Sexual minorities between equality and exclusion.

The situation of people with different sexual orientations and gender identities varies worldwide depending on the legal and social situation despite a formal depathologization in the medical classification systems DSM 1973 and ICD 1991. The spectrum ranges from equality to discrimination and exclusion to social ostracism, sometimes combined with legal persecution, in some countries even with the threat of a death penalty. On the basis of a historical overview of the medical-social discourse, it will be shown which scientific and societal advances make depathologization possible, although even in today's times a consistent and sustainable effect of this depathologization appears to be increasingly difficult in some countries, and in some cases even a societal re-pathologization is taking place. Aspects of persistent medical and societal stigma on the health of LGBT (lesbian, gay, bisexual, transgender) people are highlighted. Scientific models that empirically explain the increased risk of mental illness among LGBT people as a result of various forms of stigma and guidelines for psychotherapeutic treatment are presented. In an outlook, the continuing precarious situation of sexual minorities worldwide is pointed out and the importance of medical, social and political destig matization as a prerequisite for the mental health of LGBT people is emphasized. Non-discriminatory legislation is an important element in addition to medical statements and medical guidelines for treatment.

[Sexual minorities between equality and exclusion].

The situation of people with different sexual orientations and gender identities varies worldwide depending on the legal and social situation despite a formal depathologization in the medical classification systems DSM 1973 and ICD 1991. The spectrum ranges from equality to discrimination and exclusion to social ostracism, sometimes combined with legal persecution, in some countries even with the threat of a death penalty. On the basis of a historical overview of the medical-social discourse, it will be shown which scientific and societal advances make depathologization possible, although even in today's times a consistent and sustainable effect of this depathologization appears to be increasingly difficult in some countries, and in some cases even a societal re-pathologization is taking place. Aspects of persistent medical and societal stigma on the health of LGBT (lesbian, gay, bisexual, transgender) people are highlighted. Scientific models that empirically explain the increased risk of mental illness among LGBT people as a result of various forms of stigma and guidelines for psychotherapeutic treatment are presented. In an outlook, the continuing precarious situation of sexual minorities worldwide is pointed out and the importance of medical, social and political destig matization as a prerequisite for the mental health of LGBT people is emphasized. Non-discriminatory legislation is an important element in addition to medical statements and medical guidelines for treatment.

Ethical Aspects of Mental Health Care for Lesbian, Gay, Bi-, Pan-, Asexual, and Transgender People: A Case-based Approach.

The lives of lesbian, gay, bi-, pan-, asexual, and transgender (LGBTA+/LGBT) people are not considered to be standard in society, unlike those of heterosexual cisgender people. This can lead to prejudices against LGBT people and may negatively influence their access to high-quality health care. Medical and mental health care have been characterized by attitudes (psycho-)pathologizing LGBT lives and therefore supported the stigmatization of LGBT people in the service of heteronormativity. Mental health professionals (MHPs) largely have transferred principles guiding counseling and psychotherapy with heterosexual (straight) cisgender persons to treatment of LGBT individuals without considering the specific features of LGBT lives. This is true even if the treatment is not exclusively LGBT-related, but can address LGBT-unrelated issues. To counteract this, the present paper aims to provide an insight into ethically sound mental health care for LGBT people. By applying the principles of biomedical ethics, we have analyzed how LGBT individuals can be discriminated against in mental health care and what MHPs may need to offer LGBT-sensitive high-quality mental health care. We argue that MHPs need LGBT-related expertise as well as LGBT-related sensitivity. MHPs should acquire specialist knowledge for the diverse lives and the challenges of LGBT people. We encourage MHPs to develop an understanding of how their own implicit attitudes towards LGBT people can affect treatment. However, the demand for special training should not be mistaken as a demand for a specific type of mental health care. The principles of general psychotherapy are equally the basis of psychotherapy with LGBT people.

[Effects and side effects of the disease concept "Homosexuality"]. / Wirkungen und Nebenwirkungen des Krankheitskonzepts "Homosexualität".

