Psychiatric comorbidity in alcohol use disorders: results from the German S3 guidelines.

Alcohol use disorders (AUD) have a high comorbidity with mental disorders. Vice versa, alcohol consumption plays an important role in affective disorders, anxiety disorders, ADHD, schizophrenic psychosis, and other mental disorders. In developing the current interdisciplinary, evidence-based treatment guideline on screening, diagnostics, and treatment of AUD, available research on comorbid mental diseases in AUD has been compiled to generate recommendations for treatment. The guideline was prepared under the responsibility of the German Association for Psychiatry, Psychotherapy, and Psychosomatics (DGPPN) and the German Association for Addiction Research and Therapy (DG-Sucht). To meet the methodological criteria for the highest quality guidelines ("S3-criteria") as defined by the Association of Scientific Medical Societies in Germany (AWMF), the following criteria were employed: (1) a systematic search, selection, and appraisal of the international literature; (2) a structured process to reach consensus; and (3) inclusion of all relevant representatives of future guideline users. After assessing and grading the available literature, the expert groups generated several recommendations for the screening, diagnosis, and treatment of comorbid mental disorders. These recommendations were subdivided into psycho-, pharmaco-, and combination therapies. These are the first guidelines ever to make specific treatment recommendations for comorbid mental diseases in AUD. The recommendations extend to different treatment approaches including diagnostics and settings to present available effective and state-of-the-art treatment approaches to clinicians. Hitherto, many clinical constellations have not been addressed in research. Therefore, recommendations for future research are specified.

[Cannabis-induced disorders]. / Cannabisinduzierte Störungen.

Use and misuse of cannabis and marihuana are frequent. About 5% of the adult population are current users but only 1.2% are dependent. The medical use of cannabis is controversial but there is some evidence for improvement of chronic pain and spasticity. The somatic toxicity of cannabis is well proven but limited and psychiatric disorders induced by cannabis are of more relevance, e.g. cognitive disorders, amotivational syndrome, psychoses and delusional disorders as well as physical and psychological dependence. The withdrawal symptoms are usually mild and do not require pharmacological interventions. To date there is no established pharmacotherapy for relapse prevention. Psychosocial interventions include psychoeducation, behavioral therapy and motivational enhancement. The CANDIS protocol is the best established German intervention among abstinence-oriented therapies.

[On the legalization debate of non-medical cannabis consumption : Position paper of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Zur Legalisierungsdebatte des nichtmedizinischen Cannabiskonsums : DGPPN-Positionspapier.

Calls are increasing for the legalization of cannabis. Some legal experts, various politicians, political parties and associations are demanding a change in drug policy. The legalization debate is lively and receiving wide coverage in the media. The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) comments on the most important questions from a medical scientific perspective: can cannabis consumption trigger mental illnesses, what consequences would legalization have for the healthcare system and where is more research needed?

[Cannabis--Position Paper of the German Respiratory Society (DGP)]. / Cannabis--Positionspapier der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. (DGP).

In this position paper, the adverse health effects of cannabis are reviewed based on the existing scientific literature; in addition possible symptom-relieving effects on some diseases are depicted. In Germany, cannabis is the most widely used illicit drug. Approximately 600,000 adult persons show abusive or addictive cannabis consumption. In 12 to 17 year old adolescents, cannabis use increased from 2011 to 2014 from 2.8 to 6.4%, and the frequency of regular use from 0.2 to 1.5%. Currently, handling of cannabinoids is much debated in politics as well as in general public. Health aspects have to be incorporated into this debate. Besides analysing mental and neurological side effects, this position paper will mainly focus on the influences on the bronchopulmonary and cardiovascular system. There is strong evidence for the induction of chronic bronchitis. Allergic reactions including asthma are known, too. Associations with other diseases like pulmonary emphysema, lung cancer and pneumonia are not sufficiently proven, however cannot be excluded either. In connection with the use of cannabis cardiovascular events such as coronary syndromes, peripheral vascular diseases and cerebral complications have been noted. Often, the evidence is insufficient due to various reasons; most notably, the overlapping effects of tobacco and cannabis use can frequently not be separated adequately. Empirically, early beginning, high-dosed, long-lasting and regular cannabis consumption increase the risk of various psychological and physical impairments and negatively affect age-based development. Concerns therefore relate especially to children and adolescents. There is only little scientific evidence for medical benefits through cannabis as a remedy; systematic research of good quality, in particular prospective, randomised, placebo-controlled double-blinded studies are rare. The medical societies signing this position paper conclude that cannabis consumption is linked to adverse health effects which have to be taken into consideration in the debate about the social attitude towards cannabinoids. The societies agree that many aspects regarding health effects of cannabis are still uncertain and need clarification, preferably through research provided by controlled studies.

