Komorbidität von Sucht und anderen psychischen Störungen - Grundlagen und evidenzbasierte Therapie

Zusammenfassung

Das Vorkommen von 2 oder mehr psychischen Erkrankungen bei einem Individuum (Komorbidität, Doppeldiagnose) ist keine seltene Ausnahme, sondern ein häufiges und klinisch-therapeutisch relevantes Phänomen, zumal komorbide Patienten überzufällig häufig schwere Krankheitsausprägungen aufweisen und eine intensive therapeutische Betreuung benötigen, die den Besonderheiten beider bzw. aller psychischen Störungen und ihrer wechselseitigen Beziehungen Rechnung tragen muss. In der vorliegenden Übersicht werden die Grundlagen der Komorbidität von Sucht mit anderen psychischen Störungen behandelt. Es werden die Prävalenzdaten und die Erklärungsmodelle vorgestellt, die klinischen Charakteristika und Besonderheiten des Verlaufs komorbider Patienten beschrieben und allgemeine Therapieprinzipien, u. a. die Vorteile integrierter Behandlungsprogramme, erläutert. Hinsichtlich spezifischer pharmako- und psychotherapeutischer Maßnahmen für die häufigsten Komorbiditäten wurde eine systematische Literaturrecherche in den Datenbanken MEDLINE, EMBASE und PsycInfo (bis 12/2007) durchgeführt und die identifizierten Studien wurden hinsichtlich der Qualität ihres Designs beurteilt. Auf dieser Grundlage wird die Wirksamkeit therapeutischer Programme evidenzbasiert dargestellt und Therapieempfehlungen gestuft nach dem Grad ihrer Fundierung ausgesprochen. In der Zusammenschau sind integrierte Behandlungsprogramme in der Regel erfolgreich, solange die mehrdimensionalen Defizite der komorbiden Patienten berücksichtigt, die verschiedenen Therapiebausteine aufeinander angepasst und adaptiert, und die Behandlungsziele realistisch gesetzt sind. Für die Zukunft wäre eine stärkere Verbreitung der integrierten Behandlung mit Implementierung entsprechender Programme in die Regelversorgung wünschenswert.

Abstract

The coincidence of two or more psychiatric disorders in the same person (comorbidity or dual diagnosis) is no rare exception. It is rather common and therapeutically highly relevant. Comorbid patients exhibit frequently severe manifestations of the disorder(s) and they require intensive treatment to meet their special needs and the interdependencies of their disorders. The present overview deals with the theoretical foundations of comorbidity of substance use and other psychiatric disorders. We present data on the prevalence of different comorbidities and discuss the models, which have been proposed to explain how substance use and other disorders relate with each other. Furthermore, we describe the clinical characteristics and long-term course of comorbid patients, as well as some general therapeutic principles including the advantages of integrated therapeutic programmes. In addition, we carried out a systematic literature search on specific pharmaco- and psychotherapies for common comorbidities using the databases MEDLINE, EMBASE and PsycInfo (up to December 2007), and assessed the methodological quality of the identified trials. Based on this search we present the empirical evidence for the effectiveness of specific treatments and make therapeutic recommendations which are graded according to the strength of existing evidence. In conclusion, integrated treatment programs are more effective, provided they take into account the multiple deficits of comorbid patients, adjust and adapt the different therapeutic components to each other, and set realistic goals. The next step should be a broader application of integrated treatment programs and their adoption as standard treatment within the national health systems.

Schlüsselwörter

Komorbidität - Sucht - Doppeldiagnose - Pharmakotherapie - Psychotherapie

Key words

comorbidity - substance use disorders - dual diagnosis - pharmacotherapy - psychotherapy

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