Association of polygenic score and the involvement of cholinergic and glutamatergic pathways with lithium treatment response in patients with bipolar disorder

Lithium is regarded as the first-line treatment for bipolar disorder (BD), a severe and disabling mental health disorder that affects about 1% of the population worldwide. Nevertheless, lithium is not consistently effective, with only 30% of patients showing a favorable response to treatment. To provide personalized treatment options for bipolar patients, it is essential to identify prediction biomarkers such as polygenic scores. In this study, we developed a polygenic score for lithium treatment response (Li+PGS) in patients with BD. To gain further insights into lithium's possible molecular mechanism of action, we performed a genome-wide gene-based analysis. Using polygenic score modeling, via methods incorporating Bayesian regression and continuous shrinkage priors, Li+PGS was developed in the International Consortium of Lithium Genetics cohort (ConLi+Gen: N = 2367) and replicated in the combined PsyCourse (N = 89) and BipoLife (N = 102) studies. The associations of Li+PGS and lithium treatment response - defined in a continuous ALDA scale and a categorical outcome (good response vs. poor response) were tested using regression models, each adjusted for the covariates: age, sex, and the first four genetic principal components. Statistical significance was determined at P < 0.05. Li+PGS was positively associated with lithium treatment response in the ConLi+Gen cohort, in both the categorical (P = 9.8 × 10-12, R2 = 1.9%) and continuous (P = 6.4 × 10-9, R2 = 2.6%) outcomes. Compared to bipolar patients in the 1st decile of the risk distribution, individuals in the 10th decile had 3.47-fold (95%CI: 2.22-5.47) higher odds of responding favorably to lithium. The results were replicated in the independent cohorts for the categorical treatment outcome (P = 3.9 × 10-4, R2 = 0.9%), but not for the continuous outcome (P = 0.13). Gene-based analyses revealed 36 candidate genes that are enriched in biological pathways controlled by glutamate and acetylcholine. Li+PGS may be useful in the development of pharmacogenomic testing strategies by enabling a classification of bipolar patients according to their response to treatment.

Recommendations for Reducing the Risk of Cannabis Use-Related Adverse Psychosis Outcomes: A Public Mental Health-Oriented Evidence Review

Objective: Cannabis use is increasingly normalized; psychosis is a major adverse health outcome. We reviewed evidence on cannabis use-related risk factors for psychosis outcomes at different stages toward recommendations for risk reduction by individuals involved in cannabis use. Methods: We searched primary databases for pertinent literature/data 2016 onward, principally relying on reviews and high-quality studies which were narratively summarized and quality-graded; recommendations were developed by international expert consensus. Results: Genetic risks, and mental health/substance use problem histories elevate the risks for cannabis-related psychosis. Early age-of-use-onset, frequency-of-use, product composition (i.e., THC potency), use mode and other substance co-use all influence psychosis risks; the protective effects of CBD are uncertain. Continuous cannabis use may adversely affect psychosis-related treatment and medication effects. Risk factor combinations further amplify the odds of adverse psychosis outcomes. Conclusions: Reductions in the identified cannabis-related risks factors-short of abstinence-may decrease risks of related adverse psychosis outcomes, and thereby protect cannabis users' health.

Medication adherence and cognitive performance in schizophrenia-spectrum and bipolar disorder: results from the PsyCourse Study

Existing guidelines recommend psychopharmacological treatment for the management of schizophrenia and bipolar disorder as part of holistic treatment concepts. About half of the patients do not take their medication regularly, although treatment adherence can prevent exacerbations and re-hospitalizations. To date, the relationship between medication adherence and cognitive performance is understudied. Therefore, this study investigated the relationship between medication adherence and cognitive performance by analyzing the data of 862 participants with schizophrenia-spectrum and bipolar disorders (mean [SD] age, 41.9 [12.48] years; 44.8% female) from a multicenter study (PsyCourse Study). Z-scores for three cognitive domains were calculated, global functioning was measured with the Global Assessment of Functioning Scale, and adherence was assessed by a self-rating questionnaire. We evaluated four multiple linear regression models and built three clusters with hierarchical cluster analyses. Higher adherence behavior (p < 0.001) was associated with better global functioning but showed no impact on the cognitive domains learning and memory, executive function, and psychomotor speed. The hierarchical cluster analysis resulted in three clusters with different cognitive performances, but patients in all clusters showed similar adherence behavior. The study identified cognitive subgroups independent of diagnoses, but no differences were found in the adherence behavior of the patients in these new clusters. In summary, medication adherence was associated with global but not cognitive functioning in patients with schizophrenia-spectrum and bipolar disorders. In both diagnostic groups, cognitive function might be influenced by various factors but not medication adherence.

Association of Polygenic Score and the involvement of Cholinergic and Glutamatergic Pathways with Lithium Treatment Response in Patients with Bipolar Disorder

Lithium is regarded as the first-line treatment for bipolar disorder (BD), a severe and disabling mental disorder that affects about 1% of the population worldwide. Nevertheless, lithium is not consistently effective, with only 30% of patients showing a favorable response to treatment. To provide personalized treatment options for bipolar patients, it is essential to identify prediction biomarkers such as polygenic scores. In this study, we developed a polygenic score for lithium treatment response (Li+PGS) in patients with BD. To gain further insights into lithium's possible molecular mechanism of action, we performed a genome-wide gene-based analysis. Using polygenic score modeling, via methods incorporating Bayesian regression and continuous shrinkage priors, Li+PGS was developed in the International Consortium of Lithium Genetics cohort (ConLi+Gen: N=2,367) and replicated in the combined PsyCourse (N=89) and BipoLife (N=102) studies. The associations of Li+PGS and lithium treatment response - defined in a continuous ALDA scale and a categorical outcome (good response vs. poor response) were tested using regression models, each adjusted for the covariates: age, sex, and the first four genetic principal components. Statistical significance was determined at P<����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������.

Association of early life stress and cognitive performance in patients with schizophrenia and healthy controls

As core symptoms of schizophrenia, cognitive deficits contribute substantially to poor outcomes. Early life stress (ELS) can negatively affect cognition in patients with schizophrenia and healthy controls, but the exact nature of the mediating factors is unclear. Therefore, we investigated how ELS, education, and symptom burden are related to cognitive performance. The sample comprised 215 patients with schizophrenia (age, 42.9 ± 12.0 years; 66.0 % male) and 197 healthy controls (age, 38.5 ± 16.4 years; 39.3 % male) from the PsyCourse Study. ELS was assessed with the Childhood Trauma Screener (CTS). We used analyses of covariance and correlation analyses to investigate the association of total ELS load and ELS subtypes with cognitive performance. ELS was reported by 52.1 % of patients and 24.9 % of controls. Independent of ELS, cognitive performance on neuropsychological tests was lower in patients than controls (p < 0.001). ELS load was more closely associated with neurocognitive deficits (cognitive composite score) in controls (r = -0.305, p < 0.001) than in patients (r = -0.163, p = 0.033). Moreover, the higher the ELS load, the more cognitive deficits were found in controls (r = -0.200, p = 0.006), while in patients, this correlation was not significant after adjusting for PANSS. ELS load was more strongly associated with cognitive deficits in healthy controls than in patients. In patients, disease-related positive and negative symptoms may mask the effects of ELS-related cognitive deficits. ELS subtypes were associated with impairments in various cognitive domains. Cognitive deficits appear to be mediated through higher symptom burden and lower educational level.

Feasibility and Short-Term Effects of Low-Threshold Opioid Substitution Treatment during the COVID-19 Pandemic in Hamburg, Germany

INTRODUCTION

After rapidly opening up a low-threshold clinic to support heavily opioid-dependent persons at the beginning of the COVID-19 pandemic in April 2020 in Hamburg (Germany), this non-interventional study evaluated the feasibility and short-term effects of opioid substitution treatment (OST). The low-threshold concept was customized for the pandemic situation and is the first of its kind in Germany.

METHODS

Patients who had already begun treatment were questioned in two assessments, at T1 shortly after beginning treatment and at T2 6 months later. The primary outcome criterion was their quality of life using the OSTQOL. Secondary criteria included retention rate, their mental and physical health (measured by the BSI-18 and the OTI Health Scale), social situation, drug use, COVID-19 status, and satisfaction with treatment.

RESULTS

Out of 84 patients included in the study, 51 participated in both assessments, resulting in a 6-month retention rate of 60.7%. 27.5% were females, and 72.5% were males. The feasibility question of the low-threshold OST clinic can clearly be answered positively. During the course of the study over 6 months, the situation mainly remained stable regarding quality of life, physical and mental health, and days of drug consumption. Patients significantly reduced the time they spent on the drug scene from 8.5 (SD = 7.56) to 6.1 (SD = 6.71) hours a day between the beginning of OST and T2 (p = 0.020). While 56.9% answered to be homeless at the beginning of OST, only 33.3% answered not to have found an accommodation by T2 (p = 0.012). The number of patients having contact to social workers increased from 51.0% to 74.5% (p = 0.004). Almost 2 fifths of the patients took part in PCR testing for COVID-19 (that only being done if they had symptoms), and none of the tests were positive.

