Stefan Gutwinski

Neural Correlates of Alcohol-Approach Bias in Alcohol Addiction: the Spirit is Willing but the Flesh is Weak for Spirits

Behavioral studies have shown an alcohol-approach bias in alcohol-dependent patients: the automatic tendency to faster approach than avoid alcohol compared with neutral cues, which has been associated with craving and relapse. Although this is a well-studied psychological phenomenon, little is known about the brain processes underlying automatic action tendencies in addiction. We examined 20 alcohol-dependent patients and 17 healthy controls with functional magnetic resonance imaging (fMRI), while performing an implicit approach-avoidance task. Participants pushed and pulled pictorial cues of alcohol and soft-drink beverages, according to a content-irrelevant feature of the cue (landscape/portrait). The critical fMRI contrast regarding the alcohol-approach bias was defined as (approach alcohol>avoid alcohol)>(approach soft drink>avoid soft drink). This was reversed for the avoid-alcohol contrast: (avoid alcohol>approach alcohol)>(avoid soft drink>approach soft drink). In comparison with healthy controls, alcohol-dependent patients had stronger behavioral approach tendencies for alcohol cues than for soft-drink cues. In the approach, alcohol fMRI contrast patients showed larger blood-oxygen-level-dependent responses in the nucleus accumbens and medial prefrontal cortex, regions involved in reward and motivational processing. In alcohol-dependent patients, alcohol-craving scores were positively correlated with activity in the amygdala for the approach-alcohol contrast. The dorsolateral prefrontal cortex was not activated in the avoid-alcohol contrast in patients vs controls. Our data suggest that brain regions that have a key role in reward and motivation are associated with the automatic alcohol-approach bias in alcohol-dependent patients.

Hemispheric Asymmetry for Affective Stimulus Processing in Healthy Subjects–A fMRI Study

Background While hemispheric specialization of language processing is well established, lateralization of emotion processing is still under debate. Several conflicting hypotheses have been proposed, including right hemisphere hypothesis, valence asymmetry hypothesis and region-specific lateralization hypothesis. However, experimental evidence for these hypotheses remains inconclusive, partly because direct comparisons between hemispheres are scarce. Methods The present fMRI study systematically investigated functional lateralization during affective stimulus processing in 36 healthy participants. We normalized our functional data on a symmetrical template to avoid confounding effects of anatomical asymmetries. Direct comparison of BOLD responses between hemispheres was accomplished taking two approaches: a hypothesis-driven region of interest analysis focusing on brain areas most frequently reported in earlier neuroimaging studies of emotion; and an exploratory whole volume analysis contrasting non-flipped with flipped functional data using paired t-test. Results The region of interest analysis revealed lateralization towards the left in the medial prefrontal cortex (BA 10) during positive stimulus processing; while negative stimulus processing was lateralized towards the right in the dorsolateral prefrontal cortex (BA 9 & 46) and towards the left in the amygdala and uncus. The whole brain analysis yielded similar results and, in addition, revealed lateralization towards the right in the premotor cortex (BA 6) and the temporo-occipital junction (BA 19 & 37) during positive stimulus processing; while negative stimulus processing showed lateralization towards the right in the temporo-parietal junction (BA 37,39,42) and towards the left in the middle temporal gyrus (BA 21). Conclusion Our data suggests region-specific functional lateralization of emotion processing. Findings show valence asymmetry for prefrontal cortical areas and left-lateralized negative stimulus processing in subcortical areas, in particular, amygdala and uncus.

Context insensitivity during positive and negative emotional expectancy in depression assessed with functional magnetic resonance imaging.

