Gallus Bischof

An international consensus for assessing internet gaming disorder using the new DSM‐5 approach

AIMS For the first time, the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) introduces non-substance addictions as psychiatric diagnoses. The aims of this paper are to (i) present the main controversies surrounding the decision to include internet gaming disorder, but not internet addiction more globally, as a non-substance addiction in the research appendix of the DSM-5, and (ii) discuss the meaning behind the DSM-5 criteria for internet gaming disorder. The paper also proposes a common method for assessing internet gaming disorder. Although the need for common diagnostic criteria is not debated, the existence of multiple instruments reflect the divergence of opinions in the field regarding how best to diagnose this condition. METHODS We convened international experts from European, North and South American, Asian and Australasian countries to discuss and achieve consensus about assessing internet gaming disorder as defined within DSM-5. RESULTS We describe the intended meaning behind each of the nine DSM-5 criteria for internet gaming disorder and present a single item that best reflects each criterion, translated into the 10 main languages of countries in which research on this condition has been conducted. CONCLUSIONS Using results from this cross-cultural collaboration, we outline important research directions for understanding and assessing internet gaming disorder. As this field moves forward, it is critical that researchers and clinicians around the world begin to apply a common methodology; this report is the first to achieve an international consensus related to the assessment of internet gaming disorder.

Proactive interventions for smoking cessation in general medical practice: a quasi-randomized controlled trial to examine the efficacy of computer-tailored letters and physician-delivered brief advice*

Aims To test the efficacy of (i) computer-generated tailored letters and (ii) practitioner-delivered brief advice for smoking cessation against an assessment-only condition; and to compare both interventions directly. Design Quasi-randomized controlled trial. Setting A total of 34 randomly selected general practices from a German region (participation rate 87%). Participants A total of 1499 consecutive patients aged 18–70 years with daily cigarette smoking (participation rate 80%). Interventions The tailored letters intervention group received up to three individualized personal letters. Brief advice was delivered during routine consultation by the practitioner after an onsite training session. Both interventions were based on the Transtheoretical Model of behaviour change. Measurements Self-reported point prevalence and prolonged abstinence at 6-, 12-, 18- and 24-month follow-ups. Findings Among participants completing the last follow-up, 6-month prolonged abstinence was 18.3% in the tailored letters intervention group, 14.8% in the brief advice intervention group and 10.5% in the assessment-only control group. Assuming those lost to follow-up to be smokers, the rates were 10.2%, 9.7% and 6.7%, respectively. Analyses including all follow-ups confirmed statistically significant effects of both interventions compared to assessment only. Using complete case analysis, the tailored letters intervention was significantly more effective than brief advice for 24-hour [odds ratio (OR) = 1.4; P = 0.047] but not for 7-day point prevalence abstinence (OR = 1.4; P = 0.068) for prolonged abstinence, or for alternative assumptions about participants lost to follow-up. Conclusions The study demonstrated long-term efficacy of low-cost interventions for smoking cessation in general practice. The interventions are suitable to reach entire populations of general practices and smoking patients. Computer-generated letters are a promising option to overcome barriers to provide smoking cessation counselling routinely.

Occurence of internet addiction in a general population sample: a latent class analysis.

Background: Prevalence studies of Internet addiction in the general population are rare. In addition, a lack of approved criteria hampers estimation of its occurrence. Aims: This study conducted a latent class analysis (LCA) in a large general population sample to estimate prevalence. Methods: A telephone survey was conducted based on a random digit dialling procedure including landline telephone (n = 14,022) and cell phone numbers (n = 1,001) in participants aged 14-64. The Compulsive Internet Use Scale (CIUS) served as the basis for a LCA used to look for subgroups representing participants with Internet addiction or at-risk use. CIUS was given to participants reporting to use the Internet for private purposes at least 1 h on a typical weekday or at least 1 h on a day at the weekend (n = 8,130). Results: A 6-class model showed best model fit and included two groups likely to represent Internet addiction and at-risk Internet use. Both groups showed less social participation and the Internet addiction group less general trust in other people. Proportions of probable Internet addiction were 1.0% (CI 0.9-1.2) among the entire sample, 2.4% (CI 1.9-3.1) in the age group 14-24, and 4.0% (CI 2.7-5.7) in the age group 14-16. No difference in estimated proportions between males and females was found. Unemployment (OR 3.13; CI 1.74-5.65) and migration background (OR 3.04; CI 2.12-4.36) were related to Internet addiction. Conclusions: This LCA-based study differentiated groups likely to have Internet addiction and at-risk use in the general population and provides characteristics to further define this rather new disorder.

Randomized controlled trial of a brief intervention for problematic prescription drug use in non-treatment-seeking patients.