DISCUSSION/CONCLUSIONS

Overall, the low-threshold OST clinic has been successfully implemented in order to help a vulnerable group of people navigate through a global pandemic and support the public health sector. Further conclusions on effects are limited by the short study period and the small number of patients, which calls for further research studies in a larger setting.

Estimating the prevalence of alcohol-related disorders and treatment utilization in Bremen 2016/2017 through routine data linkage

BACKGROUND

In Germany, most individuals with alcohol dependence are recognized by the health care system and about 16% per year receive addiction-specific care. This paper aimed to analyze the prevalence and treatment utilization rate of people with alcohol dependence by type of addiction-specific care in the federal state of Bremen using routine and survey data.

METHODS

The number of individuals with alcohol dependence was estimated using data from the 2018 Epidemiological Survey of Substance Abuse (ESA). Furthermore, linked routine data of two statutory health insurances (SHIs), the German pension insurance (GPI), and the communal hospital group Gesundheit Nord - Bremen Hospital Group (GeNo), from 2016/2017, were analyzed. Based on SHI data, the administrative prevalence of various alcohol-related diagnoses according to the International Classification of Diseases (ICD-10), in various treatment settings, was extrapolated to the total population of Bremen. Based on all routine data sources, treatment and care services for individuals with alcohol dependence were also extrapolated to Bremen's total population. Care services included outpatient addiction care visits and addiction-specific treatments, [i.e., qualified withdrawal treatment (QWT), outpatient pharmacotherapy as relapse prevention, and rehabilitation treatment].

RESULTS

Of the survey-estimated 15,792 individuals with alcohol dependence in Bremen, 72.4% (n = 11,427) had a diagnosis documented with an ICD-10 code for alcohol dependence (F10.2) or withdrawal state (F10.3-4). One in 10 individuals with alcohol dependence (n = 1,577) used one or more addiction-specific care services during the observation period. Specifically, 3.7% (n = 675) received outpatient addiction care, 3.9% (n = 736) initiated QWT, 0.8% (n = 133) received pharmacotherapy, and 2.6% (n = 405) underwent rehabilitation treatment. The share of seeking addiction-specific treatment after diagnosis was highest among younger and male patients.

CONCLUSION

Although more than half of the individuals with alcohol dependence are documented in the health system, utilization rates of addiction-specific treatments are low. These low utilization rates suggest that there are existing barriers to transferring patients with alcohol dependence into addiction-specific care. Strengthening primary medical care provision in dealing with alcohol-related disorders and improving networking within the addiction support system appear to be particularly appropriate.

[Home Treatment "Bremen ambulant vor Ort (BravO)"]

OBJECTIVE

The existing legal framework to foster home treatment for severe mental illness imposes challenges for implementation. 'Bremen ambulant vor Ort (BravO)' provides home treatment on basis of the "Bundespflegesatzverordnung".

METHODS

The concept and framework of BravO will be outlined, routine data on the BravO treatment from October 1^st, 2019 to September 30^th, 2021 were analysed.

RESULTS

Financial and staff resources of 20 in-patient treatment places were equivalently transferred into BravO. 298 patients generating 392 cases received treatment. Median treatment span was 36 days, with 21 days (median) of service delivery. 74.7 % were diagnosed either in ICD-10 groups F2 or F3.

CONCLUSION

BravO was successfully implemented into routine care. BravO allows flexible home treatment for people with severe mental illness apart from existing treatment framework.

Study protocol of a randomized controlled trial evaluating home treatment with peer support for acute mental health crises (HoPe)

BACKGROUND

Home treatment (HT) is a treatment modality for patients with severe mental illness (SMI) in acute mental crises. It is frequently considered equivalent to psychiatric inpatient treatment in terms of treatment outcome. Peer Support (PS) means that people with lived experience of a mental illness are trained to support others on their way towards recovery. While PS is growing in international importance and despite a growing number of studies supporting its benefits, it is still not comprehensively implemented into routine care. The HoPe (Home Treatment with Peer Support) study investigates a combination of both - HT and PS - to provide further evidence for a recovery-oriented treatment of psychiatric patients.

METHODS

In our randomized controlled trial (RCT), HT with PS is compared with HT without PS within a network of eight psychiatric clinical centers from the North, South and East of Germany. We investigate the effects of a combination of both approaches with respect to the prevention of relapse/recurrence defined as first hospitalization after randomization (primary outcome), disease severity, general functioning, self-efficacy, psychosocial health, stigma resistance, recovery support, and service satisfaction (secondary outcomes). A sample of 286 patients will be assessed at baseline after admission to HT care (data point t₀) and randomized into the intervention (HT + PS) and control arm (HT). Follow-Up assessments will be conducted 2, 6 and 12 months after admission (resulting in three further data points, t₁ to t₃) and will be analyzed via intention-to-treat approach.

DISCUSSION

This study may determine the positive effects of PS added to HT, prove additional evidence for the efficacy of PS and thereby facilitate its further implementation into psychiatric settings. The aim is to improve quality of mental health care and patients' recovery as well as to reduce the risk of relapses and hospitalizations for patients with SMI.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov: NCT04336527 , April 7, 2020.

Patient-centered placement matching of alcohol-dependent patients based on a standardized intake assessment: process evaluation within an exploratory randomized controlled trial

BACKGROUND

In the implementation of placement matching guidelines, feasibility has been concerned in previous research. Objectives of this process evaluation were to investigate whether the patient-centered matching guidelines (PCPM) are consistently applied in referral decision-making from an inpatient qualified withdrawal program to a level of care in aftercare, which factors affect whether patients actually receive matched aftercare according to PCPM, and whether its use is feasible and accepted by clinic staff.

METHODS

The study was conducted as process evaluation within an exploratory randomized controlled trial in four German psychiatric clinics offering a 7-to-21 day qualified withdrawal program for patients suffering from alcohol dependence, and with measurements taken during detoxification treatment and six months after the initial assessment. PCPM were used with patients in the intervention group by feeding back to them a recommendation for a level of care in aftercare that had been calculated from Measurements in the Addictions for Triage and Evaluation (MATE) and discussed with the staff on the treatment unit. As measurements, The MATE, the Client Socio-Demographic and Service Receipt Inventory-European Version, a documentation form, the Control Preference Scale, and the Motivation for Treatment Scale were administered. A workshop for the staff at the participating trial sites was conducted after data collection was finished.

RESULTS

Among 250 patients participating in the study, 165 were interviewed at follow-up, and 125 had received aftercare. Although consistency in the application of PCPM was moderate to substantial within the qualified withdrawal program (Cohen's kappa ≥ .41), it was fair from discharge to follow-up. In multifactorial multinomial regression, the number of foregoing substance abuse treatments predicted whether patients received more likely undermatched (Odds Ratio=1.27; p=.018) or overmatched (Odds Ratio=0.78; p=.054) treatment. While the implementation process during the study was evaluated critically by the staff, they stated a potential of quality assurance, more transparency and patient-centeredness in the use of PCPM.

CONCLUSIONS

While the use of PCPM has the potential to enhance the quality of referral decision making within treatment, it may not be sufficient to determine referral decisions for aftercare.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00005035 . Registered 03/06/2013.

Polygenic risk scores across the extended psychosis spectrum

As early detection of symptoms in the subclinical to clinical psychosis spectrum may improve health outcomes, knowing the probabilistic susceptibility of developing a disorder could guide mitigation measures and clinical intervention. In this context, polygenic risk scores (PRSs) quantifying the additive effects of multiple common genetic variants hold the potential to predict complex diseases and index severity gradients. PRSs for schizophrenia (SZ) and bipolar disorder (BD) were computed using Bayesian regression and continuous shrinkage priors based on the latest SZ and BD genome-wide association studies (Psychiatric Genomics Consortium, third release). Eight well-phenotyped groups (n = 1580; 56% males) were assessed: control (n = 305), lower (n = 117) and higher (n = 113) schizotypy (both groups of healthy individuals), at-risk for psychosis (n = 120), BD type-I (n = 359), BD type-II (n = 96), schizoaffective disorder (n = 86), and SZ groups (n = 384). PRS differences were investigated for binary traits and the quantitative Positive and Negative Syndrome Scale. Both BD-PRS and SZ-PRS significantly differentiated controls from at-risk and clinical groups (Nagelkerke's pseudo-R2: 1.3-7.7%), except for BD type-II for SZ-PRS. Out of 28 pairwise comparisons for SZ-PRS and BD-PRS, 9 and 12, respectively, reached the Bonferroni-corrected significance. BD-PRS differed between control and at-risk groups, but not between at-risk and BD type-I groups. There was no difference between controls and schizotypy. SZ-PRSs, but not BD-PRSs, were positively associated with transdiagnostic symptomology. Overall, PRSs support the continuum model across the psychosis spectrum at the genomic level with possible irregularities for schizotypy. The at-risk state demands heightened clinical attention and research addressing symptom course specifiers. Continued efforts are needed to refine the diagnostic and prognostic accuracy of PRSs in mental healthcare.

