Barriers and opportunities for implementation of a brief psychological intervention for post-ICU mental distress in the primary care setting - results from a qualitative sub-study of the PICTURE trial.

BACKGROUND: The results of critical illness and life-saving invasive measures during intensive care unit treatment can sometimes lead to lasting physical and psychological impairments. A multicentre randomized controlled trial from Germany (PICTURE) aims to test a brief psychological intervention, based on narrative exposure therapy, for post-traumatic stress disorder symptoms following intensive care unit treatment in the primary care setting. A qualitative analysis was conducted to understand feasibility and acceptance of the intervention beyond quantitative analysis of the main outcomes in the primary study. METHODS: Qualitative explorative sub-study of the main PICTURE trial, with eight patients from the intervention group recruited for semi-structured telephone interviews. Transcriptions were analysed according to Mayring's qualitative content analysis. Contents were coded and classified into emerging categories. RESULTS: The study population was 50% female and male, with a mean age of 60.9 years and transplantation surgery being the most frequent admission diagnosis. Four main factors were identified as conducive towards implementation of a short psychological intervention in a primary care setting: 1) long-term trustful relationship between patient and GP team; 2) intervention applied by a medical doctor; 3) professional emotional distance of the GP team; 4) brevity of the intervention. CONCLUSION: The primary setting has certain qualities such as a long-term doctor-patient relationship and low-threshold consultations that offer good opportunities for implementation of a brief psychological intervention for post-intensive care unit impairments. Structured follow-up guidelines for primary care following intensive care unit treatment are needed. Brief general practice-based interventions could be part of a stepped-care approach. TRIAL REGISTRATION: The main trial was registered at the DRKS (German Register of Clinical Trials: DRKS00012589) on 17/10/2017.

Cannabis use and psychosis: a review of reviews.

We conducted a systematic review of meta-analyses and systematic reviews to evaluate the impact of cannabis use on the onset and course of psychoses. Following a systematic literature search of five data bases (2005-2016) and consecutive structured evaluation, we were able to include 26 systematic reviews and meta-analyses. The methodological quality of the included publications were in the range of high and poor. The scientific literature indicates that psychotic illness arises more frequently in cannabis users compared to non-users, cannabis use is associated with a dose-dependent risk of developing psychotic illness, and cannabis users have an earlier onset of psychotic illness compared to non-users. Cannabis use was also associated with increased relapse rates, more hospitalizations and pronounced positive symptoms in psychotic patients. We make recommendations about the type of research that is required to better characterize the relationship between cannabis use and the development and outcomes of psychosis.

[Efficacy and safety of medicinal cannabis: results of the CaPRis study]. / Wirksamkeit und Sicherheit von Cannabisarzneimitteln: Ergebnisse der CaPRis-Studie.

In the 1990s, the endocannabinoid system was discovered as part of the human physiology. Since then, the effects of cannabis as a medicine have been researched more systematically. To summarize the scientific knowledge, the German Federal Ministry of Health commissioned an expertise.The project "Cannabis: Potential and Risks: a Scientific Analysis" (CaPRis), which started in 2016, aimed at analyzing the potential of medicinal cannabis and the risks of recreational cannabis use. A search of systematic reviews (SRs) and randomized-controlled trials (RCTs) were conducted in five international databases (publication date: 2006-2017). For the medical use of cannabis 16 SRs (of 186 RCTs) were included from a global search and nine further RCTs were comprised from a de novo search. All studies were methodologically assessed.Evidence for the efficacy of cannabis medicine (given as an adjunct to other medication) was found in patients with chronic pain and spasticity due to multiple sclerosis. Benefits were also found for appetite stimulation, improvement of nausea, and weight gain in patients with cancer, HIV/AIDS or in palliative care. Effects were often small. For other physical or mental disorders, only few or no controlled human studies are available. Adverse effects of cannabis medicine are often reported; severe adverse effects were mentioned in single cases only.To provide reliable treatment recommendations for clinicians and patients, more large-sized RCTs with follow-up assessments, consistent outcome measures, and active comparisons are needed.

Correction to: How effective and safe is medical cannabis as a treatment of mental disorders? A systematic review.