AIMS Dependence on or problematic use of prescription drugs (PD) is estimated to be between 1 and 2% in the general population. In contrast, the proportion of substance-specific treatment in PD use disorders at 0.5% is comparatively low. With an estimated prevalence of 4.7%, PD-specific disorders are widespread in general hospitals compared to the general population. Brief intervention delivered in general hospitals might be useful to promote discontinuation or reduction of problematic prescription drug use. DESIGN A randomized, controlled clinical trial. SETTING Internal, surgical and gynaecological wards of a general and a university hospital. PARTICIPANTS One hundred and twenty-six patients fulfilling criteria for either regular use of PD (more than 60 days within the last 3 months) or dependence on or abuse of PD, respectively, were allocated randomly to two conditions. INTERVENTION Subjects received two counselling sessions based on Motivational Interviewing plus an individualized written feedback (intervention group, IG) or a booklet on health behaviour (control group, CG). MEASUREMENTS The outcome was measured as reduction (>25%) and discontinuation of PD intake in terms of defined daily dosages (DDD). FINDINGS After 3 months, more participants in the IG reduced their DDD compared to the participants in the CG (51.8% versus 30%; chi(2) = 6.17; P = 0.017). In the IG 17.9%, in the CG 8.6% discontinued use of PD (chi(2) = 2.42; P = 0.17). Conclusions Brief intervention based on Motivational Interviewing is effective in reducing PD intake in non-treatment-seeking patients.

Excess Mortality of Alcohol-Dependent Individuals After 14 Years and Mortality Predictors Based on Treatment Participation and Severity of Alcohol Dependence

BACKGROUND Little is known about excess mortality and its predictors among alcohol-dependent individuals in the general population. We sought to estimate excess mortality and to determine whether alcohol dependence treatment utilization, alcohol dependence severity, alcohol-related problems, and self-rated health may predict mortality over 14 years. METHODS A random sample of the general population between the ages of 18 and 64 in 1 region in Germany was drawn. Among 4,070 respondents with valid data, 153 alcohol-dependent individuals were identified. For 149 of these 153, vital status information was provided 14 years later. Baseline data from the Composite International Diagnostic Interview (German version M-CIDI) included a diagnosis of alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) of the American Psychiatric Association, alcohol dependence treatment utilization, alcohol dependence severity based on the number of DSM-IV alcohol dependence diagnostic criteria fulfilled and a symptom frequency questionnaire, alcohol-related problems, self-rated general health, cigarettes smoked per day, and the number of psychiatric disorders according to the DSM-IV at baseline. RESULTS Annualized death rates were 4.6-fold higher for women and 1.9-fold higher for men compared to the age- and sex-specific general population. Having participated in inpatient specialized alcohol dependence treatment was not related with longer survival than not having taken part in the treatment. Utilization of inpatient detoxification treatment predicted the hazard rate ratio of mortality (unadjusted: 4.2, 90% confidence interval 1.8 to 9.8). The severity of alcohol dependence was associated with the use of detoxification treatment. Alcohol-related problems and poor self-rated health predicted mortality. CONCLUSIONS According to the high excess mortality, a particular focus should be placed on women. Inpatient specialized alcohol dependence treatment did not seem to have a sufficient protective effect against dying prematurely. Having been in detoxification treatment only, the severity of alcohol dependence, alcohol-related problems, and self-rated health may be predictors of time-to-death among this general population sample.

Screening questionnaires for problem drinking in adolescents: performance of AUDIT, AUDIT-C, CRAFFT and POSIT.

Background/Aims: Only rather few data on the validity of screening questionnaires to detect problem drinking in adolescents exist. The aim of this study was to compare the performance of the Alcohol Use Disorders Identification Test (AUDIT), its short form AUDIT-C, the Substance Module of the Problem Oriented Screening Instrument for Teenagers (POSIT), and CRAFFT (acronym for car, relax, alone, forget, family, and friends). Methods: The questionnaires were filled in by 9th and 10th graders from two comprehensive schools. All students received an interview using the alcohol section of the Composite International Diagnostic Interview. Alcohol abuse and alcohol dependence according to DSM-IV as well as episodic heavy drinking served as criteria to validate the screening instruments. Results: All 9th and 10th graders (n = 225) of both schools participated. No significant differences were found for areas under the receiver operating characteristic curves ranging from 0.810 to 0.872. Cronbach’s alpha was satisfactory (0.77–0.80) but poor for CRAFFT (0.64). Different cut-offs are discussed. Conclusions: Considering validity as well as reliability, AUDIT, AUDIT-C and POSIT performed well; however, the POSIT is quite lengthy. AUDIT-C showed good psychometric properties and has clear advantages because of its brevity.

Comorbid Axis I-disorders among subjects with pathological, problem, or at-risk gambling recruited from the general population in Germany: results of the PAGE study.