Interplay between the genetics of personality traits, severe psychiatric disorders and COVID-19 host genetics in the susceptibility to SARS-CoV-2 infection

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, with its impact on our way of life, is affecting our experiences and mental health. Notably, individuals with mental disorders have been reported to have a higher risk of contracting SARS-CoV-2. Personality traits could represent an important determinant of preventative health behaviour and, therefore, the risk of contracting the virus.

AIMS

We examined overlapping genetic underpinnings between major psychiatric disorders, personality traits and susceptibility to SARS-CoV-2 infection.

METHOD

Linkage disequilibrium score regression was used to explore the genetic correlations of coronavirus disease 2019 (COVID-19) susceptibility with psychiatric disorders and personality traits based on data from the largest available respective genome-wide association studies (GWAS). In two cohorts (the PsyCourse (n = 1346) and the HeiDE (n = 3266) study), polygenic risk scores were used to analyse if a genetic association between, psychiatric disorders, personality traits and COVID-19 susceptibility exists in individual-level data.

RESULTS

We observed no significant genetic correlations of COVID-19 susceptibility with psychiatric disorders. For personality traits, there was a significant genetic correlation for COVID-19 susceptibility with extraversion (P = 1.47 × 10^-5; genetic correlation 0.284). Yet, this was not reflected in individual-level data from the PsyCourse and HeiDE studies.

CONCLUSIONS

We identified no significant correlation between genetic risk factors for severe psychiatric disorders and genetic risk for COVID-19 susceptibility. Among the personality traits, extraversion showed evidence for a positive genetic association with COVID-19 susceptibility, in one but not in another setting. Overall, these findings highlight a complex contribution of genetic and non-genetic components in the interaction between COVID-19 susceptibility and personality traits or mental disorders.

Substance Use and Chemsex in MSM - A Latent Class Analysis

Engagement in “chemsex” among men who have sex with men is associated with higher rates of STIs and HIV seroconversion as well as an increased mental health burden. MSM were recruited for an anonymous online survey. The survey included questions of substance use, consumption motives, sexual risk behavior, HIV serostatus, and psychological characteristics. A latent class analysis was used to identify subgroups based on the consumed substances. 597 MSM answered the questionnaire. The latent class analysis revealed four different clusters. Most men described the use of amyl nitrite and cannabis ( n = 370). One cluster consumed mainly MDMA, cocaine, and amphetamine ( n = 106) and another cluster used mainly chemsex-related drugs ( n = 43). A fourth cluster reported a range of consumed substances ( n = 78). This cluster reported higher rates of suicide attempts, STIs, and risk behaviors. Substances typically related to chemsex were consumed in a sexualized context to a relevant extent.

Editorial

Liebe Leserin, lieber Leser,

ich weiß nicht, ob Sie ‚White Lines‘ - eine in der Hauptsache auf Ibiza spielende Netflix Serie aus dem Frühjahr 2020 - gesehen haben. Die Süddeutsche Zeitung schrieb „eine Krimi-, Familien- und Hedonismusgeschichte mit skurrilen Elementen, elektronischer Musik und spektakulär inszenierten Partys“. Die Serie, die ich vor gut einem Jahr vergnügt verfolgt habe, fiel mir beim Lesen des Beitrags der Autoren Köhler und Grau, Köln, zum Thema ‚Kokain abseits von pathologischem Konsum‘ ein.

Barrieren und Umsetzungsstrategien für die Implementierung der S3-Leitlinie Screening, Diagnose und Behandlung alkoholbezogener Störungen aus Sicht von Behandlern und Betroffenen

Ziel der Studie Für die erfolgreiche Implementierung von Leitlinien sind kontextspezifische Umsetzungsstrategien, welche die spezifische Versorgungssituation sowie mögliche Umsetzungsbarrieren berücksichtigen, vielversprechend. Ziel dieser Untersuchung war es, mögliche Barrieren und präferierte Umsetzungsstrategien für die Implementierung der S3-Leitlinie „Screening, Diagnose und Behandlung alkoholbezogener Störungen“ aus der Perspektive von Behandlern und Betroffenen zu erfassen.

Methodik Als Teil des vom Bundesministerium für Gesundheit geförderten Projekts Implementierung und Evaluation der S3-Leitlinie zu Screening, Diagnose und Behandlung alkoholbezogener Störungen (IMPELA) wurden Barrieren und mögliche Strategien für die Umsetzung der Leitlinienempfehlungen mithilfe eines selbst entwickelten Fragebogens querschnittlich erhoben. Sowohl Gesundheitsfachpersonal aus Primärversorgung und Suchthilfe (Behandler) als auch Betroffene von alkoholbezogenen Störungen und deren Angehörige in der Modellregion Bundesland Bremen wurden mithilfe unterschiedlicher Rekrutierungsstrategien (postalisch, persönlich, über ausgelegte Flyer) zur Teilnahme eingeladen. Der Fragebogen konnte in Papierversion oder online bearbeitet werden. Zusätzlich wurde der Fragebogen online über relevante Fachgesellschaften und Patientenorganisationen mithilfe von E-Mailverteilern bundesweit verbreitet.

Ergebnisse Datensätze von 263 Behandlern wurden in die Auswertung eingeschlossen, davon 163 (62%) Behandler aus Bremen und 100 (38%) aus anderen Bundesländern. Die Behandler waren im Mittel zwischen 51,7 (Bremen) und 50,9 (Bundesweit) Jahre alt und hatten 22,8 (Bremen) bzw. 23,7 (Bundesweit) Jahre Berufserfahrung. Die Mehrheit der Befragten waren Ärzte (62,6% Bremen; 50% Bundesweit). Als Hauptbarrieren empfanden die Behandler das mangelnde Wissen über die Existenz der Leitlinie (65,6% Bremen; 44% Bundesweit) und die geringen zeitlichen Ressourcen im Behandlungsalltag (68,7% Bremen; 50% Bundesweit). Als mögliche Umsetzungsstrategien wurden u. a. die stärkere Information der Fachöffentlichkeit (33,7% Bremen; 39% Bundesweit) sowie Fact-Sheets (34,9% Bremen; 38% Bundesweit) genannt. Zusätzlich konnten Daten von 94 Betroffenen/Angehörigen ausgewertet werden (57,7% männlich; Alter M=44,7 Jahre). Von diesen gaben 51 Personen (54,3%) an, bereits selbst eine Suchtbehandlung in Anspruch genommen zu haben. Als Schwierigkeiten für die Versorgung benannten die Betroffenen/Angehörigen am häufigsten, dass Betroffene aus Angst vor Konsequenzen keine Hilfe suchen (n=51; 54%) oder ihre Probleme nicht wahrhaben wollen (n=49, 52,1%), sowie zu lange Wartezeiten auf Behandlungsplätze (n=45; 47,8%). Verbesserungspotential sahen die Betroffenen v. a. in den Bereichen Screening („Ansprechen des Alkoholkonsums“; n=44; 46,8%) und einem nahtlosen Übergang zwischen verschiedenen Behandlungssettings (n=42; 44,6%).

Schlussfolgerungen Zusätzlich zu den bisherigen Bemühungen zur Disseminierung der S3-Leitlinie Screening, Diagnose und Behandlung alkoholbezogener Störungen legen die Ergebnisse dieser Studie die Notwendigkeit einer kontextspezifischen Förderung der Leitlinienumsetzung nahe.

Substitution treatment for opioid dependence with slow-release oral morphine: Retention rate, health status, and substance use after switching to morphine

INTRODUCTION

Since April 2015, slow-release oral morphine (SROM) has been approved for opioid agonist treatment (OAT) in Germany. Experimental studies show that benefits of SROM over methadone include less heroin craving, better tolerability, and higher patient satisfaction and mental stability. The SROMOS study (Efficacy and Tolerability of Slow-Release Oral Morphine in Opioid Substitution Treatment) aims to investigate the long-term effects (effectiveness and safety) of morphine substitution under routine care in Germany.

MATERIAL AND METHODS

This is a prospective, noninterventional, naturalistic, observational study. Between July 2016 and November 2017, this study recruited patients in OAT who decided to switch to SROM from 23 outpatient addiction treatment centers in Germany. The study collected data on mental health (Brief Symptom Inventory - BSI-18), substance use, somatic health (Opiate Treatment Index Health-Symptoms-Scale - OTI-HSS), opioid craving (visual analogue scale), and withdrawal symptoms (Short Opiate Withdrawal Scale) at baseline (t0) and after 3 (t3), 6 (t6) and 12 (t12) months. Physicians documented side effects as adverse events (AEs) and adverse drug reactions (ADRs).

RESULTS

Three-quarters of the enrolled study participants (N = 180) were male. The average age was 44.4 years. Patients were opioid-dependent for 23 years and had been in OAT for almost seven years on average. After 12 months, 60.6% were still being treated with SROM. Mental health improved significantly under SROM treatment between t0 and t12. The intention-to-treat (ITT), as well as the per-protocol (PP) analysis, shows a statistically significant improvement of the mean Global Severity Index (GSI) of the BSI-18 value of 20% (ITT) and 24% (PP). Physical health also improved significantly under SROM treatment. There were no statistically significant changes in the use of cannabis, cocaine, amphetamines, and tranquillizers in the past 30 days, but heroin use, intravenous consumption, and the number of drinking days significantly decreased.

