Psychiatrische und soziale Versorgungssituation von Menschen mit Substanzgebrauchsstörungen

Die vorliegende Habilitationsschrift umfasst fünf Veröffentlichungen zu klinischen und sozialen Faktoren bei Menschen mit Substanzgebrauchsstörungen. Die erste in diese Habilitationsschrift einfließende Arbeit untersucht mittels Metaanalysen die Prävalenz psychischer Erkrankungen unter Wohnungslosen in wohlhabenden Ländern und zeigte dabei, dass bei mehr als zwei Drittel der Personen seelische Erkrankungen vorlagen. An erster Stelle stehen Substanzgebrauchsstörungen, gefolgt von Persönlichkeitsstörungen, depressiven Störungen und psychotischen Störungen. Die Daten unterstreichen die besondere Bedeutung von Substanzgebrauchsstörungen, die vermutlich sowohl die Wohnungslosigkeit mit verursachen können als auch eine wichtige Coping-Strategie für wohnungslosen Menschen darstellen. Die Daten legen zudem den Schluss nahe, dass die Abstinenzausrichtung im Hilfesystem in einigen Bereichen zu hinterfragen ist, da dadurch eine Vielzahl von Patienten nicht erreicht werden. Die große Heterogenität der Studien unterstreicht die Notwendigkeit, zukünftig einheitlichere Definitionen zum Beispiel von Wohnungslosigkeit zu verwenden. In der zweiten in diese Habilitationsschrift einfließenden Arbeit wurde das Nutzungsverhalten des psychiatrischen Versorgungssystems bei Menschen mit Substanzgebrauchsstörungen unter besonderer Berücksichtigung der Wohnsituation dieser Personen untersucht. Es zeigt sich, dass Personen mit Substanzgebrauchsstörungen, die in instabilen Wohnsituationen leben (Wohnungslosigkeit oder bei Freunden, Bekannten oder Familie untergekommen), signifikant früher in ihrem Leben psychiatrische und suchttherapeutische Behandlung erhalten hatten als Personen, die in eigener Wohnung leben. Auch sind komorbide Erkrankungen aus dem Psychose-Spektrum neben diagnostizierten Substanzgebrauchsstörungen mit dem Faktor Wohnungslosigkeit signifikant assoziiert. Die Befunde der Studie unterstreichen die Bedeutung einer sicheren sozialen Nachsorgeplanung mit besonderem Fokus auf die Wohnsituation bei Personen mit Substanzgebrauchsstörungen und einem frühen Alter bei erster psychiatrischer Behandlung, sowie bei komorbiden psychotischen Störungen. Die dritte in diese Habilitationsschrift einfließende Arbeit untersucht das Vorhandensein von und den Zugang zu einem eigenen Bankkonto bei psychiatrischen Patienten. Die Befunde zeigen, dass psychiatrische Patienten häufiger kein eigenes Bankkonto oder den Zugang dazu haben. Dies betrifft besonders männliche Personen mit Substanzgebrauchsstörungen, mit weniger Bildungsjahren, in instabilen Wohnverhältnissen und abhängig von Sozialleistungen lebend. Dies steht im Kontrast zu einer sehr guten Verfügbarkeit eines Kontozugangs der deutschen Allgemeinbevölkerung. Die Befunde sind von besonderer Bedeutung, da ein Bankkonto ein wichtiges Element für die Teilhabe an der Gesellschaft ist, beispielsweise zum Abschluss von Miet- oder Arbeitsverträgen, welche wiederum wichtig für die klinische Reintegration insbesondere von marginalisierten Patientengruppen sind. Die vierte Arbeit untersucht Menschen mit und ohne Migrationshintergrund in opioidgestützter Substitutionsbehandlung und zeigt, dass sich Menschen mit Migrationshintergrund etwa entsprechend ihres Bevölkerungsanteils in Substitutionsbehandlung befinden und demnach nicht unterpräsentiert sind, und auch genauso häufig wie Menschen ohne Migrationshintergrund Entgiftungs- und Langzeitbehandlungen in Anspruch nehmen. Damit weichen unsere Ergebnisse von anderen Untersuchungen ab, welche zeigen, dass Personen mit Migrationshintergrund Einrichtungen der Suchthilfe in Deutschland weniger häufig nutzen. In der Bewertung der Substitutionsbehandlung und der Dauer der Behandlung berichten Menschen mit Migrationshintergrund häufiger den Wunsch, die Behandlung zu beenden und zeigen zudem kürzere Behandlungszeiten. Beide Faktoren sind vermutlich bedingt durch ein anderes Krankheitsverständnis bei Personen mit Migrationshintergrund in der Bewertung von Suchterkrankungen, welche häufiger als stigmatisierend erlebt werden, andererseits auch dadurch, dass eigene Ressourcen überschätzt werden können. Die fünfte Arbeit untersucht, ob die Richtlinien der Bundesärztekammer bei Menschen in opioidgestützter Substitutionsbehandlung mit Take-Home-Verordnung erfüllt sind. Hierbei zeigt sich, dass die wichtigen Kriterien bei den meisten Personen erfüllt sind, wie bereits lange bestehende Substitutionsbehandlung, als Ausdruck einer stabilen medizinischen Einstellung, oder Berufstätigkeit, als Ausdruck einer psychosozialen Reintegration. Hinsichtlich des Konsums weiterer Substanzen zeigte sich, dass auch hier der Großteil der Personen mit Take-Home-Verordnung den Kriterien der Bundesärztekammer entsprach, es aber einzelne Personen mit anhaltendem Konsum stark sedierender Substanzen oder multiplem Substanzkonsum gab, was auf die Notwendigkeit von Urinkontrollen auch bei Personen mit Take-Home-Verordnung hinweist