The aim of the present study was to analyze comorbid Axis I-disorders in a sample of individuals with at-risk, problem, and pathological gambling. A number of 164 adult gamblers derived from a random sample of 15,023 individuals were compared with a general population sample. The lifetime prevalence of any psychiatric disorder was 93.6% among pathological (five-10 criteria), 83.5% among problem (three or four criteria), and 81.0% among at-risk gamblers (one or two criteria). Substance use disorders were the most common comorbid disorders in gamblers. Logistic regression analyses revealed elevated odds ratios for having a comorbid disorder in at-risk (Conditional Odds Ratio (COR) 3.5, Confidence Interval (CI) 2.6-4.6), problem (COR 4.9, CI 3.3-7.3), and pathological gamblers (COR 4.6, CI 3.0-6.9) compared to the general population. No significant differences were found between at-risk and problem gamblers or problem and pathological gamblers. Compared to at-risk gamblers, pathological gamblers showed elevated rates of comorbid substance use disorders. The data suggest a linear association between gambling disorder severity and comorbid Axis I-disorders. In conclusion, comorbid disorders are very prevalent in individuals with gambling problems. Even at-risk gamblers with one or two DSM-IV criteria show high rates of Axis I-disorders. Therefore, this group should be included in further studies on problematic gambling.

Effectiveness of brief alcohol interventions for general practice patients with problematic drinking behavior and comorbid anxiety or depressive disorders.

BACKGROUND Brief interventions (BIs) are effective methods to reduce problematic drinking. It is not known, if the effectiveness of BI differs between patients with or without comorbid depression or anxiety disorders. METHODS In a randomized controlled BI study with two intervention groups and one control condition, data were collected from 408 general practice (GP) patients with alcohol use disorders, at-risk drinking or binge drinking. 88 participants were diagnosed with comorbid anxiety and/or depressive disorders. The effectiveness of BI was assessed at a 12-month follow-up in relation to the presence and absence of comorbidity. Reduction of drinking in six ordered categories (g/alcohol) between baseline and follow-up served as the outcome variable. RESULTS BI were significantly related to reduction of drinking in the non-comorbid (-2.64 g/alcohol vs. -8.61 g/alcohol; p=.03) but not in the comorbid subsample (-22.06 g/alcohol vs. -22.09 g/alcohol; p=.76). Compared to non-comorbid participants, a significantly higher reduction of drinking was found for comorbid individuals (-6.55 g/alcohol vs. -22.08 g/alcohol; p=.01). An ordinal regression analysis revealed comorbidity to be a positive predictor for reduction of drinking (estimator=.594; CI=.175-1.013; p<.01). When entering the variables amount of drinking at baseline, intervention and classification of problematic drinking, these became significant predictors, whereas comorbidity showed only a tendency. CONCLUSION BI did not significantly effect a reduction of drinking in comorbid patients. As BI are known to be less effective for dependent drinkers, a larger proportion of dependents among the comorbid might have limited the effectiveness of BI. Future studies with larger sample sizes of comorbid problem drinkers are necessary to confirm the results.

The Role of Family and Partnership in Recovery from Alcohol Dependence: Comparison of Individuals Remitting with and without Formal Help

The aim of this study was to analyse the role of family and partnership in remission from alcohol dependence in treated (n = 50) and untreated (n = 115) individuals. Standardised questionnaires to assess social support, social pressure, coping behaviour, and self-efficacy to stay remitted were used. In both media-solicited samples, social support increased from the pre- to the post-resolution period and was stated as an important resolution maintenance factor. Remitters with formal help experienced more partnership conflicts prior to remission and tended to experience more social pressure from their partner. Social support and social pressure from the family and partner were related to an increase in cognitive coping, as hypothesised, however, only in remitters without formal help, whereas an inverse relationship was found in formal help seekers. Implications for alcohol-related interventions are discussed.

Brief intervention in general hospital for problematic prescription drug use: 12-Month outcome

BACKGROUND The problematic use of prescription drugs (PDs) and related disorders are considerably prevalent but evidence concerning brief intervention for problematic PD users is sparse. A previous analysis of the present study on the effectiveness of brief intervention for problematic PD use in a general hospital revealed a significant reduction in PD use after 3 months. The analyses presented herein provides data from the 12-month follow-up. METHOD In a randomized controlled trial, 126 proactively recruited general hospital patients were analyzed. The intervention group received two brief Motivational Interviewing (MI) sessions. Two follow-ups (after 3 and 12 months) were conducted. Intervention effects at 12-month follow-up on PD cessation and reduction were analyzed using regression methods and controlling for significant group differences. Subgroups of sedative/hypnotic- and opioid-users were examined. RESULTS No significant intervention effects were found in the overall sample. Respecting significant differences between the intervention and control groups, we detected no effects of the intervention for the subgroups of sedative/hypnotic- or opioid-users. CONCLUSIONS In contrast to the short-term effects after 3 months, no long-term effects of brief MI sessions on PD use were found. More intensive interventions, booster-sessions or regular aftercare might help in stabilizing intervention effects on PD use among hospital patients. However, studies using larger samples are needed to allow more powerful and specific analyses. Different samples should be examined. Problems concerning the recruitment of study participants in PD research were discussed and should be considered in further studies.