Patients with depression show an enhanced preoccupation with negative expectations and are often unable to look forward to positive events. Here we studied anticipatory emotional processes in unmedicated depressed patients using functional magnetic resonance imaging. Consistent with a negative processing bias, we hypothesized enhanced responses to negative and attenuated responses to positive expectancy cues in brain areas associated with emotional expectancy. Participants comprised 19 drug-free depressed patients and 19 matched healthy control subjects who viewed affective photographs. Pictures were preceded by an expectancy cue which signaled the emotional valence of the upcoming picture in half of the trials. Depressed patients showed attenuated blood-oxygen-level-dependent responses in the left lateral prefrontal cortex (inferior frontal gyrus, Brodmann area 44) during positive expectancy and-contrary to our hypothesis-in the right lateral orbitofrontal cortex (middle frontal gyrus, Brodmann area 47) during negative expectancy. This attenuation was specific for the anticipation (as opposed to the perception) of emotional pictures and correlated with a clinical measure of depressive symptoms. The observed attenuation suggests emotion-context insensitivity rather than a negative processing bias during anticipatory emotional processes in depression. This hyporeactivity may contribute to clinical features like anergia, apathy, and loss of motivation in the context of both positive and negative incentives.

Methadon und Levomethadon – Dosierung und Nebenwirkungen

OBJECTIVE The aim of our survey was to assess the dosage and the frequency of side effects in patients with opioid dependency receiving opioid maintenance therapy (OMT). METHODS A region-wide anonymous survey was carried out in the city of Berlin. The dosage, the frequency of side effects, data on the dependence disorder and type of OMT was assessed. RESULTS Out of all 5032 patients receiving OMT in Berlin 986 participated in the study. Of all included patients 460 were treated with methadone, 371 with levomethadone. The average dose of levomethadone was significantly higher than the dose of methadone even when adequately adjusting for differential effect sizes. In the total sample, 484 participants reported side effects. The most frequent named ones were sweating and sedation. The incidence of the side effects irritability and gastrointestinal troubles was significantly higher under OMT with levomethadone, although when an adjustment for dosage was performed. CONCLUSIONS Levomethadone is dosed significantly higher than methadone. After an adjustment for dosage was performed, some of the specific side effects occurred more often under OMT with levomethadone. The results of our survey support the use of methadone as first line treatment for OMT.

Why do Patients Stay in Opioid Maintenance Treatment

Opioid maintenance treatment (OMT) successfully improves social functioning and leads to an increase of survival rates, by reducing drug-related mortality and infections. A region-wide anonymous survey was performed to evaluate subjective factors that could potentially contribute to growing numbers of patients in OMT in the city of Berlin, Germany. In the survey, performed in 2011, 46 staff members and 986 patients participated. Both patients and staff members report beneficial effects of OMT on physical and mental health, and reduction of criminality. Patients on average consider the detoxification from OMT more difficult than from heroin. Staff members underestimate the wish of patients to reach abstinence of OMT. We conclude that besides reduced mortality, these subjective factors may contribute to a growing number of patients in OMT. No financial or material support was received in any phase of the study.

Heroin or conventional opioid maintenance? The patients' perspective.

Objective:This study focused on the question whether patients with conventional opioid maintenance treatment (COMT) would prefer a switch to heroin maintenance treatment (HMT). Methods:We performed a region-wide anonymous survey of patients in the opioid maintenance program in Berlin, Germany. All 20 psychiatric hospitals and all 110 physicians’ practices in Berlin licensed to offer COMT were approached to reach patients under COMT and also fulfilling the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria of opiate dependence. The anonymous questionnaire focused on the question whether patients would prefer HMT to COMT. In our study, 986 of 5032 patients (19.6%) with COMT in Berlin participated. Of them, 881 (89.4%) patients gave information whether they would prefer HMT to COMT. Results:Of the participating patients, 40.9% would prefer HMT to COMT. These patients report more detoxification therapies (P < 0.001), a higher dose of methadone equivalent (P = 0.001), and more often continued use of multiple illegal drugs despite COMT (P < 0.001) than patients not preferring HMT. They also report less improvement in mental health (P < 0.001) and working abilities (P < 0.001) because of COMT than patients not preferring HMT. Conclusions:The data on the patients’ perspective complement the existing clinical studies, showing that previously unresponsive opioid-addicted patients especially would switch to HMT, whereas most patients would prefer continuation of COMT.