CONCLUSIONS

This study provides some of the first long-term data on OAT with SROM under routine care conditions. SROM treatment is an effective alternative for a subgroup of opioid-dependent patients with an unsatisfactory course of OAT or in cases where undesirable side effects due to alternative substances have occurred.

ETHICAL STATEMENT

The study protocol was approved by the Ethics Committee of the Chamber of Physicians in Hamburg in March 2016 (No. PV5222). The study was conducted by following the Declaration of Helsinki and is registered with the German Register of Clinical Trials (DRKS, ID: DRKS00010712).

[Weighing the benefits and harms of psychotropic and analgesic substances - A perspective of German addiction medicine experts]

BACKGROUND

In Europe, there have been several addiction-expert rankings of harms related to the use of psychotropic substances in the last 15 years. Among them, only one expert ranking took into account the potential benefits of these drugs. Non-Opioidergic Analgesics (NOAs), such as gabapentinoids and NSAIDs, which have been increasingly the subject of abuse / misuse reports, have not been considered in such expert rankings. Likewise, there is currently no multi-substance comparison as to whether the valuation rank of the harmfulness of an illegal drug may change along with an imagined change in legal status in Germany.

OBJECTIVES AND METHODS

Using a questionnaire, 101 experienced addiction physicians (first cohort) evaluated 33 psychoactive substances including analgesics with regard to their health and social harms as well as potential usefulness for the consumer and their environment / society ('others'). In addition, this cohort investigated whether the harmfulness assessment of an illegal substance changes if it would be legalized. In order to obtain the average overall harmfulness (overall risk) of a substance, the percentage contribution of each dimension to the overall harmfulness was determined in a second survey (second cohort, 36 experienced addiction medicine experts). Finally, the average benefit and overall risk ratings of each substance were related to each other.

RESULTS

Prescription psychoactive substances such as analgesics, NOAs (including gabapentinoids) and opioidergic maintenance medications to treat opiate dependence were judged to have a favorable benefit-harm profile. Cannabis and ketamine were placed in the midfield of both, the harm and benefit rankings. Together with most illicit narcotic drugs, alcohol and nicotine, have been ranked among the most harmful and least useful substances, whereby alcohol was judged on average to be more harmful but also more useful than nicotine. In the event of potential legalization, the overall harm of the traditional illegal drugs methamphetamine, heroin, cocaine and cannabis was estimated to be reduced. This was mainly due to a more favorable valuation of the harm to others under these virtual conditions.

CONCLUSION

Prescription substances including opioidergic and non-opioidergic analgesics as well as opioid maintenance therapy medications (methadone and buprenorphine) were assigned a favorable benefit-harm profile. Alcohol, nicotine and traditional illicit drugs (with the exception of cannabis and ketamine) were determined to have an unfavorable profile. The overall harm of traditional illicit drugs was assessed to decrease along with legalization, mainly by decreasing the harm to others in this virtual event.

Hepatitis C Virus Prevalence and Incidence in a Large Nationwide Sample of Patients in Opioid Substitution Treatment in Germany: A Prospective Cohort Study

BACKGROUND

Hepatitis C virus (HCV) infection is highly prevalent among people who inject drugs (PWID). Accurate data on HCV prevalence and incidence rates among patients receiving opioid substitution treatment (OST) are needed to estimate the current and future burden of HCV infections in this high-risk population.

METHODS

Baseline data from routine care were collected between October 2014 and June 2016 from randomly selected OST facilities in Germany. The primary outcome measure was the HCV status (antibody and RNA prevalence). Patients who were HCV antibody-negative at baseline were followed up after 12 months to calculate the HCV incidence rate.

RESULTS

Sixty-three facilities from 14 German Federal States provided clinical data for a total of 2466 OST patients. HCV antibody and HCV RNA prevalence were 58.8% (95% confidence interval [CI], 56.8%-60.8%) and 27.3% (95% CI, 25.5%-29.2%), respectively. At baseline, a total of 528 patients (21.4%) had previously undergone antiviral treatment. Moreover, lower HCV RNA prevalence was associated with female gender, employment, younger age, and shorter duration of OST and opioid dependence. The HCV incidence rate was 2.5 cases per 100 person-years.

CONCLUSIONS

The low HCV RNA prevalence and HCV incidence rates confirm that OST in Germany is an effective setting both for treating chronic HCV infections and for preventing new infections among PWID. Scaling up the provision of OST, HCV testing, and HCV treatment among OST patients are important public health strategies for reducing HCV infections in this high-risk population.

Medication Adherence in a Cross-Diagnostic Sample of Patients From the Affective-to-Psychotic Spectrum: Results From the PsyCourse Study

INTRODUCTION

According to the World Health Organization, medication adherence is defined as the extent to which a person's behavior corresponds with an agreed recommendation from a healthcare provider. Approximately 50% of patients do not take their medication as prescribed, and non-adherence can contribute to the progress of a disease. For patients suffering from mental diseases non-adherence plays an important role. Various factors have been proposed as contributing to non-adherence, however the literature remains heterogeneous dependent on the analyzed patient subgroups. This study comprehensively evaluates the association of sociodemographic, clinical, personality and quality of life related factors with medication adherence by analyzing data from the PsyCourse study. The PsyCourse study is a large and cross-diagnostic cohort of psychiatric patients from the affective-to-psychotic spectrum.

METHODS

The study sample comprised 1,062 patients from the PsyCourse study with various psychiatric diagnoses (mean [SD] age, 42.82 [12.98] years; 47.4% female). Data were analyzed to identify specific factors associated with medication adherence, and adherence was measured by a self-rating questionnaire. Odds ratios (OR) were estimated by a logistic regression for binary outcomes. Missing data were imputed using multiple imputation.

RESULTS

The following factors showed the strongest association with medication adherence: never having used illicit drugs (OR, 0.71), number of prescribed antipsychotics (OR, 1.40), the personality trait conscientiousness (OR, 1.26), and the environmental domain of quality of life (OR, 1.09).

CONCLUSION

In a large and cross-diagnostic sample, we could show that a higher level of conscientiousness, a higher number of antipsychotic medication, a better quality of life within the environmental domain, and the absence of substance abuse contribute to a better medication adherence independent of the underlying disorder.

[Screening for Problematic Alcohol Consumption - A Survey on Guideline Implementation in Transdisciplinary Health Care of a Model Region]

AIM

Recording the frequency of screenings for problematic alcohol consumption by professionals involved in the health care of respective patients. The German S3-guideline "screening, diagnosis and treatment of alcohol-related disorders" recommends the use of questionnaire-based screenings for all patients in all settings.

METHODS

Cross-sectional survey on screening frequency among general practitioners, gynecologists, psychiatrists, child- and adolescent therapists, psychotherapists, social workers and midwives. Logistic regression was used to explore how healthcare professionals' attributes were associated with the implementation of screenings.

RESULTS

With response rates of about 20%, health care professionals reported using screening instruments for an average of 6.9% of all patients during the previous four weeks. Most of the time, custom-made questions were used instead of the recommended instruments (AUDIT, AUDIT-C). Higher screening rates were reported for patients with newly diagnosed hypertension (21.2%), alcohol-related disorders (43.3%) and mental disorders (39.3%). Knowledge of the guideline was associated with implementation of screenings (OR=4.67; 95% KI 1.94-11.25, p<0.001).

CONCLUSIONS

Comprehensive screening for problematic alcohol use with questionnaire-based instruments in accordance with guidelines is far from being routinely implemented in the studied health care settings. Measures to increase the knowledge of the guidelines are necessary in order to increase the frequency of alcohol screening in health care.

Telemedizin

Liebe Leserinnen und Leser,

aktueller könnte unser Themenschwerpunkt kaum sein. Als wir das Thema Telemedizin in der Suchttherapie planten, war das uns derzeit beschäftigende Coronavirus noch unbekannt. Was danach kam ist uns allen mehr als präsent.

Diagnostik und Behandlung alkoholbezogener Störungen – Versorgerbefragung zur Erarbeitung von Strategien der Leitlinienimplementierung

Ziel der Studie Die Art und Häufigkeit durchgeführter Diagnostik, Kurzintervention und Behandlung bei PatientInnen mit bekanntem problematischen Alkoholkonsum und Alkoholkonsumstörungen durch Berufsgruppen der Gesundheitsversorgung soll erfasst werden. Diese Informationen dienen der Bedarfsabschätzung zur Entwicklung von Strategien zur weiteren Implementierung der S3-Leitlinie „Screening, Diagnose und Behandlung alkoholbezogener Störungen“.