The diagnosis of homosexuality was removed from the DSM in 1973 and from the ICD in 1991. Despite this formal depathologization, negative effects of the concept of "homosexuality" as a disease, which stems from the 19th century, are still evident to this day and will be highlighted in this article. Furthermore, we also demonstrate the related interactions between social and medical processes. First, we give a global overview of the legal and social situation of sexual minorities, ranging from gender equality to marginalization and persecution. This is followed by a historical outline of the medical-social discourses in order to understand the connection between social stigmatization and pathologizing theories on homosexuality. Thereby, it can be demonstrated how scientific and social progress made the depathologization of homosexuality necessary, but also how difficult a consistent and sustainable effect of this depathologization appears to be. Additionally, we focus on the effects of persistent medical and social stigma on the health of LGB (lesbian, gay, bisexual) people. For this purpose, scientific models will be utilised in order to explain the increased risk of mental illness in LGB people arising as a direct result of various forms of stigmatization. In an outlook, we point out the ongoing precarious situation of sexual minorities in many parts of the world and emphasize the importance of destigmatizing polices and guidelines as carried out by the World Medical Association in 2013.

[Pathogenetic and salutogenetic aspects of physicians' health]. / Pathogenetische und salutogenetische Aspekte der Ärztegesundheit - eine qualitative Katamnese betroffener Ärzte.

OBJECTIVE: To analyse pathogenetic and salutogenetic processes of physicians suffering from depression, burnout and drug addiction. METHODS: Qualitative follow-up interviews with 32 former physician patients from the Oberbergkliniken hospital group. RESULTS: Long working hours, bureaucratic restrictions and double burdens of combining family life and professional demands are major pathogenetic strains. They interact with biographic performance scripts. Major salutogenetic factors are the expansion of self care with regard to physical, spiritual and social needs and the reconstruction of resources outside the job. CONCLUSIONS: Prevention programmes for health care professionals should focus on the reflection of biographic performance scripts, on maintaining multifaceted sources of gratification and the buildup of extra-professional resources.

Course of life satisfaction in patients with depressive and addictive disorders after therapeutic intervention.

BACKGROUND/AIM: To analyse the course of life satisfaction during the clinic stay of patients with depressive and/or addictive disorders. METHODS: In a cohort study, 199 patients with depressive and addictive diseases were asked to complete a series of questionnaires at the start and the end of their psychotherapeutic treatment (on average 4.2 ± 2.3 weeks later). The questionnaires were the Brief Multidimensional Life Satisfaction Scale (BMLSS), the Positive Life Construction/Contentedness/Well-Being Scale from the ERDA (Emotional/Rational Disease Acceptance) questionnaire, Beck's Depression Inventory and the revised Symptom Checklist (SCL-90-R). RESULTS: The psychotherapeutic interventions improved the clinical situation of the patients and resulted in strong effects with respect to positive life construction (d = 1.07) and moderate effects on life satisfaction (d = 0.71). Stronger effects were noted in patients with depressive disorders (d = 0.80) than in patients with addictive disorders (d = 0.69). Regression analyses revealed that pre-treatment life satisfaction can be explained negatively by an escape-avoidance strategy (Escape from Illness), and positively by positive life construction. In contrast, post-treatment life satisfaction can be explained negatively by psychological distress and depression, and positively by positive life construction and living with a partner. CONCLUSION: The hypothesis that life satisfaction changes are associated with the clinical situation of patients was confirmed. In particular, patients with depressive disorders profited from the psychotherapeutic interventions.

Emotional and rational disease acceptance in patients with depression and alcohol addiction.

BACKGROUND: The concept of a rational respectively emotional acceptance of disease is highly valued in the treatment of patients with depression or addiction. Due to the importance of this concept for the long-term course of disease, there is a strong interest to develop a tool to identify the levels and factors of acceptance. We thus intended to test an instrument designed to assess the level of positive psychological wellbeing and coping, particularly emotional disease acceptance and life satisfaction METHODS: In an anonymous cross-sectional survey enrolling 115 patients (51% female, 49% male; mean age 47.6 +/- 10.0 years) with depression and/or alcohol addiction, the ERDA questionnaire was tested. RESULTS: Factor analysis of the 29-item construct (Cronbach's alpha = 0.933) revealed a 4-factor solution, which explained 59.4% of variance: (1) Positive Life Construction, Contentedness and Well-Being; (2) Conscious Dealing with Illness; (3) Rejection of an Irrational Dealing with Disease; (4) Disease Acceptance. Two factors could be ascribed to a rational, and two to an emotional acceptance. All factors correlated negatively with Depression and Escape, while several aspects of Life Satisfaction" (i.e. myself, overall life, where I live, and future prospects) correlated positively. The highest factor scores were found for the rational acceptance styles (i.e. Conscious Dealing with Illness; Disease Acceptance). Emotional acceptance styles were not valued in a state of depression. Escape from illness was the strongest predictor for several acceptance aspects, while life satisfaction was the most relevant predictor for "Positive Life Construction, Contentedness and Well-Being". CONCLUSION: The ERDA questionnaire was found to be a reliable and valid assessment of disease acceptance strategies in patients with depressive disorders and drug abuses. The results indicate the preferential use of rational acceptance styles even in depression. Disease acceptance should not be regarded as a coping style with an attitude of fatalistic resignation, but as a complex and active process of dealing with a chronic disease. One may assume that an emotional acceptance of disease will result in a therapeutic coping process associated with higher level of life satisfaction and overall quality of life.

