Psychosoziale Behandlungen bei Suchterkrankungen – Suchtspezifische Psychotherapieformen und ihre Wirksamkeit

Functional and clinical outcomes of FMRI-based neurofeedback training in patients with alcohol dependence: a pilot study

Identifying treatment options for patients with alcohol dependence is challenging. This study investigates the application of real-time functional MRI (rtfMRI) neurofeedback (NF) to foster resistance towards craving-related neural activation in alcohol dependence. We report a double-blind, placebo-controlled rtfMRI study with three NF sessions using alcohol-associated cues as an add-on therapy to the standard treatment. Fifty-two patients (45 male; 7 female) diagnosed with alcohol dependence were recruited in Munich, Germany. RtfMRI data were acquired in three sessions and clinical abstinence was evaluated 3 months after the last NF session. Before the NF training, BOLD responses and clinical data did not differ between groups, apart from anger and impulsiveness. During NF training, BOLD responses of the active group were decreased in medial frontal areas/caudate nucleus, and increased, e.g. in the cuneus/precuneus and occipital cortex. Within the active group, the down-regulation of neuronal responses was more pronounced in patients who remained abstinent for at least 3 months after the intervention compared to patients with a relapse. As BOLD responses were comparable between groups before the NF training, functional variations during NF cannot be attributed to preexisting distinctions. We could not demonstrate that rtfMRI as an add-on treatment in patients with alcohol dependence leads to clinically superior abstinence for the active NF group after 3 months. However, the study provides evidence for a targeted modulation of addiction-associated brain responses in alcohol dependence using rtfMRI.

[How to deal with alcohol: a qualitative evaluation of 30 interviews with alcohol-dependent patients]

INTRODUCTION

Alcohol dependence syndrome is a chronic-recurrent substance use disorder. Various treatments have been shown to be effective with a positive impact on the course of the disease. The patients' subjective perception of their disease and the offered treatments remain unclear.

METHODS

30 alcohol-dependent patients (n = 20 psychiatric clinic, n = 10 addiction counseling) were asked how they had dealt with their alcohol problem in the past. The interviews were recorded, transcribed and analyzed using current qualitative research methods.

RESULTS

While most patients positively rated many aspects in the three areas of alcohol abstinence, treatment and the social environment, they also described negative aspects in these areas.

DISCUSSION

The contradicting statements show an area of conflict that demonstrates the ambivalence of alcohol-dependent patients in relevant fields. This ambivalence can be considered as important for the therapy and the course of the disease.

Ethische Aspekte internet- und mobilgestützter Interventionen (IMIs) bei Suchtstörungen

Ziel der Studie Internet- und mobilgestützte Interventionen (IMIs) werden häufig bei Suchtstörungen eingesetzt. Für die Wirksamkeit von IMIs liegt eine umfangreiche Evidenz vor. Hinsichtlich der spezifischen ethischen Aspekte, die sich aus dem Einsatz von IMIs bei Suchtstörungen ergeben, fehlt es bislang an Forschung. Mit unserem Beitrag leisten wir die erste eingehende ethische Analyse von IMIs in der Suchttherapie. Dabei orientieren wir uns an normativen Aspekten, die spezifisch für die Behandlung von Suchtstörungen sind. Dazu gehören die besondere Stigmatisierung von Suchtkranken, die Zuschreibung von Schuld und Eigenverantwortung, die mangelnde Akzeptanz des Krankheitskonzepts Sucht sowie die daraus resultierende Ablehnung und Abwertung von Betroffenen.

Methode Als methodisches Instrument verwenden wir den 3 ACES-Ansatz von Thornicroft und Tansella. Dieses Instrument erlaubt eine umfassende ethische Analyse des Einsatzes von IMIs im konkreten Einzelfall sowie der Implementierung von IMIs im Versorgungssystem.

Ergebnisse Unsere Analyse zeigt, dass IMIs in der Suchttherapie das Potential haben, ein Empowerment von PatientInnen zu leisten, die Stigmatisierung zu umgehen und einen niedrigschwelligen Zugang zu Versorgungsleistungen zu ermöglichen. Kritisch zu sehen sind Aspekte der Passung von Anwendungen auf die Bedürfnisse einzelner Patientengruppen und individueller PatientInnen, der therapeutischen Verantwortung, des Datenschutzes, der Datensicherheit und Privatheit sowie der Vernetzung unterschiedlicher Anbieter von Versorgungsleistungen.

Schlussfolgerung Eine weitere Implementierung von IMIs in der Suchttherapie ist nur dann wünschenswert, wenn verbindliche Qualitätsstandards geschaffen und die patientenzentrierte Anwendung unter Berücksichtigung individueller Patientencharakteristika sichergestellt wird.

Alcohol Dependence and Harmful Use of Alcohol

BACKGROUND

In Germany today, there are more than 1.8 million persons who are dependent on alcohol, and 1.6 million persons whose use of alcohol is harmful. The many complications of alcohol use are both mental and physical-in particular, gastrointestinal and neurological. Yet more than 80% of persons whose alcohol use is problematic still receive no treatment for their harmful use or dependence, despite contact with the health-care system.

METHODS

This article is a selective review of the pertinent literature, including guidelines, meta-analyses, and Cochrane Reviews.

RESULTS

The treatment is divided into an early interventional and motivational phase, qualified withdrawal, long-term cessation therapy, and a stabilization phase. Pharmacotherapy with acamprosate or naltrexone increases the rate of abstinence (number needed to treat: 12 and 20, respectively). If a patient lacks the motivation to abstain from alcohol entirely, reduced consumption can be agreed upon as a goal of treatment. 85% of patients relapse if no further treatment is given after initial detoxification.

CONCLUSION

What is needed in routine medical practice is practical diagnostic evaluation followed by individually tailored treatment, based on the severity of the condition, the development of the patient's motivation to be treated, and the local treatment options (e.g., outpatient addiction clinics, counseling centers, or day clinics).