New Approaches in Drug Dependence: Opioids

Purpose of Review: This article aims to provide an overview of standard and adjunctive treatment options in opioid dependence in consideration of therapy-refractory courses. The relevance of oral opioid substitution treatment (OST) and measures of harm reduction as well as heroin-assisted therapies are discussed alongside non-pharmacological approaches. Recent Findings: Currently, recommendation can be given for OST with methadone, buprenorphine, slow-release oral morphine (SROM), and levomethadone. Heroin-assisted treatment using diamorphine shall be considered as a cost-effective alternative for individuals not responding to the afore-mentioned opioid agonists in order to increase retention and reduce illicit opioid use. The modalities of application and the additional benefits of long-acting formulations of buprenorphine should be sufficiently transferred to clinicians and the eligible patients; simultaneously methods to improve planning of actions and self- management need to be refined. Regarding common primary outcomes in research on opioid treatment, evidence of the effectiveness of adjunctive psychological interventions is scarce. Summary: Maintaining a harm reduction approach in the treatment of opioid addiction, a larger range of formulations is available for the prescribers. Embedding the pharmacological, ideally individualized treatment into a holistic, structure-giving concept also requires a reduction of fragmentation of ancillary services available, drug policies, and treatment philosophies on a global scale

Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders

Purpose: Substance use disorders (SUD) are burdening chronic conditions characterized by high relapse rates despite severe negative consequences. Substance-related cues that elicit craving by means of automatic physiological and behavioural responses have long been suggested to predict relapse. One major mechanism contributing to relapse behaviour are cue-induced behavioural approach tendencies towards the addictive agent. Recently, there has been an emerging interest in virtual reality (VR)-based approaches to assess and modify craving and its related responses. This review aims at elucidating (1) VR techniques applied in the field of SUD, (2) VR as an induction/assessment tool for biopsychological correlates of craving and (3) VR-based therapeutic approaches. Findings: There is an emerging number of studies focusing on different substances of abuse incorporating VR in craving induction/assessment as well as therapy. Despite some limitations as missing of randomized controlled clinical trials with large samples and missing data on the long-term effects of VR treatment, the VR approach showed consistent results in eliciting and reducing craving across different substances. Summary: This review suggests virtual reality as a promising tool for the assessment and treatment of craving among individuals with substance use disorders. Because of its ecological validity, VR unifies the benefits of a laboratory setting with the advantages of a realistic environment. Further studies with large samples and randomized controlled clinical trials using more homogenous VR techniques as well as assessment of objective biophysiological craving markers are required