Methodik Schriftliche Befragung von FachärztInnen (hausärztlich allgemeinmedizinisch/internistische, gynäkologische, psychiatrische, pädiatrische, Kinder- und jugendpsychiatrische), PsychotherapeutInnen, SozialarbeiterInnen und Hebammen/Entbindungspflegern in einer Querschnittsstudie in der Modellregion Bremen.

Ergebnisse 34% der PatientInnen mit bekanntem problematischen Alkoholkonsum erhielten eine leitlinienkonforme Diagnostik, 39% eine spezifische Kurzintervention. Von den PatientInnen mit diagnostizierter alkoholbezogener Störung wurde bei 34% eine spezifische Behandlung in eigener Praxis durchgeführt und bei 37% eine Weiterbehandlung anderswo empfohlen. Validierte Instrumente zur Diagnostik alkoholbezogener Störungen fanden selten Anwendung. Kurzinterventionen beinhalteten meist informelle motivierende Gespräche. Als Postakutbehandlungen wurden überwiegend Suchtberatungen und Selbsthilfe und nur selten pharmakologische Rückfallprophylaxe durchgeführt.

Schlussfolgerungen Die Umsetzung strukturierter Diagnostik und Kurzinterventionen, sowie die zielgerichtete Empfehlung pharmakologischer Rückfallprophylaxe und ambulanter Angebote ist für eine leitliniengerechte Versorgung unzureichend. Sie sollten daher Gegenstand von Strategien zur weiteren Leitlinienimplementierung sein.

Clinical and Patient-Reported Outcomes of Direct-Acting Antivirals for the Treatment of Chronic Hepatitis C Among Patients on Opioid Agonist Treatment: A Real-world Prospective Cohort Study

Background

Patient-reported outcomes (PROs) can help to reduce uncertainties about hepatitis C virus (HCV) treatment with direct-acting antivirals (DAAs) among people who inject drugs and increase treatment uptake in this high-risk group. Besides clinical data, this study analyzed for the first time PROs in a real-world sample of patients on opioid agonist treatment (OAT) and HCV treatment with DAAs.

Methods

HCV treatment data including virological response, adherence, safety, and PROs of 328 German patients on OAT were analyzed in a pragmatic prospective cohort study conducted from 2016 to 2018. Clinical effectiveness was defined as sustained virological response (SVR) at week 12 after end of treatment and calculated in per-protocol (PP) and intention-to-treat (ITT) analyses. Changes over time in PROs on health-related quality of life, physical and mental health, functioning, medication tolerability, fatigue, concentration, and memory were analyzed by repeated-measures analyses of variances (ANOVAs).

Results

We found high adherence and treatment completion rates, a low number of mainly mild adverse events, and high SVR rates (PP: 97.5% [n = 285]; ITT: 84.5% [n = 328]). Missing SVR data in the ITT sample were mainly caused by patients lost to follow-up after treatment completion. Most PROs showed statistically significant but modest improvements over time, with more pronounced improvements in highly impaired patients.

Conclusions

This real-world study confirms that DAA treatment among OAT patients is feasible, safe, and effective. PROs show that all patients, but particularly those with higher somatic, mental, and social burden, benefit from DAA treatment.

An Investigation of Psychosis Subgroups With Prognostic Validation and Exploration of Genetic Underpinnings: The PsyCourse Study

IMPORTANCE

Identifying psychosis subgroups could improve clinical and research precision. Research has focused on symptom subgroups, but there is a need to consider a broader clinical spectrum, disentangle illness trajectories, and investigate genetic associations.

OBJECTIVE

To detect psychosis subgroups using data-driven methods and examine their illness courses over 1.5 years and polygenic scores for schizophrenia, bipolar disorder, major depression disorder, and educational achievement.

DESIGN, SETTING, AND PARTICIPANTS

This ongoing multisite, naturalistic, longitudinal (6-month intervals) cohort study began in January 2012 across 18 sites. Data from a referred sample of 1223 individuals (765 in the discovery sample and 458 in the validation sample) with DSM-IV diagnoses of schizophrenia, bipolar affective disorder (I/II), schizoaffective disorder, schizophreniform disorder, and brief psychotic disorder were collected from secondary and tertiary care sites. Discovery data were extracted in September 2016 and analyzed from November 2016 to January 2018, and prospective validation data were extracted in October 2018 and analyzed from January to May 2019.

MAIN OUTCOMES AND MEASURES

A clinical battery of 188 variables measuring demographic characteristics, clinical history, symptoms, functioning, and cognition was decomposed using nonnegative matrix factorization clustering. Subtype-specific illness courses were compared with mixed models and polygenic scores with analysis of covariance. Supervised learning was used to replicate results in validation data with the most reliably discriminative 45 variables.

RESULTS

Of the 765 individuals in the discovery sample, 341 (44.6%) were women, and the mean (SD) age was 42.7 (12.9) years. Five subgroups were found and labeled as affective psychosis (n = 252), suicidal psychosis (n = 44), depressive psychosis (n = 131), high-functioning psychosis (n = 252), and severe psychosis (n = 86). Illness courses with significant quadratic interaction terms were found for psychosis symptoms (R2 = 0.41; 95% CI, 0.38-0.44), depression symptoms (R2 = 0.28; 95% CI, 0.25-0.32), global functioning (R2 = 0.16; 95% CI, 0.14-0.20), and quality of life (R2 = 0.20; 95% CI, 0.17-0.23). The depressive and severe psychosis subgroups exhibited the lowest functioning and quadratic illness courses with partial recovery followed by reoccurrence of severe illness. Differences were found for educational attainment polygenic scores (mean [SD] partial η2 = 0.014 [0.003]) but not for diagnostic polygenic risk. Results were largely replicated in the validation cohort.

CONCLUSIONS AND RELEVANCE

Psychosis subgroups were detected with distinctive clinical signatures and illness courses and specificity for a nondiagnostic genetic marker. New data-driven clinical approaches are important for future psychosis taxonomies. The findings suggest a need to consider short-term to medium-term service provision to restore functioning in patients stratified into the depressive and severe psychosis subgroups.

Acculturation and mental distress among Russian and Iranian migrants in Germany

Several studies have stressed a correlation between difficulties in acculturation and mental distress or even mental disorders. The stress related to the process of acculturation can lead to depressive symptoms by way of changes in the activity of the HPA axis. However, it remains difficult to measure acculturation stress, as difficulties in acculturation strongly depend on subjective interpretations of every day experiences. The association between acculturation stress and mental distress was examined in two different migrant groups in Germany, 202 migrants of Russian and 100 of Iranian origin. In both migrant groups a significant correlation between acculturation stress and mental distress was found, yet no significant association between acculturation stress and length of residency in Germany. These findings will have to be replicated with representative samples and also with other migrant groups, both in and out of treatment. Considering the fact that the Russian sample was younger and nonetheless had relatively high acculturation stress scores, prevention of future mental health problems among migrants will have to focus on easing the process of integration into the host society.

The role of environmental stress and DNA methylation in the longitudinal course of bipolar disorder

BACKGROUND

Stressful life events influence the course of affective disorders, however, the mechanisms by which they bring about phenotypic change are not entirely known.

METHODS

We explored the role of DNA methylation in response to recent stressful life events in a cohort of bipolar patients from the longitudinal PsyCourse study (n = 96). Peripheral blood DNA methylomes were profiled at two time points for over 850,000 methylation sites. The association between impact ratings of stressful life events and DNA methylation was assessed, first by interrogating methylation sites in the vicinity of candidate genes previously implicated in the stress response and, second, by conducting an exploratory epigenome-wide association analysis. Third, the association between epigenetic aging and change in stress and symptom measures over time was investigated.

RESULTS

Investigation of methylation signatures over time revealed just over half of the CpG sites tested had an absolute difference in methylation of at least 1% over a 1-year period. Although not a single CpG site withstood correction for multiple testing, methylation at one site (cg15212455) was suggestively associated with stressful life events (p < 1.0 × 10^-5). Epigenetic aging over a 1-year period was not associated with changes in stress or symptom measures.

CONCLUSIONS

To the best of our knowledge, our study is the first to investigate epigenome-wide methylation across time in bipolar patients and in relation to recent, non-traumatic stressful life events. Limited and inconclusive evidence warrants future longitudinal investigations in larger samples of well-characterized bipolar patients to give a complete picture regarding the role of DNA methylation in the course of bipolar disorder.

Opioide

Liebe Leserinnen, liebe Leser,

in den USA hat die Opioidkrise zum ersten Mal seit den 1990er Jahren zu einem Rückgang der Lebenserwartung beigetragen. Hintergrund dieser Krise ist die weitverbreitete niedrigschwellige Verschreibung opioidhaltiger Schmerzmittel. Zur Überwindung der Krise werden drastische Maßnahmen diskutiert, wie bspw. die Todesstrafe für den illegalen Handel mit Fentanyl.

The potential effects of an extended alcohol withdrawal treatment programme on morbidity and mortality among inpatients in the German city of Bremen: a simulation study

BACKGROUND

According to the German guidelines, people with severe alcohol use disorders (AUDs) should receive withdrawal treatment. Compared to somatic withdrawal treatment (SWT), extended duration and psychosocial elements of so-called "qualified withdrawal treatment" (QWT) aim to reduce relapse rates. Despite promising results of prospective studies on QWT, only few German inpatients seeking withdrawal treatment receive QWT. We estimated the potential effects on mortality and morbidity for higher proportions of treatment-seeking patients receiving QWT rather than SWT in the German city of Bremen.