Alcoholism in women: is it different in onset and outcome compared to men?

Onset and course of alcohol dependence show gender related differences (telescoping effect) suggesting that women are more vulnerable to chronic alcohol consumption. This raises the question whether the differences are associated with a different treatment outcome as well. We hypothesized, that alcohol dependent women with a telescoping course show a less favourable treatment outcome compared to men. We investigated 212 alcohol dependent patients; matching 106 consecutively admitted women with 106 men drawn from a total sample of 343 male patients. The treatment program consisted of a 6 week inpatient treatment and 12 months of outpatient aftercare. We assessed milestone variables in development and course of alcoholism and carried out standardized diagnostic tests, physical and blood examinations to evaluate the course of the disease and treatment outcome. Overall, we confirm the telescoping effect, a faster progression in the course of alcoholism (developmental events and adverse consequences) in women compared to men ("telescoping effect"). However, despite the telescoping effect treatment outcome was similar in women and men. During the inpatient treatment program no alcohol relapse occurred. Throughout the 12 months outpatient treatment we found no significant differences in the survival analysis between women (283.29+/-11.26 days) and men (284.72+/-12.16 days). At the end of the 12 months both groups had an abstinence rate of approximately 50% and a drop-out rate of 33%.

Detection and management of alcohol use disorders in German primary care influenced by non-clinical factors.

AIMS: The primary objective was to assess the proportion of detected and correctly referred patients in German primary care. The secondary objective was to identify patient and practitioner characteristics that predict detection and correct referral. METHODS: In this clustered cross-sectional survey in German primary care, 3003 patients were consecutively invited to participate, and were asked to fill in a standardized health questionnaire. They were then screened for problematic alcohol consumption using the Alcohol Use Disorders Identification Test. The physicians recorded their assessment of the presence of any alcohol use disorder and documented the treatment course of all identified patients for 3 months. RESULTS: Correctly identified problem drinkers were 38.6% in a per-protocol analysis and 33.6% using a worst-case scenario. Referral behaviour of physicians was in conformity with current practice guidelines in 64.6% of the documented cases and 27.0% in a worst-case scenario. Several patient (e.g. sex, age) and practitioner characteristics (e.g. age), which influence the diagnosis and referral of patients, could be identified. CONCLUSIONS: There is a clear need to increase the special diagnostic and therapeutic skills of general practitioners so that they may be able to indicate and perform secondary prevention. Further research should focus on the likely effects of the implementation of these diagnostic and management tools.

The validity of the laboratory marker combinations DOVER and QUVER to detect physician's diagnosis of at-risk drinking.

Especially in situations where it might be favorable for the patient to dissimulate the existing alcohol problem, 'objective' laboratory tests can be helpful. In this study we report validation of the two combinations DOVER (DOctor VERified) and QUVER (QUestionnarie VERified) of the biological markers percent carbohydrate-deficient transferrin (%CDT) and gamma-glutamyl-transferase (gamma-GT) to detect patients that have been identified by their physicians with at-risk drinking behavior. Fifty-eight general practitioners (GPs) participated at two study sites in South-West Germany. Patients filled in a questionnaire that included the alcohol use disorders identification test (AUDIT) and gave a blood sample. The GP recorded his/her assessment about the presence of an alcohol-related disorder in the patient. Receiver operating characteristics (ROC) analyses of the marker combinations DOVER and QUVER were performed. A total of 2940 patients participated in the study, of which 2496 completed data sets that could be used for further analysis. The area under the curve (AUC) of 79.5% for DOVER and 77.2% (QUVER) are in a higher range than the values for gamma%CDT (75.7%) or gamma-GT (72.5%) and %CDT (64.5%) and suggest superiority of the proposed marker combinations. Cross-validation results were almost identical with 76.6% and 73.3% for DOVER and QUVER, respectively. Our analysis demonstrated that the combination of the markers gamma-GT and %CDT with the physician's judgement of the condition as reference was superior to the use of single markers.

DOVER and QUVER-new marker combinations to detect and monitor at-risk drinking.