The Prevalence of Mental Illness in Homeless People in Germany

BACKGROUND The number of homeless people in Germany is increasing. Studies from multiple countries have shown that most homeless people suffer from mental illnesses that require treatment. Accurate figures on the prevalence of mental illness among the homeless in Germany can help improve care structures for this vulnerable group. METHODS We carried out a systematic review and meta-analysis on the prevalence of mental illness among homeless people in Germany. RESULTS 11 pertinent studies published from 1995 to 2013 were identified. The overall study population consisted of 1220 homeless people. The pooled prevalence of axis I disorders was 77.4%, with a 95% confidence interval [95% CI] of [71.3; 82.9]. Substance-related disorders were the most common type of disorder, with a pooled prevalence of 60.9% [53.1; 68.5]. The most common among these was alcoholism, with a prevalence of 55.4% [49.2; 61.5]. There was marked heterogeneity across studies. CONCLUSION In Germany, the rate of mental illness requiring treatment is higher among the homeless than in the general population. The development and implementation of suitable care models for this marginalized and vulnerable group is essential if their elevated morbidity and mortality are to be reduced.

Opioidsubstitution bei heroinabhängigen Patienten mit Migrationshintergrund

ZusammenfassungHintergrundBisher liegen im deutschsprachigen Raum keine regionsumfassenden Untersuchungen zu opioidabhängigen Patienten mit Migrationshintergrund in Substitutionsbehandlung vor.Ziel der ArbeitDie vorliegende Arbeit untersucht, inwieweit sich opioidabhängige Patienten mit und ohne Migrationshintergrund in Substitutionsbehandlung hinsichtlich sozioökonomischer Parameter, Charakteristika der Abhängigkeitserkrankung sowie der Bewertung der Substitutionstherapie unterscheiden.Material und MethodenVon Mai bis Oktober 2011 wurden substituierte Personen in allen 20 psychiatrischen Kliniken sowie den 110 Praxen mit Lizenz zur Opioidsubstitution in Berlin befragt.ErgebnisseVon 986 teilnehmenden Personen machten 956 Angaben zur Herkunft. Davon gaben 204 Personen (21,3 %) einen Migrationshintergrund an. Diese waren, verglichen mit Patienten ohne Migrationshintergrund, signifikant kürzer substituiert, wünschten häufiger eine Möglichkeit zur Beendigung ihrer Substitutionstherapie und sprachen sich häufiger für deren grundsätzliche zeitliche Begrenzung aus.DiskussionDie Unterschiede hinsichtlich der Substitutionsdauer und des Beendigungswunsches können für einen stärkeren Abstinenzwunsch und für eine andere Bewertung der Substitutionstherapie von Personen mit Migrationshintergrund stehen.SummaryBackgroundNo regional analyses regarding opioid-dependent patients in maintenance treatment with a migration background have so far been performed in German-speaking countries.ObjectivesThis study examined patients with and without a migration background regarding socioeconomic parameters, characteristics of dependency and attitude towards opiate maintenance treatment (OMT).Material and methodsFrom May to October 2011 patients in OMT from all of the 20 psychiatry clinics and 110 physician practices in Berlin with a licence to provide OMT were included in this analysis.ResultsOut of the 986 participating patients, 956 gave information on migration background and of these, 204 (21.3 %) originated from a country other than Germany. Compared to patients without a migration background, their participation in a maintenance program was significantly shorter and they more often expressed a desire to end OMT and wanted a limited duration of OMT.ConclusionThe differences regarding duration of OMT and the wish to end OMT can reflect a stronger desire for abstinence and a different attitude towards maintenance treatment of patients with a migration background.BACKGROUND No regional analyses regarding opioid-dependent patients in maintenance treatment with a migration background have so far been performed in German-speaking countries. OBJECTIVES This study examined patients with and without a migration background regarding socioeconomic parameters, characteristics of dependency and attitude towards opiate maintenance treatment (OMT). MATERIAL AND METHODS From May to October 2011 patients in OMT from all of the 20 psychiatry clinics and 110 physician practices in Berlin with a licence to provide OMT were included in this analysis. RESULTS Out of the 986 participating patients, 956 gave information on migration background and of these, 204 (21.3 %) originated from a country other than Germany. Compared to patients without a migration background, their participation in a maintenance program was significantly shorter and they more often expressed a desire to end OMT and wanted a limited duration of OMT. CONCLUSION The differences regarding duration of OMT and the wish to end OMT can reflect a stronger desire for abstinence and a different attitude towards maintenance treatment of patients with a migration background.

