore aimed at determining the extent to which the ability to infer other people's mental states and underlying neural mechanisms were affected by ALC. We examined 48 men, who suffered either from ALC, schizophrenia, both disorders or none of these disorders, using functional magnetic resonance imaging while performing on a mind reading task that involves both cognitive and affective aspects of empathy. Using voxel-based morphometry, we additionally examined whether between-group differences in functional activity were associated with deficits in brain structural integrity. During mental state attribution, all clinical groups as compared with healthy controls exhibited poor performance as well as reduced right-hemispheric insular function with the highest error rate and insular dysfunction seen in the schizophrenic patients without ALC. Accordingly, both behavioral performance and insular functioning revealed schizophrenia × ALC interaction effects. In addition, schizophrenic patients relative to non-schizophrenic subjects (regardless of ALC) exhibited deficits in structural integrity and task-related recruitment of the left ventrolateral prefrontal cortex (vlPFC). Our data suggest that ALC-related impairment in the ability to infer other people's mental states is limited to insular dysfunction and thus deficits in affective empathy. By contrast, mentalizing in schizophrenia (regardless of ALC) may be associated with insular dysfunction as well as a combination of structural and functional deficits in the left vlPFC.

Increased gray matter density in patients with schizophrenia and cannabis use: a voxel-based morphometric study using DARTEL

Alterations in gray matter density as well as cognitive impairments are commonly described in patients with schizophrenia (SCH patients). Both gray matter deficits and cognitive impairments have recently been discussed to represent vulnerability markers of schizophrenia. The counterintuitive finding of better cognitive performance in patients with schizophrenia and cannabis use (SCH+CAN patients) compared to cannabis naïve patients is discussed as a reflection of lower vulnerability for schizophrenia in at least one subgroup of SCH+CAN patients. We hypothesized that SCH+CAN patients would display fewer gray matter deficits compared to SCH patients reflecting their presumed lower vulnerability. We therefore compared gray matter density in 30 first episode SCH+CAN and 24 first episode SCH patients using a fast diffeomorphic registration algorithm (DARTEL) and voxel-based morphometry (VBM). We found less severe cognitive impairments and middle frontal gray matter deficits in the SCH+CAN patients. In the pooled sample gray matter density was positively associated with cognitive functioning. Results may support the hypothesis of a lower biological vulnerability in at least one subgroup of SCH+CAN patients.

[Substance use associated disorders: frequency in patients with schizophrenic and affective psychoses]

BACKGROUND

Alcohol and substance use disorders (ASUD) are considered to be among the most frequent comorbidities in schizophrenic and affective psychoses and have a significant negative influence on their course and prognosis. In the present study patients with diagnosis from the ICD-10 category F2 or F3 were examined regarding a substance use disorder in a multicentre cross-section evaluation at nine psychiatric hospitals in Baden-Württemberg. The aim of this study is to discuss the current research on substance use disorders and psychosis comorbidity regarding the theoretical models by means of collected data.

METHODS

The examination of 50 consecutive admissions per centre is based on a shortened version of the European Severity Index (Europ ASI). An initial urine drug screening was carried out with all patients after admission. Statistical assessment was based on percentage distributions, mean values, standard deviations and suitable correlation analysis.

RESULTS

The representative sample included 448 patients. A proportion of 169 patients (37.7%) had a dual diagnosis F2 and F1 and a proportion of 144 patients (32.1%) had a dual diagnosis F3 and F1; 64 patients (14.3%) had an F2 diagnosis and 71 patients (15.8%) had an F3 diagnosis without ASUD. Apart from lifetime use of alcohol (n = 268) and tobacco (n = 325) hypnotics/tranquilizers (n = 214), cannabis (n = 156), opioids (n = 71), stimulants (n = 96) and hallucinogens (n = 36) were consumed. The most frequent combination and long-term intake consisted of tobacco, alcohol, hypnotics/tranquilizer, cannabis and psychostimulants especially in men with schizophrenic disorders. Regarding motivation before first substance use general psychological adjustment disorders (51%), peer impact (42%) and unspecific affective symptoms were predominant.

CONCLUSIONS

Altogether the present study clearly demonstrates that patients suffering from schizophrenia, affective disorders and ASUD have significantly higher rates of more severe substance use disorders in their psychosocial environment and more suicidal behaviour than patients without substance misuse. The high rate in the cross-sectional prevalence of tobacco, alcohol, cannabis and psychostimulant use calls for more effective drug prevention.

An epidemiologic and clinical overview of medical and psychopathological comorbidities in major psychoses

The presence of comorbidity in major psychoses (e.g., schizophrenia and psychotic subtypes of bipolar disorder and major depressive disorder) seems to be the rule rather than the exception in both DSM-IV and ICD-10. Examining comorbidity in major psychoses, however, requires an investigation into the different levels of comorbidity (either full-blown and subsyndromal) which should be analyzed in both psychopathological and medical fields. On one hand, the high prevalence of psychiatric comorbidity in major psychoses may be the result of the current nosographic systems. On the other hand, it may stem from a common neurobiological substrate. In fact, comorbid psychopathological conditions may share a biological vulnerability, given that dysfunction in specific brain areas may be responsible for different symptoms and syndromes. The high rates of comorbidity in major psychoses require targeted pharmacological treatments in order to effectively act on both the primary diagnosis and comorbid conditions. Nevertheless, few controlled trials in comorbid major psychoses had been carried out and treatment recommendations in this field have mostly an empirical basis. The aim of the present article is to provide a comprehensive and updated overview in relation to epidemiological and clinical issues of comorbidity in major psychoses.