METHODS

In 2016 and 2017, 2051 inpatients were admitted to two specialised hospitals for withdrawal treatment. The potential beneficial effects of QWT over SWT were estimated by simulating treatment outcomes taken from two prospective studies. Outcomes comprised number and length of all-cause hospitalisations within 5 years, as well as abstinence and all-cause mortality rates within 28 months. Outcomes were estimated for actual and increased rates of QWT (25, 50%) among inpatients seeking alcohol treatment.

RESULTS

In the selected hospitals, 170 patients (8%) received QWT. If 25% of AUD inpatients were to receive QWT, benefits in abstinence rates (+ 18%), the total number of hospitalisations (- 9%) and hospital days (- 10%) could be expected. If 50% of AUD inpatients were to receive QWT, benefits in abstinence rates (+ 45%), the total number of hospitalisations (- 23%) and hospital days (- 26%) were more pronounced, in addition to reductions in mortality (- 20%).

CONCLUSION

Increasing the proportion of people with severe AUD enrolled in extended withdrawal treatment programs (such as QWT) may contribute to reduce overall alcohol-attributable burden of disease. Randomised controlled trials or other prospective studies controlling for confounding factors are needed to determine the potential at the population level.

[Provision of healthcare for people with risky alcohol use and severe alcohol use disorders in the state of Bremen, Germany: demand and guideline concordance?]

BACKGROUND

Early detection of risky alcohol use and severe alcohol use disorders (AUDs) is crucial to avoid adverse health consequences. The German "Guidelines on Screening, Diagnosis and Treatment of Alcohol Use Disorders" recommend to routinely screen patients for hazardous alcohol use and to subsequently conduct brief interventions, for example in primary healthcare. For severe AUDs, provision of withdrawal treatment is recommended in inpatient settings if complications are anticipated.

OBJECTIVES

To estimate the proportion of people with hazardous alcohol use or severe AUDs receiving healthcare as stipulated by the guidelines.

MATERIALS AND METHODS

The prevalence of hazardous use (female ≥12 g; male ≥24 g) and severe AUDs (female ≥60 g; male ≥90 g) was estimated using per capita consumption of pure alcohol. Treatment rates were estimated using survey data (for hazardous use) and inpatient admissions (for severe AUDs). All estimates refer to the adult population (15 years or older) of the federal state of Bremen for 2016.

RESULTS

Physicians screened 2.9% of all people with hazardous alcohol use and conducted brief interventions with 1.4%. Among people with severe AUDs, 7.1% received inpatient treatment. Among people with severe AUDs who required inpatient treatment, 14.1% received withdrawal treatment in inpatient settings. Treatment rates below average were registered among 21- to 39-year-olds.

CONCLUSIONS

In Bremen, provision of guideline-conform healthcare for hazardous alcohol use and severe AUDs is insufficient, especially among 21- to 39-year-olds.

Addiction Recovery Among Opioid-Dependent Patients Treated With Injectable Subcutaneous Depot Buprenorphine: Study Protocol of a Non-randomized Prospective Observational Study (ARIDE)

Introduction: Once-weekly or once-monthly injectable depot buprenorphine is a new opioid substitution treatment (OST) medication that provides clinically relevant plasma concentrations without daily peaks. Together with a high tolerability and acceptance reported by patients, the prolonged release of injectable depot buprenorphine might have beneficial implications on the patients' quality of life and social participation. The primary objective of this prospective non-interventional observational study is to evaluate the effects of subcutaneous injectable depot buprenorphine on the quality of life of patients in routine OST care in Germany. Secondary outcomes like illicit substance use, psychological distress, social participation and activity are assessed to provide an overall evaluation toward addiction recovery. Methods and Analysis: The present study is a non-randomized prospective observational study with a control group (treatment-as-usual). To ensure comparability between both patient groups, suitable control patients (n = 213) from the same OST unit will be matched pairwise to each patient treated with injectable depot buprenorphine (n = 213). Matching variables are gender, duration of OST, take-home prescription and psychosocial functioning (according to the Global Assessment of Functioning scale). Primary study endpoint is the difference of change in quality of life, assessed with the recently developed Opioid Substitution Treatment Quality of Life scale (OSTQOL), within the depot buprenorphine group between baseline and month 12. The primary analysis will be carried out according to the intention-to-treat principle (ITT) by comparing OSTQOL mean scores using dependent t-tests. For secondary analyses, group comparisons will be done by mixed model approaches with baseline OSTQOL score and the (pairwise) cluster term as covariates. Discussion: The study combines clinical, routine OST care data with relevant patient reported outcome data. The pairwise matching allows conclusions on effects of different OST medications. The study findings will provide new insights in the addiction recovery processes of OST patients treated with depot buprenorphine. Ethics and Dissemination: The study protocol has been approved by the Ethics Committee of the Hamburg Chamber of Physicians (Ärztekammer Hamburg) (reference number: PV7078). The study results will be disseminated through peer-reviewed publications and presentations on scientific conferences. Clinical Trial Registration: German Clinical Trials Register DRKS-ID: DRKS00020797.

Impact of Buprenorphine Dosage on the Occurrence of Relapses in Patients with Opioid Dependence

OBJECTIVES

Buprenorphine (BUP) is used in opioid maintenance treatment (OMT) for opioid-dependent patients. Previous real-world evidence suggests that many patients receive lower BUP dosage than recommended, with 38% of patients receiving <6 mg BUP per day. The goal of this research is to evaluate the impact of BUP dosage on the risk of relapses in the real world.

METHODS

This study was based on German claims data of 4 million patients. Patients identified by International Classification of Diseases, 10th Edition F11.2 (opioid dependence) between 2011 and 2012 and at least one BUP prescription were selected for this study (n = 364) and followed up over 4 years. Patients were assigned to 6 dosage groups, with <6 mg/day serving as low dosage/reference category. The impact of dosage on the occurrence of relapses (indicated by treatment interruption of >3 months without OMT prescription or hospital admissions) was examined using multivariate logistic regression. Age, gender, comorbidities, fixed/variable dosing, and up-dosing were used as covariates.

RESULTS

Results showed a protective effect of higher BUP as higher BUP dosages were significantly associated with a lower risk of relapse. Using low dosage (<6 mg/day) as the reference category, ORs were 0.40 (95% CI 0.19-0.87) at 6-<8 mg/day, 0.28 (0.15-0.56) at 8-<10 mg/day, 0.26 (0.10-0.67) at 10-<12 mg/day, 0.40 (0.18-0.92) at 12-<16 mg/day, and 0.18 (0.09-0.37) at ≥16 mg/day. No covariate showed a significant effect on the probability of relapse.

CONCLUSIONS

The present study used a large German health claims dataset to confirm that higher BUP dosages are a protective factor for avoiding relapses in opioid-dependent patients, thus highlighting the importance of adequate BUP dosing in relapse prevention.

Patient-Centered Placement Matching of Alcohol-Dependent Patients Based on a Standardized Intake Assessment: Primary Outcomes of an Exploratory Randomized Controlled Trial

BACKGROUND

Placement matching guidelines are promising means to optimize patient-centered care and to match patients' treatment needs. Despite considerable research regarding placement matching approaches to optimize alcohol abuse treatment, findings are inconclusive.

OBJECTIVES

To investigate whether the use of patient-centered placement matching (PCPM) guidelines is more effective in reducing heavy drinking and costs 6 months after discharge from an inpatient alcohol withdrawal treatment compared to usual referral to aftercare. Secondary aims were to investigate whether age, gender, trial site or level of care (LOC) are moderators of efficacy and whether patients who were actually referred to the recommended LOC had better treatment outcomes compared to patients who were treated under- or overmatched.

METHODS

Design. Exploratory randomized controlled trial with measurements during withdrawal treatment and 6 months after initial assessment.

SETTING

Four German psychiatric clinics offering a 7-21 day inpatient qualified withdrawal program for patients suffering from alcohol dependence.

PARTICIPANTS

From 1,927 patients who had a primary diagnosis of alcohol dependence and did not have organized aftercare when entering withdrawal treatment, 299 were invited to participate. Of those, 250 were randomized to the intervention group (IG, n = 123) or the control group (CG, n = 127).

INTERVENTION

The PCPM were applied to patients of the IG by feeding back a recommendation to a LOC for aftercare that was calculated from the Measurements in the Addictions for Triage and Evaluation (MATE) and discussed with the staff of the treatment unit. Patients of the CG received a general feedback regarding their MATE interview on request.

MEASUREMENTS

The MATE, the Client Socio-Demographic and Service Receipt Inventory--European Version and the MATE-Outcomes were administered. Data were analyzed using generalized linear models.