[Maintenance treatment in opioid-dependent patients with migration background].

ZusammenfassungHintergrundBisher liegen im deutschsprachigen Raum keine regionsumfassenden Untersuchungen zu opioidabhängigen Patienten mit Migrationshintergrund in Substitutionsbehandlung vor.Ziel der ArbeitDie vorliegende Arbeit untersucht, inwieweit sich opioidabhängige Patienten mit und ohne Migrationshintergrund in Substitutionsbehandlung hinsichtlich sozioökonomischer Parameter, Charakteristika der Abhängigkeitserkrankung sowie der Bewertung der Substitutionstherapie unterscheiden.Material und MethodenVon Mai bis Oktober 2011 wurden substituierte Personen in allen 20 psychiatrischen Kliniken sowie den 110 Praxen mit Lizenz zur Opioidsubstitution in Berlin befragt.ErgebnisseVon 986 teilnehmenden Personen machten 956 Angaben zur Herkunft. Davon gaben 204 Personen (21,3 %) einen Migrationshintergrund an. Diese waren, verglichen mit Patienten ohne Migrationshintergrund, signifikant kürzer substituiert, wünschten häufiger eine Möglichkeit zur Beendigung ihrer Substitutionstherapie und sprachen sich häufiger für deren grundsätzliche zeitliche Begrenzung aus.DiskussionDie Unterschiede hinsichtlich der Substitutionsdauer und des Beendigungswunsches können für einen stärkeren Abstinenzwunsch und für eine andere Bewertung der Substitutionstherapie von Personen mit Migrationshintergrund stehen.SummaryBackgroundNo regional analyses regarding opioid-dependent patients in maintenance treatment with a migration background have so far been performed in German-speaking countries.ObjectivesThis study examined patients with and without a migration background regarding socioeconomic parameters, characteristics of dependency and attitude towards opiate maintenance treatment (OMT).Material and methodsFrom May to October 2011 patients in OMT from all of the 20 psychiatry clinics and 110 physician practices in Berlin with a licence to provide OMT were included in this analysis.ResultsOut of the 986 participating patients, 956 gave information on migration background and of these, 204 (21.3 %) originated from a country other than Germany. Compared to patients without a migration background, their participation in a maintenance program was significantly shorter and they more often expressed a desire to end OMT and wanted a limited duration of OMT.ConclusionThe differences regarding duration of OMT and the wish to end OMT can reflect a stronger desire for abstinence and a different attitude towards maintenance treatment of patients with a migration background.BACKGROUND No regional analyses regarding opioid-dependent patients in maintenance treatment with a migration background have so far been performed in German-speaking countries. OBJECTIVES This study examined patients with and without a migration background regarding socioeconomic parameters, characteristics of dependency and attitude towards opiate maintenance treatment (OMT). MATERIAL AND METHODS From May to October 2011 patients in OMT from all of the 20 psychiatry clinics and 110 physician practices in Berlin with a licence to provide OMT were included in this analysis. RESULTS Out of the 986 participating patients, 956 gave information on migration background and of these, 204 (21.3 %) originated from a country other than Germany. Compared to patients without a migration background, their participation in a maintenance program was significantly shorter and they more often expressed a desire to end OMT and wanted a limited duration of OMT. CONCLUSION The differences regarding duration of OMT and the wish to end OMT can reflect a stronger desire for abstinence and a different attitude towards maintenance treatment of patients with a migration background.