[Mental comorbidities of alcohol-related disorders]. / Psychische Komorbiditäten bei alkoholbedingten Störungen.

BACKGROUND: Alcohol-related disorders have a high comorbidity with mental disorders and vice versa, alcohol consumption plays an important role in affective disorders and schizophrenic psychoses. In developing the current S3 guidelines evidence-based knowledge on the rate and significance of comorbid disorders in alcohol use disorders has been compiled to generate recommendations for treatment. METHODS: In preparation for the guidelines, previous international guidelines and a systematic literature search were taken into consideration. Recommendations for various and specific clinical situations were derived from these sources based on evidence grading. Evidence and recommendations were subdivided into psychotherapy, pharmacotherapy and combination therapy, each having differential efficacies in the treatment of psychiatric symptoms and alcohol consumption behavior. Furthermore, a separate treatment pathway was developed for a stepwise approach to affective disorders for both comorbidities. CONCLUSION: Appearing for the first time in guidelines are specific treatment recommendations for comorbid mental diseases in alcohol use disorders. These recommendations extend to different treatment approaches including diagnostics and settings, affording clinicians more pragmatic relevance.

[Psychiatric comorbidities with tobacco-related disorders]. / Psychiatrische Komorbiditäten bei tabakbedingten Störungen.

The coincidence of tobacco smoking and psychiatric disorders is of great epidemiological and therapeutic importance. Tobacco smoking by people with mental disorders leads to disproportionately high somatic health risks, an adverse clinical course, poorer clinical outcomes and reduced quality of life (QoL). The etiological causes of the high comorbidity between smoking and mental disorders are still unclear: currently, tobacco smoking is discussed as being either the consequence or contributory cause of psychological disorders or both disorders share common antecedents and interactions. Psychiatric patients are motivated to quit and smoking cessation is not generally less effective with smokers with mental disorders than with mentally healthy individuals. Specific smoking cessation programs in the inpatient and outpatient settings are time-consuming and complex but effective. Within the framework of the current S3 guidelines the international evidence has been updated and transformed into treatment guidelines following an elaborate consensus process. Basically the same interventional measures should be used as with mentally healthy individuals; however, smokers with a psychological comorbidity often need more intensive adjuvant psychotherapeutic interventions and often need pharmaceutical support, (bupropion, varenicline and nicotine replacement therapy). Due to the overall unsatisfactory findings the treatment guidelines are partially based on clinical consensus decisions. In this field, a considerable need for research has been determined.

[Psychotherapy and pharmacotherapy for harmful tobacco use and tobacco dependency]. / Psycho- und Pharmakotherapie bei schädlichem Tabakgebrauch und -abhängigkeit.

Tobacco consumption is one of the major preventable health risk factors. In Germany approximately 110,000 people prematurely die from tobacco-related diseases and approximately 50% of regular smokers are considered to be tobacco dependent. Nevertheless, motivation to quit smoking is low and the long-term abstinence rates after attempts to stop smoking without professional support are far below 10%. As part of the S3 treatment guidelines 78 recommendations for motivation and early interventions for smokers unwilling to quit as well as psychotherapeutic and pharmacological support for smokers willing to quit were formulated after an systematic search of the current literature. More than 50 professional associations adopted the recommendations and background information in a complex certification process. In this article the scientific evidence base regarding the psychotherapeutic and pharmacological treatment options as well as recommendations and further information about indications and treatment implementation are presented. By following these guidelines for treatment of heavy smokers who are willing to quit combined with individual and group therapies on the basis of behavioral treatment strategies and pharmacological support, long-term success rates of almost 30% can be achieved.

[Methodology of the S3 guidelines on alcohol and tobacco-related disorders]. / Methodik der S3-Leitlinien für alkohol- und tabakbezogene Störungen.