The article "How effective and safe is medical cannabis as a treatment of mental disorders? A systematic review", written by Eva Hoch, was originally published Online First without open access. After publication in volume 269, issue 1, page 87-105 the author decided to opt for Open Choice and to make the article an Open Access publication. Therefore, the copyright of the article has been changed to © The Author(s) 2019 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

How effective and safe is medical cannabis as a treatment of mental disorders? A systematic review.

We conducted a review of systematic reviews (SRs) and randomized-controlled trials (RCTs) to analyze efficacy and safety of cannabis-based medication in patients with mental disorders. Five data bases were systematically searched (2006-August 2018); 4 SRs (of 11 RCTs) and 14 RCTs (1629 participants) were included. Diagnoses were: dementia, cannabis and opioid dependence, psychoses/schizophrenia, general social anxiety, posttraumatic stress disorder, anorexia nervosa, attention-deficit hyperactivity disorder, and Tourette`s disorder. Outcome variables were too heterogeneous to conduct a  meta-analysis. A narrative synthesis method was applied. The study quality was assessed using the risk-of-bias tool and SIGN-checklists. THC- and CBD-based medicines, given as adjunct to pharmaco- and psychotherapy, were associated with improvements of several symptoms of mental disorders, but not with remission. Side effects occurred, but severe adverse effects were mentioned in single cases only. In order to provide reliable treatment recommendations, more and larger RCTs with follow-up assessments, consistent outcome measures and active comparisons are needed.

Ontogeny of sensorimotor gating and short-term memory processing throughout the adolescent period in rats.

Adolescence and puberty are highly susceptible developmental periods during which the neuronal organization and maturation of the brain is completed. The endocannabinoid (eCB) system, which is well known to modulate cognitive processing, undergoes profound and transient developmental changes during adolescence. With the present study we were aiming to examine the ontogeny of cognitive skills throughout adolescence in male rats and clarify the potential modulatory role of CB1 receptor signalling. Cognitive skills were assessed repeatedly every 10th day in rats throughout adolescence. All animals were tested for object recognition memory and prepulse inhibition of the acoustic startle reflex. Although cognitive performance in short-term memory as well as sensorimotor gating abilities were decreased during puberty compared to adulthood, both tasks were found to show different developmental trajectories throughout adolescence. A low dose of the CB1 receptor antagonist/inverse agonist SR141716 was found to improve recognition memory specifically in pubertal animals while not affecting behavioral performance at other ages tested. The present findings demonstrate that the developmental trajectory of cognitive abilities does not occur linearly for all cognitive processes and is strongly influenced by pubertal maturation. Developmental alterations within the eCB system at puberty onset may be involved in these changes in cognitive processing.

Enhanced Functional Activity of the Cannabinoid Type-1 Receptor Mediates Adolescent Behavior.

Adolescence is characterized by drastic behavioral adaptations and comprises a particularly vulnerable period for the emergence of various psychiatric disorders. Growing evidence reveals that the pathophysiology of these disorders might derive from aberrations of normal neurodevelopmental changes in the adolescent brain. Understanding the molecular underpinnings of adolescent behavior is therefore critical for understanding the origin of psychopathology, but the molecular mechanisms that trigger adolescent behavior are unknown. Here, we hypothesize that the cannabinoid type-1 receptor (CB1R) may play a critical role in mediating adolescent behavior because enhanced endocannabinoid (eCB) signaling has been suggested to occur transiently during adolescence. To study enhanced CB1R signaling, we introduced a missense mutation (F238L) into the rat Cnr1 gene that encodes for the CB1R. According to our hypothesis, rats with the F238L mutation (Cnr1(F238L)) should sustain features of adolescent behavior into adulthood. Gain of function of the mutated receptor was demonstrated by in silico modeling and was verified functionally in a series of biochemical and electrophysiological experiments. Mutant rats exhibit an adolescent-like phenotype during adulthood compared with wild-type littermates, with typical high risk/novelty seeking, increased peer interaction, enhanced impulsivity, and augmented reward sensitivity for drug and nondrug reward. Partial inhibition of CB1R activity in Cnr1(F238L) mutant rats normalized behavior and led to a wild-type phenotype. We conclude that the activity state and functionality of the CB1R is critical for mediating adolescent behavior. These findings implicate the eCB system as an important research target for the neuropathology of adolescent-onset mental health disorders. SIGNIFICANCE STATEMENT: We present the first rodent model with a gain-of-function mutation in the cannabinoid type-1 receptor (CB1R). Adult mutant rats exhibit an adolescent-like phenotype with typical high risk seeking, impulsivity, and augmented drug and nondrug reward sensitivity. Adolescence is a critical period for suboptimal behavioral choices and the emergence of neuropsychiatric disorders. Understanding the basis of these disorders therefore requires a comprehensive knowledge of how adolescent neurodevelopment triggers behavioral reactions. Our behavioral observations in adult mutant rats, together with reports on enhanced adolescent CB1R signaling, suggest a pivotal role for the CB1R in an adolescent brain as an important molecular mediator of adolescent behavior. These findings implicate the endocannabinoid system as a notable research target for adolescent-onset mental health disorders.