Opioidsubstitution bei heroinabhängigen Patienten mit Migrationshintergrund@@@Maintenance treatment in opioid-dependent patients with migration background

ZusammenfassungHintergrundBisher liegen im deutschsprachigen Raum keine regionsumfassenden Untersuchungen zu opioidabhängigen Patienten mit Migrationshintergrund in Substitutionsbehandlung vor.Ziel der ArbeitDie vorliegende Arbeit untersucht, inwieweit sich opioidabhängige Patienten mit und ohne Migrationshintergrund in Substitutionsbehandlung hinsichtlich sozioökonomischer Parameter, Charakteristika der Abhängigkeitserkrankung sowie der Bewertung der Substitutionstherapie unterscheiden.Material und MethodenVon Mai bis Oktober 2011 wurden substituierte Personen in allen 20 psychiatrischen Kliniken sowie den 110 Praxen mit Lizenz zur Opioidsubstitution in Berlin befragt.ErgebnisseVon 986 teilnehmenden Personen machten 956 Angaben zur Herkunft. Davon gaben 204 Personen (21,3 %) einen Migrationshintergrund an. Diese waren, verglichen mit Patienten ohne Migrationshintergrund, signifikant kürzer substituiert, wünschten häufiger eine Möglichkeit zur Beendigung ihrer Substitutionstherapie und sprachen sich häufiger für deren grundsätzliche zeitliche Begrenzung aus.DiskussionDie Unterschiede hinsichtlich der Substitutionsdauer und des Beendigungswunsches können für einen stärkeren Abstinenzwunsch und für eine andere Bewertung der Substitutionstherapie von Personen mit Migrationshintergrund stehen.SummaryBackgroundNo regional analyses regarding opioid-dependent patients in maintenance treatment with a migration background have so far been performed in German-speaking countries.ObjectivesThis study examined patients with and without a migration background regarding socioeconomic parameters, characteristics of dependency and attitude towards opiate maintenance treatment (OMT).Material and methodsFrom May to October 2011 patients in OMT from all of the 20 psychiatry clinics and 110 physician practices in Berlin with a licence to provide OMT were included in this analysis.ResultsOut of the 986 participating patients, 956 gave information on migration background and of these, 204 (21.3 %) originated from a country other than Germany. Compared to patients without a migration background, their participation in a maintenance program was significantly shorter and they more often expressed a desire to end OMT and wanted a limited duration of OMT.ConclusionThe differences regarding duration of OMT and the wish to end OMT can reflect a stronger desire for abstinence and a different attitude towards maintenance treatment of patients with a migration background.BACKGROUND No regional analyses regarding opioid-dependent patients in maintenance treatment with a migration background have so far been performed in German-speaking countries. OBJECTIVES This study examined patients with and without a migration background regarding socioeconomic parameters, characteristics of dependency and attitude towards opiate maintenance treatment (OMT). MATERIAL AND METHODS From May to October 2011 patients in OMT from all of the 20 psychiatry clinics and 110 physician practices in Berlin with a licence to provide OMT were included in this analysis. RESULTS Out of the 986 participating patients, 956 gave information on migration background and of these, 204 (21.3 %) originated from a country other than Germany. Compared to patients without a migration background, their participation in a maintenance program was significantly shorter and they more often expressed a desire to end OMT and wanted a limited duration of OMT. CONCLUSION The differences regarding duration of OMT and the wish to end OMT can reflect a stronger desire for abstinence and a different attitude towards maintenance treatment of patients with a migration background.