BACKGROUND: At-risk drinking is a common medical problem. "Objective" laboratory tests are widely used, especially in situations where it might be favorable for the patient to dissimulate the existing alcohol problem. In this study, we report a new approach to combine the biological markers % carbohydrate-deficient transferrin (%CDT) and gamma-glutamyltransferase (gammaGT) to increase diagnostic properties to identify patients with at-risk drinking behavior. METHODS: Fifty-eight general practitioners (GPs) participated in the study at 2 study sites in South-West Germany. Patients filled in a questionnaire that included the Alcohol Use Disorders Identification Test (AUDIT) and gave a blood sample. The GP recorded his assessment about the presence of an alcohol-related disorder in the patient. Screening results of 1 test center were used as a calculation sample. The results at the other site were used to cross-validate the study outcomes. The markers were combined by 2 methods. The first approach used the AUDIT (QUestionnaire VERified; QUVER), and the second was performed using the clinical judgment of the treating GP (DOctor VERified; DOVER). The formulas were calculated using linear and logistic regression models, respectively. RESULTS: A total of 2,940 patients participated in the study, of whom 2,496 completed data sets that could be used for further analysis. In the receiver-operating characteristics (ROC) curves with the reference standard of an AUDIT> or =8, the area under the curve (AUC) of 78.8% for DOVER and 80.6% (QUVER) are in a higher range than the values for gamma-%CDT (75.4%) or gamma-GT (66.3%) and %CDT (74.3%) and suggest a clear superiority of the proposed marker combinations. Regarding the combinations DOVER and QUVER, the cross-validation results were almost identical, with 78.4/78.8% and 80.6/79.5%, respectively. CONCLUSION: Our study is to date the largest practice-based trial that examines the value of the markers CDT and gamma-GT and their combinations for the screening of at-risk drinking in general practice under routine conditions. Our ROC analysis clearly demonstrated that the combination of the markers gamma-GT and %CDT under routine conditions with a behaviorally oriented reference standard leads to an improvement of diagnostic performance, more so than the use of single markers.

Correlation of stable elevations in striatal mu-opioid receptor availability in detoxified alcoholic patients with alcohol craving: a positron emission tomography study using carbon 11-labeled carfentanil.

BACKGROUND: The pleasant effects of food and alcohol intake are partially mediated by mu-opiate receptors in the ventral striatum, a central area of the brain reward system. Blockade of mu-opiate receptors with naltrexone reduces the relapse risk among some but not all alcoholic individuals. OBJECTIVE: To test the hypothesis that alcohol craving is pronounced among alcoholic individuals with a high availability of mu-opiate receptors in the brain reward system. DESIGN: Patients and comparison sample. The availability of central mu-opiate receptors was measured in vivo with positron emission tomography (PET) and the radioligand carbon 11-labeled carfentanil in the ventral striatum and compared with the severity of alcohol craving as assessed by the Obsessive Compulsive Drinking Scale (OCDS). SETTING: Hospitalized care. PARTICIPANTS: Volunteer sample of 25 male alcohol-dependent inpatients assessed after detoxification of whom 12 underwent PET again 5 weeks later. Control group of 10 healthy men. MAIN OUTCOME MEASURES: After 1 to 3 weeks of abstinence, the availability of mu-opiate receptors in the ventral striatum, including the nucleus accumbens, was significantly elevated in alcoholic patients compared with healthy controls and remained elevated when 12 alcoholic patients had these levels measured 5 weeks later (P<.05 corrected for multiple testing). Higher availability of mu-opiate receptors in this brain area correlated significantly with the intensity of alcohol craving as assessed by the OCDS. CONCLUSIONS: Abstinent alcoholic patients displayed an increase in mu-opiate receptors in the ventral striatum, including the nucleus accumbens, which correlated with the severity of alcohol craving. These findings point to a neuronal correlate of alcohol urges.

[The qualified-detoxification-of-alcoholics procedure--in light of the development of guidelines for the treatment of substance-related disorders]. / Die "Qualifizierte Entgiftung Alkoholkranker"--Im Lichte der Entwicklung von Behandlungsleitlinien für substanzbezogene Störungen.

The qualified-detoxification-of-alcoholics procedure encompasses the diagnosis and treatment of ethanol intoxication, the states of complicated and uncomplicated withdrawal, addiction as the underlying disease and the consequences of heavy drinking. There is empirical evidence that treatment periods of 3 weeks for inpatients are efficient and cost-effective and there are indications that the shorter treatment periods enforced by health insurance companies may lead to rapid relapse and readmission and hence to longer total treatment times and higher costs.