The Prevalence of Mental Illness in Homeless People in Germany

BACKGROUND The number of homeless people in Germany is increasing. Studies from multiple countries have shown that most homeless people suffer from mental illnesses that require treatment. Accurate figures on the prevalence of mental illness among the homeless in Germany can help improve care structures for this vulnerable group. METHODS We carried out a systematic review and meta-analysis on the prevalence of mental illness among homeless people in Germany. RESULTS 11 pertinent studies published from 1995 to 2013 were identified. The overall study population consisted of 1220 homeless people. The pooled prevalence of axis I disorders was 77.4%, with a 95% confidence interval [95% CI] of [71.3; 82.9]. Substance-related disorders were the most common type of disorder, with a pooled prevalence of 60.9% [53.1; 68.5]. The most common among these was alcoholism, with a prevalence of 55.4% [49.2; 61.5]. There was marked heterogeneity across studies. CONCLUSION In Germany, the rate of mental illness requiring treatment is higher among the homeless than in the general population. The development and implementation of suitable care models for this marginalized and vulnerable group is essential if their elevated morbidity and mortality are to be reduced

comparison of methadone and levomethadone in long-term treatment

Background This study aimed to investigate the development of opioid tolerance in patients receiving long-term methadone maintenance treatment (MMT). Methods A region-wide cross-sectional study was performed focusing on dosage and duration of treatment. Differences between racemic methadone and levomethadone were examined. All 20 psychiatric hospitals and all 110 outpatient clinics in Berlin licensed to offer MMT were approached in order to reach patients under MMT fulfilling the DSM IV criteria of opiate dependence. In the study, 720 patients treated with racemic methadone or levomethadone gave information on the dosage of treatment. Out of these, 679 patients indicated the duration of MMT. Results Treatment with racemic methadone was reported for 370 patients (54.5 %), with levomethadone for 309 patients (45.5 %). Mean duration of MMT was 7.5 years. We found a significant correlation between dosage and duration of treatment, both in a conjoint analysis for the two substances racemic methadone and levomethadone and for each substance separately. These effects remained significant when only patients receiving MMT for 1 year or longer were considered, indicating proceeding tolerance development in long-term treatment. When correlations were compared between racemic methadone and levomethadone, no significant difference was found. Conclusions Our data show a tolerance development under long-term treatment with both racemic methadone and levomethadone. Tolerance development did not differ significantly between the two substances

Antipsychotic Withdrawal Symptoms: A Systematic Review and Meta-Analysis

Objective Avoiding withdrawal symptoms following antipsychotic discontinuation is an important factor when planning a safe therapy. We performed a systematic review and meta-analysis concerning occurrence of withdrawal symptoms after discontinuation of antipsychotics. Data Sources We searched the databases CENTRAL, Pubmed, and EMBASE with no restriction to the beginning of the searched time period and until October 1, 2019 (PROSPERO registration no. CRD42019119148). Study Selection Of the 18,043 screened studies, controlled and cohort trials that assessed withdrawal symptoms after discontinuation of oral antipsychotics were included in the random-effects model. Studies that did not implement placebo substitution were excluded from analyses. The primary outcome was the proportion of individuals with withdrawal symptoms after antipsychotic discontinuation. We compared a control group with continued antipsychotic treatment in the assessment of odds ratio and number needed to harm (NNH). Data Extraction We followed guidelines by the Cochrane Collaboration, PRISMA, and MOOSE. Results Five studies with a total of 261 individuals were included. The primary outcome, proportion of individuals with withdrawal symptoms after antipsychotic discontinuation, was 0.53 (95% CI, 0.37–0.70; I2 = 82.98%, P < 0.01). An odds ratio of 7.97 (95% CI, 2.39–26.58; I2 = 82.7%, P = 0.003) and NNH of 3 was calculated for the occurrence of withdrawal symptoms after antipsychotic discontinuation. Conclusion Withdrawal symptoms appear to occur frequently after abrupt discontinuation of an oral antipsychotic. The lack of randomized controlled trials with low risk of bias on antipsychotic withdrawal symptoms highlights the need for further research