BACKGROUND: From 2010 until 2015 two interdisciplinary evidence-based guidelines were developed to summarize the current knowledge regarding screening, diagnostics and treatment of alcohol and tobacco-related disorders. METHODS: Both guidelines were prepared under the auspices of the German Society for Psychiatry, Psychotherapy and Psychosomatics (Deutsche Gesellschaft für Psychiatrie, Psychotherapie, Psychosomatik und Nervenheilkunde, DGPPN) and the German Society for Addiction Research and Therapy (Deutsche Gesellschaft für Suchtforschung und -therapie, DG-Sucht). To meet the methodological criteria for the highest quality guidelines (S3 criteria) as defined by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) the following criteria were realized: (1) a systematic search, selection and appraisal of the international literature, (2) a structured process to reach consensus and (3) inclusion of all relevant representatives of future guideline users. RESULTS: More than 60 clinical experts and researchers analyzed the scientific literature. In total 41 international and national guidelines (23 for alcohol and 18 for tobacco) were used. Moreover, 83 systematic Cochrane reviews (alcohol 28, tobacco 55) and 5863 articles (alcohol 2213, tobacco 3650) were analyzed. A total of 7 expert groups formulated 174 recommendations for the screening, diagnosis and treatment of alcohol-related disorders. Six expert groups created 81 recommendations for the screening, diagnosis and treatment of tobacco-related disorders. Approximately 50 scientific associations, professional organizations, patient and family initiatives, as well as representatives of the healthcare system formed a consensus group. In seven 1 and 2-day conferences, all clinical recommendations were discussed and approved by this group. Both guidelines will be revised on a regular basis to guarantee that the clinical recommendations are kept up to date. CONCLUSIONS: Both systematically developed, evidence-based treatment guidelines are comprehensive instruments to provide orientation and assist the decision-making process for physicians, psychologists and other therapists as well as patients and their families in the diagnosis and treatment of alcohol and tobacco use related disorders.

[Guideline-oriented treatment of alcohol-related disorders]. / Leitlinienorientierte Behandlung alkoholbezogener Störungen.

Alcohol use disorders (e.g. abuse and dependence) account for a plethora of consequences for affected individuals and for a substantial proportion of the overall burden of disease for the community. To date, existing treatment options are either poorly known by doctors or they are not fully applied and only approximately 15% of potential patients are treated with a mean latent period of 10 years between early symptoms and the first intervention. So-called S3 treatment guidelines were recently developed to close this gap. Representatives of more than 50 learned societies, families and patients were involved. A systematic literature search from 2005 to 2012 was performed and more than 120 recommendations were made. Financing came exclusively from those societies and the academic and treatment institutes involved.This article summarizes the recommendations pertinent for psychiatrists and include early detection and intervention, acute withdrawal and long-term psychotherapy and pharmacotherapy. Classical and new treatment goals are discussed. If the new guidelines were properly applied an increase in patients receiving treatment to 30-40% could be expected, which would improve the quality of lives of affected persons and their families and in Germany would save several thousand lives per year.

Simultaneous extension of both basic microstructural components in scleractinian coral skeleton during night and daytime, visualized by in situ 86Sr pulse labeling.

Using in situ (12 h) pulse-labeling of scleractinian coral aragonitic skeleton with stable 86Sr isotope, the diel pattern of skeletal extension was investigated in the massive Porites lobata species, grown at 5 m depth in the Gulf of Eilat. Several microstructural aspects of coral biomineralization were elucidated, among which the most significant is simultaneous extension of the two basic microstructural components Rapid Accretion Deposits (RAD; also called Centers of Calcification) and Thickening Deposits (TD; also called fibers), both at night and during daytime. Increased thickness of the 86Sr-labeled growth-front in the RADs compared to the adjacent TDs revealed that in this species RADs extend on average twice as fast as TDs. At the level of the individual corallite, skeletal extension is spatially highly heterogeneous, with sporadic slowing or cessation depending on growth directions and skeletal structure morphology. Daytime photosynthesis by symbiotic dinoflagellates is widely acknowledged to substantially increase calcification rates at the colony and the corallite level in reef-building corals. However, in our study, the average night-time extension rate (visualized in three successive 12 h pulses) was similar to the average daytime extension (visualized in the initial 12 h pulse), in all growth directions and skeletal structures. This research provides a platform for further investigations into the temporal calibration of coral skeletal extension via cyclic growth increment deposition, which is a hallmark of coral biomineralization.

CANDIS treatment program for cannabis use disorders: findings from a randomized multi-site translational trial.