RESULTS

In the intention-to-treat analysis, there were no significant differences between IG and CG regarding days of heavy drinking (incident risk ratio [IRR] 1.09; p = 0.640), direct (IRR 1.06; p = 0.779), indirect (IRR 0.77; p = 0.392) and total costs (IRR 0.89; p = 0.496). Furthermore, none of the investigated moderator variables affected statistically significant drinking or cost-related primary outcomes. Regardless of group allocation, patients who received matched aftercare reported significantly fewer days of heavy drinking than undermatched patients (IRR 2.09; p = 0.004). For patients who were overmatched, direct costs were significantly higher (IRR 1.79; p = 0.024), but with no additional effects on alcohol consumption compared to matched patients.

CONCLUSIONS

While the use of PCPM failed to affect the actual referral to aftercare, our findings suggest that treating patients on the recommended LOC may have the potential to reduce days of heavy drinking compared to undertreatment and costs compared to overtreatment.

Ranking the Harm of Psychoactive Drugs Including Prescription Analgesics to Users and Others-A Perspective of German Addiction Medicine Experts

Background: Over the past 15 years, comparative assessments of psychoactive substance harms to both users and others have been compiled by addiction experts. None of these rankings however have included synthetic cannabinoids or non-opioid prescription analgesics (NOAs, e.g., gabapentinoids) despite evidence of increasing recreational use. We present here an updated assessment by German addiction medicine experts, considering changing Western consumption trends-including those of NOAs. Methods: In an initial survey, 101 German addiction medicine physicians evaluated both physical and psychosocial harms (in 5 dimensions) of 33 psychoactive substances including opioids and NOAs, to both users and others. In a second survey, 36 addiction medicine physicians estimated the relative weight of each health and social harm dimension to determine the overall harm rank of an individual substance. We compared our ranking with the most recent European assessment from 2014. Results: Illicit drugs such as methamphetamine, heroin, cocaine and also alcohol were judged particularly harmful, and new psychoactive drugs (cathinones, synthetic cannabinoids) were ranked among the most harmful substances. Cannabis was ranked in the midrange, on par with benzodiazepines and ketamine-somewhat more favorable compared to the last European survey. Prescribed drugs including opioids (in contrast to the USA, Canada, and Australia) were judged less harmful. NOAs were at the bottom end of the ranking. Conclusion: In Germany, alcohol and illicit drugs (including new psychoactive substances) continue to rank among the most harmful addictive substances in contrast to prescribed agents including opioid analgesics and NOAs. Current laws are incongruent with these harm rankings. This study is the first of its kind to include comparative harm rankings of several novel abused substances, both licit/prescribed and illicit.

Opioid use disorder in Germany: healthcare costs of patients in opioid maintenance treatment

Background

Opioid Use Disorder (OUD) is a substance use disorder with a chronic course associated with comorbid mental and somatic disorders, a high burden of psychosocial problems and opioid maintenance treatment (OMT) as a standard treatment. In the US, OUD imposes a significant economic burden on society, with annual societal costs estimated at over 55 billion dollars. Surprisingly, in Europe and especially in Germany, there is currently no detailed information on the healthcare costs of patients with OUD. The goal of the present research is to gather cost information about OUD patients in OMT with a focus on maintenance medication and relapses.

Methods

We analysed health claims data of four million persons covered by statutory health insurance in Germany, applying a cost-of-illness approach and aimed at examining the direct costs of OMT patients in Germany. Patients with an ICD-10 code F11.2 and at least one claim of an OMT medication were stratified into the treatment groups buprenorphine, methadone or levomethadone, based on the first prescription in each of the follow-up years. Costs were stratified for years with and without relapses. Group comparisons were performed with ANOVA.

Results

We analysed 3165 patient years, the total annual sickness funds costs were on average 7470 € per year and patient. Comparing costs of levomethadone (8400 €, SD: 11,080 €), methadone (7090 €, SD: 10,900 €) and buprenorphine (6670 €, SD: 7430 €) revealed significant lower costs of buprenorphine compared to levomethadone (p < 0.0001). In years with relapses, costs were higher than in years without relapses (8178 € vs 7409 €; SD: 11,622, resp. 10,378 €). In years with relapses, hospital costs were the major cost driver.

Conclusions

The present study shows the costs of OUD patients in OMT for the first time with a German dataset. Healthcare costs for patients with an OUD in OMT are associated with more than two times the cost of an average German patients. Preventing relapses might have significant impact on costs. Patients in different OMT were dissimilar which may have affected the cost differences.

Tailored interventions to support the implementation of the German national guideline on screening, diagnosis and treatment of alcohol-related disorders: a project protocol

Abstract. Background: The German Guideline on Screening, Diagnosis and Treatment of Alcohol Use Disorders aims to increase the uptake of evidence-based interventions for the early identification, diagnosis, prevention and treatment of alcohol-related disorders in relevant healthcare settings. To date, dissemination has not been accompanied by a guideline implementation strategy. The aim of this study is to develop tailored guideline implementation strategies and to field-test these in relevant medical and psycho-social settings in the city of Bremen, Germany. Methods: The study will conduct an impact and needs assessment of healthcare provision for alcohol use orders in Bremen, drawing on a range of secondary and primary data to: evaluate existing healthcare services; model the potential impact of improved care on public health outcomes; and identify potential barriers and facilitators to implementing evidence-based guidelines. Community advisory boards will be established for the selection of single-component or multi-faceted guideline implementation strategies. The tailoring approach considers guideline, provider and organizational factors shaping implementation. In field tests quality outcome indicators of the delivery of evidence-based interventions will be evaluated accompanied by a process evaluation to examine patient, provider and organizational factors. Outlook: This project will support the translation of guideline recommendations for the identification, prevention and treatment of AUD in routine practice and therefore contributes to the reduction of alcohol-related burden in Germany. The project is running since October 2017 and will provide its main outcomes by end of 2020. Project results will be published in scientific journals and presented at national and international conferences.

[Motivational interviewing : A possibility for doctor-patient communication in schizophrenia?]

Motivational interviewing (MI) has become established nowadays as an approach for a cooperative style of conversation to promote intrinsic motivation for change by exploring and resolving ambivalences. The change of addictive behavior is no longer sought by exerting pressure or lecturing/converting attempts of convincing or persuasion but by activating existing but "buried" or newly acquired self-motivation to change. The MI is now also used to change the treatment of other health-related behavior and chronic diseases, including schizophrenic disorders. Compared to the efficacy of MI in the addiction area, the data situation in schizophrenic patients is still insufficient. According to the available studies, MI can positively influence important aspects of disease-related impairments, such as medication adherence, the frequency and severity of psychotic relapses, the duration of hospitalization, the level of function, insight into the disease and cognitive rehabilitation. The practical implementation of MI requires a good knowledge of the method as well as changes in treatment principles and work processes.

The genetic relationship between educational attainment and cognitive performance in major psychiatric disorders

Cognitive deficits are a core feature of psychiatric disorders like schizophrenia and bipolar disorder. Evidence supports a genome-wide polygenic score (GPS) for educational attainment (GPSEDU) can be used to explain variability in cognitive performance. We aimed to identify different cognitive domains associated with GPSEDU in a transdiagnostic clinical cohort of chronic psychiatric patients with known cognitive deficits. Bipolar and schizophrenia patients from the PsyCourse cohort (N = 730; 43% female) were used. Likewise, we tested whether GPSs for schizophrenia (GPSSZ) and bipolar disorder (GPSBD) were associated with cognitive outcomes. GPSEDU explained 1.5% of variance in the backward verbal digit span, 1.9% in the number of correctly recalled words of the Verbal Learning and Memory Test, and 1.1% in crystallized intelligence. These effects were robust to the influences of treatment and diagnosis. No significant associations between GPSSZ or GPSBD with cognitive outcomes were found. Furthermore, these risk scores did not confound the effect of GPSEDU on cognitive outcomes. GPSEDU explains a small fraction of cognitive performance in adults with psychiatric disorders, specifically for domains related to linguistic learning and working memory. Investigating such a proxy-phenotype longitudinally, could give intriguing insight into the disease course, highlighting at what time genes play a more influential role on cognitive performance. Better understanding the origin of these deficits might help identify those patients at risk for lower levels of functioning and poor social outcomes. Polygenic estimates may in the future be part of predictive models for more personalized interventions.

The influence of religious activity and polygenic schizophrenia risk on religious delusions in schizophrenia

BACKGROUND

Religious delusions are a common symptom in patients experiencing psychosis, with varying prevalence rates of religious delusions across cultures and societies. To enhance our knowledge of this distinct psychotic feature, we investigated the mutually-adjusted association of genetic and environmental factors with occurrence of religious delusions.

METHODS

We studied 262 adult German patients with schizophrenia or schizoaffective disorder. Association with lifetime occurrence of religious delusions was tested by multiple logistic regression for the following putative predictors: self-reported degree of religious activity, DSM-IV diagnosis, sex, age, education level, marital status, presence of acute delusion at the time of interview and an individual polygenic schizophrenia-risk score (SZ-PRS, available in 239 subjects).