The CB1 receptor as an important mediator of hedonic reward processing.

The endocannabinoid (ECB) system has emerged recently as a key mediator for reward processing. It is well known that cannabinoids affect appetitive learning processes and can induce reinforcing and rewarding effects. However, the involvement of the ECB system in hedonic aspects of reward-related behavior is not completely understood. With the present study, we investigated the modulatory role of the ECB system on hedonic perception, measured by the pleasure attenuated startle (PAS) paradigm for a palatable food reward. Here, a conditioned odor is thought to induce a pleasant affective state that attenuates an aversive reflex-the acoustic startle response. Modulatory effects of the CB1 receptor antagonist/inverse agonist SR1411716 and the cannabinoid agonist WIN 55 212-2 on PAS were examined in rats. PAS was also measured in CB1 receptor knockout (KO) and wild-type (WT) mice. Pharmacological inhibition as well as the absence of CB1 receptors was found to reduce PAS, whereas WIN 55 212-2 administration increased PAS. Finally, presentation of a conditioned reward cue was found to induce striatal FosB/ΔFosB expression in WT mice, but not in KO mice, indicating a reduced stimulation of reward-related brain regions in conditioned KO mice by odor presentation. We here show that in addition to our previous studies in rats, PAS may also serve as a valuable and suitable measure to assess hedonic processing in mice. Our data further indicate that the ECB system, and in particular CB1 receptor signaling, appears to be highly important for the mediation of hedonic aspects of reward processing.

Impact of pubertal stage at first drink on adult drinking behavior.

BACKGROUND: Early alcohol use is one of the strongest predictors of later alcohol use disorders, with early use usually taking place during puberty. Many researchers have suggested drinking during puberty as a potential biological basis of the age at first drink (AFD) effect. However, the influence of the pubertal phase at alcohol use initiation on subsequent drinking in later life has not been examined so far. METHODS: Pubertal stage at first drink (PSFD) was determined in N = 283 young adults (131 males, 152 females) from an epidemiological cohort study. At ages 19, 22, and 23 years, drinking behavior (number of drinking days, amount of alcohol consumed, hazardous drinking) was assessed using interview and questionnaire methods. Additionally, an animal study examined the effects of pubertal or adult ethanol (EtOH) exposure on voluntary EtOH consumption in later life in 20 male Wistar rats. RESULTS: PSFD predicted drinking behavior in humans in early adulthood, indicating that individuals who had their first drink during puberty displayed elevated drinking levels compared to those with postpubertal drinking onset. These findings were corroborated by the animal study, in which rats that received free access to alcohol during the pubertal period were found to consume more alcohol as adults, compared to the control animals that first came into contact with alcohol during adulthood. CONCLUSIONS: The results point to a significant role of stage of pubertal development at first contact with alcohol for the development of later drinking habits. Possible biological mechanisms and implications for prevention are discussed.

Behavioral differences in three Wistar Han rat lines for emotional reactivity, cognitive processing and ethanol intake.