BACKGROUND: In a recent paper, we reported the efficacy of a modular cognitive-behavioral intervention for treating adolescents and adults with cannabis use disorders (CUD). In this study, we examine the outcome of this intervention after translating it into clinical practice. METHODS: A multi-site, randomized controlled trial of 279 treatment seekers with ICD-10 cannabis use disorders aged 16- 63 years was conducted in 11 outpatient addiction treatment centers in Germany. Patients were randomly assigned to an Active Treatment (AT, n=149) or Delayed Treatment Control (DTC, n=130). Treatment consisted of 10 sessions of fully manualized individual psychotherapy that combined Cognitive-Behavioral Therapy, Motivational EnhancementTherapy and problem-solving training. Assessments were conducted at baseline, during each therapy session, at post-treatment and at three and six month follow-ups. RESULTS: At post assessment 53.3% of AT patients reported abstinence (46.3% negative urine screenings) compared to 22% of DTC patients (17.7% negative drug screenings) (p<0.001, Intention-to-treat analysis). AT patients improved in the frequency of cannabis use, number of cannabis dependence criteria, severity of dependence, as well as number and severity of cannabis-related problems. Effect sizes were moderate to high. While abstinence rates in the AT group decreased over the 3-month (negative urine screenings: 32.4%) and 6-month (negative urine screenings: 35.7%) follow-up periods, the effects in secondary outcomes were maintained. CONCLUSIONS: The intervention can successfully be translated to and applied in clinical practice. It has the potential to improve access to evidence-based care for chronic CUD patients.

Efficacy of a targeted cognitive-behavioral treatment program for cannabis use disorders (CANDIS).

AIMS: To examine the efficacy, 3- and 6-month follow-up effects of a psychological treatment for older adolescents and adults with DSM-IV cannabis use disorders. The program was tailored to the needs of this patient population. EXPERIMENTAL PROCEDURES: A randomized controlled clinical trial of 122 patients aged 16 to 44 years with DSM-IV cannabis dependence as the main substance use diagnosis was conducted. Patients were randomly assigned to either Active Treatment (AT, n = 90) or a Delayed Treatment Control group (DTC, n = 32). Treatment consisted of 10 sessions of therapy, detailed in a strictly enforced manual. Assessments were conducted at baseline, during each therapy session, at post treatment and at follow-up assessments at 3 and 6 months. RESULTS: The treatment retention rate was 88%. Abstinence was achieved in 49% of AT patients and in 13% of those in DTC (p < 0.001; intend-to-treat (ITT) analysis). Further, AT patients improved significantly (p < = 0.001) in the frequency of cannabis use per week, addiction severity, number of disability days, and overall level of psychopathology. Program effects were maintained over a 3-month- (abstinence rate: 51%) and 6-month follow-up (45%) period. CONCLUSION: The treatment program is effective in obtaining abstinence as well as reducing cannabis use and improves the associated social and mental health burden.

The German monitoring and reporting system for the treatment of substance-related problems: a national system on the basis of aggregated data.

The German treatment monitoring and reporting system EBIS for out-patient centres treating clients with substance-related problems and disorders was set up in 1980. A parallel system for in-patient treatment was added in 1993 under the name of SEDOS. Together they are based nation-wide on more than 600 specialised treatment centres which collect diagnosis- and treatment-related data as well as information on socio-economic and family background. As part of the data relate to the end of treatment, also evaluative elements are included. In EBIS and SEDOS, aggregated data are the basis of the national and regional statistics produced, which offers a very high level of data protection for the clients treated. The revision of the national system implementing the Treatment Demand Indicator Protocol as the European Monitoring Centre for Drugs and Drug Addiction standard has already been started.

Experiences with psychotherapy training in India.