RESULTS

Of the 262 patients, 101 (39%) had experienced religious delusions. The risk of experiencing religious delusions was significantly increased in patients with strong religious activity compared to patients without religious affiliation (OR = 3.6, p = 0.010). Low or moderate religious activity had no significant effect. The same analysis including the SZ-PRS confirmed the effect of high religious activity on occurrence of religious delusions (OR = 4.1, p = 0.008). Additionally, the risk of experiencing religious delusions increased with higher SZ-PRS (OR 1.4, p = 0.020, using pT = 0.05 for SZ-PRS calculation). None of the other variables were significantly associated with lifetime occurrence of religious delusions.

CONCLUSIONS

Our results suggest that strong religious activity and high SZ-PRS are independent risk factors for the occurrence of religious delusions in schizophrenia and schizoaffective disorder.

Alcohol and Cannabis Consumption Does Not Diminish Cure Rates in a Real-World Cohort of Chronic Hepatitis C Virus Infected Patients on Opioid Substitution Therapy-Data From the German Hepatitis C-Registry (DHC-R)

BACKGROUND

The importance of alcohol and cannabis consumption for the effectiveness of treatment of chronic hepatitis C virus (HCV) infection with direct acting antivirals (DAAs) in people on opioid substitution therapy (OST) has not been investigated in detail.

METHODS

We investigated sustained virological response (SVR) rates and proportion of lost to follow-up (LTFU) between OST (n = 739) and non-OST patients (n = 7008) in the German Hepatitis C-Registry (Deutsches Hepatitis C-Register, DHC-R), which is a national multicenter prospective non-interventional real-world registry. Non-OST patients comprised patients with former/current drug use (non-OST/DU; n = 1500) and patients never consuming drugs (non-OST/NDU; n = 5508).

FINDINGS

SVR 12/24 rates (intention to treat [ITT]) in patients consuming no or less than 30 g/day (women) or 40 g/day (men) were significantly higher in non-OST/NDU (range 91%-92%) vs OST patients (range 83%-86%), mainly due to significantly higher LTFU rates in OST (range 11%-12%) compared with non-OST/NDU (range 2%-3%). In non-OST/NDU with high alcohol consumption of more than 30/40 g/day, SVR 12/24 rates (ITT) were lower (85%) but did not differ to OST (85%) with high alcohol consumption. No significant differences could be seen for SVR 12/24 in per-protocol (PP) analysis independent of alcohol consumption or amount of alcohol intake. Cannabis use did not significantly influence SVR 12/24 in ITT or PP or LTFU.

CONCLUSIONS

High SVR rates could be achieved in both OST and non-OST patients irrespective of alcohol or cannabis consumption. However, LTFU is more likely in patients with current or former drug use than in patients without drug history and in patients with high alcohol consumption but occurred mainly after end of antiviral treatment (EOT), leaving a high chance for HCV elimination in these patients.

A longitudinal approach to biological psychiatric research: The PsyCourse study

In current diagnostic systems, schizophrenia and bipolar disorder are still conceptualized as distinct categorical entities. Recently, both clinical and genomic evidence have challenged this Kraepelinian dichotomy. There are only few longitudinal studies addressing potential overlaps between these conditions. Here, we present design and first results of the PsyCourse study (N = 891 individuals at baseline), an ongoing transdiagnostic study of the affective-to-psychotic continuum that combines longitudinal deep phenotyping and dimensional assessment of psychopathology with an extensive collection of biomaterial. To provide an initial characterization of the PsyCourse study sample, we compare two broad diagnostic groups defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification system, that is, predominantly affective (n = 367 individuals) versus predominantly psychotic disorders (n = 524 individuals). Depressive, manic, and psychotic symptoms as well as global functioning over time were contrasted using linear mixed models. Furthermore, we explored the effects of polygenic risk scores for schizophrenia on diagnostic group membership and addressed their effects on nonparticipation in follow-up visits. While phenotypic results confirmed expected differences in current psychotic symptoms and global functioning, both manic and depressive symptoms did not vary between both groups after correction for multiple testing. Polygenic risk scores for schizophrenia significantly explained part of the variability of diagnostic group. The PsyCourse study presents a unique resource to research the complex relationships of psychopathology and biology in severe mental disorders not confined to traditional diagnostic boundaries and is open for collaborations.

Sucht und Essstörungen

Liebe Leserinnen und Leser,

wann und was haben Sie zuletzt gegessen? Und, hatten Sie Hunger, war es im Rahmen eines gesellschaftlichen Rituals oder haben Sie der kurzen Vergnügung wegen gar ein Stück Schokolade genascht? Mit der Nahrungsaufnahme sind unterschiedliche Kontexte und Funktionen verbunden. Im Vorgenannten existenzielle, soziale und hedonistische. Unser Gehirn ist primär darauf ausgelegt, die existenziellen Bedürfnisse zu befriedigen.

Investigating polygenic burden in age at disease onset in bipolar disorder: Findings from an international multicentric study

OBJECTIVES

Bipolar disorder (BD) with early disease onset is associated with an unfavorable clinical outcome and constitutes a clinically and biologically homogenous subgroup within the heterogeneous BD spectrum. Previous studies have found an accumulation of early age at onset (AAO) in BD families and have therefore hypothesized that there is a larger genetic contribution to the early-onset cases than to late onset BD. To investigate the genetic background of this subphenotype, we evaluated whether an increased polygenic burden of BD- and schizophrenia (SCZ)-associated risk variants is associated with an earlier AAO in BD patients.

METHODS

A total of 1995 BD type 1 patients from the Consortium of Lithium Genetics (ConLiGen), PsyCourse and Bonn-Mannheim samples were genotyped and their BD and SCZ polygenic risk scores (PRSs) were calculated using the summary statistics of the Psychiatric Genomics Consortium as a training data set. AAO was either separated into onset groups of clinical interest (childhood and adolescence [≤18 years] vs adulthood [>18 years]) or considered as a continuous measure. The associations between BD- and SCZ-PRSs and AAO were evaluated with regression models.

RESULTS

BD- and SCZ-PRSs were not significantly associated with age at disease onset. Results remained the same when analyses were stratified by site of recruitment.

CONCLUSIONS

The current study is the largest conducted so far to investigate the association between the cumulative BD and SCZ polygenic risk and AAO in BD patients. The reported negative results suggest that such a polygenic influence, if there is any, is not large, and highlight the importance of conducting further, larger scale studies to obtain more information on the genetic architecture of this clinically relevant phenotype.

Vermittlung von Patienten in eine Postakutbehandlung nach dem stationären qualifizierten Alkoholentzug

Ziel der Studie Ziel dieser Studie war es, einen Eindruck über die klinische Praxis der Indikationsstellung und Empfehlung für eine Postakutbehandlung aus dem qualifizierten Alkoholentzug zu gewinnen. Im Einzelnen wurde untersucht, welche möglichen Barrieren für die Empfehlung und Planung einer geeigneten Postakutbehandlung aus Sicht der verantwortlichen Mitarbeiterinnen und Mitarbeiter im qualifizierten Alkoholentzug bestehen. Weiterhin wurde erfasst, welche Kriterien für die Indikationsstellung für Postakutbehandlungen in der klinischen Praxis als relevant erachtet werden.

Methodik Mit insgesamt 3 Erinnerungsrunden wurden 418 Kliniken mit dem Angebot einer stationären qualifizierten Alkoholentzugsbehandlung zu einer schriftlichen Befragung eingeladen. Die Teilnahme war sowohl online als auch schriftlich möglich und sollte von jeweils einem Mitarbeiter stellvertretend für die gesamte Station beantwortet werden. Die Befragung enthielt Fragen zu Barrieren für eine Weiterverweisung, der Bedeutung verschiedener Indikationskriterien sowie Fragen zur Einrichtungsstruktur.

Ergebnisse Von 88 antwortenden Einrichtungen (21% Rücklauf), gaben 81 Behandlungsplätze für den qualifizierten Alkoholentzug an und wurden in die deskriptive Auswertung einbezogen. Die meisten Teilnehmer sahen lange Wartezeiten auf eine psychotherapeutische Weiterbehandlung (65,4%), Rehabilitation (48,1%), fehlende Behandlungsangebote für schwer beeinträchtigte Patienten (61,7%) sowie die Klärung der Kostenübernahme (45,7%) als starke Barriere für die Vermittlung in eine Postakutbehandlung. Für eine differentielle Indikationsstellung wurden symptombezogene Kriterien wie die Schwere der Abhängigkeit und das Rückfallrisiko mit einem Mittelwert über 5 auf einer 6stufigen Skala als besonders relevant erachtet.

Schlussfolgerungen Die benannten Barrieren beziehen sich v. a. auf die Versorgungsorganisation und sollten vor dem Hintergrund aktueller struktureller Änderungen repliziert werden, um einen Vergleich zu ermöglichen. Eine stärkere Betonung auch teilhabeorientierter Kriterien für die Wahl einer Postakutbehandlung sollte angestrebt werden, um die Wiederherstellung der Teilhabe als langfristigem Behandlungsziel stärker zu betonen.