Housing situation and healthcare for patients in a psychiatric centre in Berlin, Germany: a cross-sectional patient survey

OBJECTIVE: To determine the housing situation among people seeking psychiatric treatment in relation to morbidity and service utilisation. DESIGN: Cross-sectional patient survey. SETTING: Psychiatric centre with a defined catchment area in Berlin, Germany, March-September 2016. PARTICIPANTS: 540 psychiatric inpatients including day clinics (43.2% of all admitted patients in the study period (n=1251)). MAIN OUTCOME MEASURES: Housing status 30 days prior the interview as well as influencing variables including service use, psychiatric morbidity and sociodemographic variables. RESULTS: In our survey, 327 participants (68.7%) currently rented or owned an own apartment; 62 (13.0%) reported to be homeless (living on the street or in shelters for homeless or refugees); 87 (18.3%) were accommodated in sociotherapeutic facilities. Participants without an own apartment were more likely to be male and younger and to have a lower level of education. Homeless participants were diagnosed with a substance use disorder significantly more often (74.2%). Psychotic disorders were the highest among homeless participants (29.0%). Concerning service use, we did neither find a lower utilisation of ambulatory services nor a higher utilisation of hospital-based care among homeless participants. CONCLUSIONS: Our findings underline the need for effective housing for people with mental illness. Despite many sociotherapeutic facilities, a concerning number of people with mental illness is living in homelessness. Especially early interventions addressing substance use might prevent future homelessness

Bank Account Ownership and Access Among In-Patients in Psychiatric Care in Berlin, Germany-A Cross-Sectional Patient Survey

Background: Access to a bank account is critical for overall participation in social life and an indicator for social integration. Worldwide about 1.7 billion people remain with no access to banking facilities as a form of financial exclusion which represents 31% of the world's general population. In contrast, in Western countries like Germany, 99% of the general population use bank accounts. Methods: We conducted an exploratory cross-sectional survey on bank account ownership and bank account access among psychiatric in-patients in a psychiatric hospital in Berlin. Out of 540 participants who were reached for an interview, 486 shared information about bank account ownership and 469 on access. Results: Out of 486 participants 49 (10.1%) did not own a bank account. Among the remaining 420 participants owning a bank account, 36 (8.3%) did not have direct access to their bank account, but only, e.g., their legal guardian. Regression results found psychosis, intellectual disabilities, a longer treatment duration, as well as being of male gender and a more instable housing status to be significantly associated with a missing bank account or a missing access to one's bank account. Conclusions: The lack of bank account ownership and access among this population of psychiatric patients is concerning. The interrelationship between factors of financial exclusion and mental health should be further explored in longitudinal studies. More attention is needed to support people with severe mental illness to be able to access resources associated with financial inclusion

Attitudes towards psychopharmacology and psychotherapy in psychiatric patients with and without migration background

Background: Sociodemographic factors, attitude towards treatment and acculturation may be important factors influencing the decision of immigrants to seek and maintain psychiatric treatment. A better understanding of these factors may significantly improve treatment adherence and outcome in these patients. Therefore, we investigated factors associated the attitude towards psychotherapy and medication in a sample of psychiatric outpatients with and without migration background. Methods: N = 381 patients in a psychiatric outpatient unit offering specialized treatment for migrants were included in this study. Attitude towards psychotherapy was assessed using the Questionnaire on Attitudes Toward Psychotherapeutic Treatment, attitude towards medication with the Drug Attitude Inventory-10. Acculturation, symptom load and sociodemographic variables were assessed in a general questionnaire. Statistical analyses included analyses of covariance and hierarchical regression. Results: Patients of Turkish and Eastern European origin reported a significantly more positive attitude towards medication than patients without migration background. When controlling for sociodemographic and clinical variables, we did not observe any significant differences in attitude towards psychotherapy. Acculturation neither influenced the attitude towards psychotherapy nor towards medication. Conclusion: Our study indicates that sociodemographic and clinical factors may be more relevant for patients´ attitudes towards treatment than acculturation. Considering these factors in psychiatric treatment of patients with migration background may improve treatment outcome and adherence