On the basis of 32 years of psychiatric experience in India, the author tries to show how difficulties encountered not only in psychotherapy with Indian patients, but also in supervision of candidates in training for psychotherapy can be related to specific cultural patterns of personality development and social intercourse and, beyond this, traced back to their deeper roots in the traditional Indian world view, as represented by the ancient Hindu scriptures. Starting with the latter, she shows how the lack of an 'anthropocentric orientation', the discouragement of egoistic and individualistic strivings, the doctrine of 'karma' and re-incarnation, all essential elements of traditional Hindu philosophy, and all pointing to an ultimate reality that goes beyond anything that speech or even thought can reach, leave very little to work on for someone who were to approach an entirely traditional Indian scene with the tools and methods of Western psychotherapy. Yet, in view of the present trend towards 'Westernisation', Western methods of psychotherapy have their place, at least for the most modernised sectors of the population. Even then, traditional patterns of personality development and family organisation which, even in a modern setting, still persist, place obstacles in the way of a smooth and meaningful application of Western psychotherapeutic models, not only in clinical practice, but also in the training of therapists. In addition, certain traditional notions concerning the relationship of an Indian 'guru' to his disciples work against a ready understanding and acceptance of Western theories and practices. This applies in particular to 'transference' and more so to 'negative transference' in the therapeutic relationship.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunobiology of molar pregnancy and gestational trophoblastic tumors.

Because all the chromosomes in complete molar pregnancy are of paternal origin, complete moles are complete allografts (transplants). Complete moles may therefore be expected to induce a vigorous maternal host immunologic response. Further understanding of the relationships between the normal placenta, mole and choriocarcinoma may provide important insights into the basic mechanisms of teratogenesis and carcinogenesis.

Histocompatibility antigens (HLA-A,B,C) are not detectable in molar villous fluid.

Cell-free villous fluid from healthy and necrotic molar villi did not contain detectable soluble HLA Class I (HLA-A,B,C) antigens; therefore, HLA sensitization of the maternal host is probably not attributable to shedding of HLA antigens by viable or degenerating HLA-positive stromal cells. The method developed for this study, a combination of immunoprecipitation and Western blot techniques, employed specific antibodies for positive identification of the HLA heavy chain. The pathogenesis of complete molar pregnancy may be better understood through further study of the mechanisms of HLA sensitization of the maternal host and the host's response to these foreign antigens.

A specific estrogen receptor in the mouse spleen. Characterization and evidence of physiological regulation.

We have used the synthetic estrogen [3H]-R2858 (11 beta-methoxy-17-ethnyl-1,3,5(10)-estratriene-3,17-diol) to characterize a cytoplasmic estrogen receptor in the mouse spleen. This receptor is specific for estrogens and binds to the steroids with high affinity. The binding is abolished by pronase or 37 C treatment, and the 8S peak is shifted to the 4S region on sucrose gradients under conditions of high salt. The concentration of spleen receptor increased significantly during pregnancy, and decreased after immunization with foreign protein. Estrogen receptors may be confined to certain subpopulations of spleen cells that change in numbers during pregnancy or after immunization.

Evaluation of blood pressure in vasectomized and nonvasectomized men.

We assessed the effect of vasectomy on blood pressure by collecting cross-sectional data on the systolic and diastolic blood pressure of 946 male volunteer blood donors; of these, 30% were vasectomized. We used analysis of multiple covariance to correct both pressures for variation in age, weight, and height. Vasectomized and nonvasectomized men did not differ significantly in mean systolic or diastolic blood pressures. However, many of these men had been vasectomized for only a short period of time. We analysed the vasectomy subsample by multiple regression to determine whether blood pressures adjusted for age, body mass index, and height changed with time since vasectomy and found a slight, but non-significant, rise in the systolic pressure with square of time since vasectomy. The data are sufficiently strong to raise concern that data from a sample of men who have been vasectomized for longer periods of time would have shown a more dramatic increase.

PIP: This study evaluates the extent to which vasectomy might affect blood pressure thus contributing to hasten the rate of atherogenesis in men. Data were collected from 946 men, of whom 30.1% had been vasectomised; variables considered were number of years since vasectomy, weight, height, body mass and age. No significant differences were found in mean systolic or distolic blood pressure between the 2 groups of men, it was noted, however, that many men had been vasectomized only for a short period of time. When the group of vasectomized men were analyzed by multiple regression to determine the relation of blood pressure, age, body mass index, and height with time since vasectomy, a slight rise in systolic pressure was found, related with time since vasectomy. Conclusions from this investigation may not be correct for the general population since the sample studied here was nontypical and was not checked for factors such as race, diet, smoking habit, or physical fitness, which may potentially affect blood pressure. However, if the data are consistent with the hypothesis that there are no effects on blood pressure attributable to vasectomy, they also are consistent with a moderate rise in the systolic blood pressure of vasectomized males; the effect seems to accelerate with time. This problem should be further investigated on a larger number of males vasectomized for a period of 15 years or more.