Motivationsbehandlung bei Patienten mit der Doppeldiagnose Psychose und Sucht

Zusammenfassung

Patienten mit schizophrenen Störungen und Komorbiditäten in Form eines Substanzabusus oder einer Substanzabhängigkeit [Doppeldiagnosepatienten (DD)] zeigen einen besonders ungünstigen Krankheitsverlauf und wenig Bereitschaft, speziell entwickelte integrierte Behandlungsangebote in Anspruch zu nehmen. Deshalb wurden die bei Suchterkrankungen ohne weitere Komorbidität bereits erfolgreich angewendete Motivationsbehandlung („Motivational Interviewing”, MI), welche darauf abzielt, die intrinsische Motivation für eine Veränderung hinsichtlich des Problemverhaltens zu fördern, für DD adaptiert. In der vorliegenden Arbeit wird eine Übersicht über die derzeitige empirische Evidenz für die Effektivität von MI bei DD gegeben. Eine Literatursuche in den Datenbanken MEDLINE, EMBASE und PsycInfo wurde durchgeführt und die Qualität der identifizierten Studien nach Kriterien der Cochrane-Gesellschaft und denen von Jadad u. Mitarb. beurteilt. Es wurden 4 randomisierte Studien mit insgesamt 334 Teilnehmern identifiziert, in denen MI von 1 - 3 Sitzungen Dauer mit unterschiedlichen Kontrollinterventionen über einen Katamnesezeitraum bis zu 6 Monaten verglichen wurden. Bezüglich der Hauptinterventionsziele „Inanspruchnahme weiterführender psychotherapeutischer Behandlung” (1 × positiv, 2 × negativ) und „Substanzkonsum/Abstinenz” (1 × positiv, 1 × negativ) kamen die Studien zu widersprüchlichen Ergebnissen. Bei allen 4 Studien fanden sich erhebliche allgemeine Limitationen (Randomisierungsmodus, Verblindung der Rater, Beschreibung der Studien- und Therapieabbrecher) sowie spezielle methodische Mängel (Stichprobengröße und -homogenität, Dauer des MI, Verlauf des Motivationsstadiums). Schlussfolgernd ist derzeit nicht zu entscheiden, ob die mangelnde empirisch zu zeigende Effektivität auf die oben genannten methodischen Probleme zurückzuführen ist oder ob MI bei DD tatsächlich nicht wirkt. Demzufolge besteht erheblicher Forschungsbedarf zu MI bei DD.

Abstract

Patients with schizophrenia and substance abuse disorders [dually diagnosed patients (DD)] show an unfavourable course of the illness and little interest in participating on specific integrated treatment programmes. Motivational interviewing (MI) has been shown to be effective among other substance abuse disorders and it aims to enhance intrinsic motivation to change problem behaviour. MI has been adapted for DD. The present paper reviews the empirical evidence for the efficacy of MI in DD. A search in the databases MEDLINE, EMBASE, PsycINFO was conducted and the methodological quality of the identified trials was assessed according to the Cochrane Collaboration and to the JADAD Scale. We identified 4 randomised studies with a total of 346 participants, in which MI interventions of 1 to 3 sessions were compared with various control conditions over a follow-up period of up to 6 months. With regard to the main outcome measures „subsequent participation at integrated treatment programme” (1 × positive, 2 × negative) and „substance use” (1 × positive, 1 × negative,) the studies gained contradictory results. In all 4 studies, there were relevant general methodological limitations (randomisation, blindness of raters, description of the reasons for drop-outs) and specific methodological shortcomings (sample size and sample homogenity, numbers of MI sessions, assessment of motivational status). Hence, at present the evidence for supporting MI in DD is not clear. This may be due to the methodological problems mentioned above or it may be that there is, in fact, no effect. Therefore, there is an urgent need for further research of MI in DD.

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