Many laboratories obtain their experimental animals from commercial suppliers and are therefore dependent on their conditions and breeding schedules. A breeding stop or the substitution of a particular rat line by the supplier forces the customers to abandon their conventional test animals and to re-establish all behavioral paradigms with a new rat line. Therefore, it is vital to know whether behavioral differences emerge in various breeding lines of the same rat strain. In a recent case, the commercial supplier Harlan Laboratories GmbH is substituting the previous HsdHan:WIST line of Wistar rats with the RccHan:WIST line descending from a different breeding stock. We therefore tested animals of both lines (RccHan:WIST and HsdHan:WIST from Harlan Laboratories GmbH) as well as Wistar rats of the same line but obtained from a different supplier (Janvier) in a broad range of behavioral paradigms. We observed differences in locomotor activity, in classical anxiety-related paradigms (elevated plus maze and light/dark emergence test), as well as in object recognition memory and prepulse inhibition (PPI) of the acoustic startle reflex (ASR). We also found differences in ethanol intake and preference, but not regarding the intake of a palatable food reward and a bitter solution (quinine). These results demonstrate considerable variations in the behavioral phenotype between different breeding lines of the same Wistar rat strain and aim to increase the awareness of behavioral scientists for line and supplier differences affecting animal behavior.

AAV-Mediated Overexpression of the CB1 Receptor in the mPFC of Adult Rats Alters Cognitive Flexibility, Social Behavior, and Emotional Reactivity.

The endocannabinoid (ECB) system is strongly involved in the regulation of cognitive processing and emotional behavior and evidence indicates that ECB signaling might affect these behavioral abilities by modulations of prefrontal cortical functions. The aim of the present study was to examine the role of the CB1 receptor in the medial prefrontal cortex (mPFC) on cognitive flexibility and emotional behavior. Therefore, the CB1 receptor was overexpressed by adeno-associated virus vector-mediated gene transfer specifically in the mPFC of adult Wistar rats. Animals were then tested in different anxiety-related paradigms for emotional reactivity [e.g., elevated plus maze (EPM), light/dark emergence test (EMT), social interaction] and the attentional set shift task (ASST) - an adaptation of the human Wisconsin card sorting test - for cognitive abilities and behavioral flexibility. A subtle increase in exploratory behavior was found in CB1 receptor overexpressing animals (CB1-R) compared to Empty vector injected controls (Empty) in the EMT and EPM, although general locomotor activity did not differ between the groups. During social interaction testing, social contact behavior toward the unknown conspecific was found to be decreased, whereas social withdrawal was increased in CB1-R animals and they showed an inadequate increase in exploratory behavior compared to control animals. In the ASST, impaired reversal learning abilities were detected in CB1-R animals compared to controls, indicating reduced behavioral flexibility. In conclusion, upregulation of the CB1 receptor specifically in the rat mPFC induces alterations in emotional reactivity, leads to inadequate social behavior, and impairs cognitive flexibility. These findings might be relevant for neuropsychiatric disorders, since higher cortical CB1 receptor expression levels as well as similar behavioral impairments as observed in the present study have been described in schizophrenic patients.

Reward sensitivity for a palatable food reward peaks during pubertal developmental in rats.

Puberty is a critical period for the initiation of drug use and abuse. Because early drug use onset often accounts for a more severe progression of addiction, it is of importance to understand the underlying mechanisms and neurodevelopmental changes during puberty that are contributing to enhanced reward processing in teenagers. The present study investigated the progression of reward sensitivity toward a natural food reward over the whole course of adolescence in male rats (postnatal days 30-90) by monitoring consummatory, motivational behavior and neurobiological correlates of reward. Using a limited-free intake paradigm, consumption of sweetened condensed milk (SCM) was measured repeatedly in adolescent and adult rats. Additionally, early- and mid-pubertal animals were tested in Progressive Ratio responding for SCM and c-fos protein expression in reward-associated brain structures was examined after odor conditioning for SCM. We found a transient increase in SCM consumption and motivational incentive for SCM during puberty. This increased reward sensitivity was most pronounced around mid-puberty. The behavioral findings are paralleled by enhanced c-fos staining in reward-related structures revealing an intensified neuronal response after reward-cue presentation, distinctive for pubertal animals. Taken together, these data indicate an increase in reward sensitivity during adolescence accompanied by enhanced responsiveness of reward-associated brain structures to incentive stimuli, and it seems that both is strongly pronounced around mid-puberty. Therefore, higher reward sensitivity during pubertal maturation might contribute to the enhanced vulnerability of teenagers for the initiation of experimental drug use.