Die Adipositas geht im Erwachsenenalter oft mit psychischer Komorbidität einher, die den Gewichtsreduktionserfolg beeinflussen und eine Behandlung indizieren kann, die von Standardprogrammen der multimodalen Adipositasverhaltenstherapie (AVT) nicht abgedeckt wird. Dieser Artikel diskutiert am Beispiel der häufig komorbiden Binge-Eating-Störung (BES) aktuelle Forschungsergebnisse zu Ätiologie und Intervention bei Komorbidität mit dem Ziel, Implikationen für die weitere Forschung und Behandlung abzuleiten. Weil die Kognitive Verhaltenstherapie (KVT), die am besten belegte Therapieform für Erwachsene mit BES, der AVT bei der Reduktion der Essstörungssymptomatik überlegen war, bei der Gewichtsreduktion nur tendenziell und ausschließlich kurzfristig unterlegen, sollte sich die weitere Interventionsentwicklung auf graduelle Anpassungen der KVT zur Verbesserung der Gewichtsreduktion bei Patienten mit Adipositas und BED konzentrieren. Hierfür kommen mit dem Ziel einer geringfügigen Gewichtsreduktion einzelne adaptierte AVT-Interventionen in Betracht, während sich gleichzeitige oder sequentielle Kombinationen dieser beiden Therapieformen nicht eindeutig bewährt haben. Interventionen, die auf aktuellen Forschungsergebnissen für die Komorbidität beider Störungsbilder fußen, könnten individualisiert einbezogen werden, um die Wirksamkeit für Essstörungssymptomatik und Körpergewicht zu erhöhen. Neue digitale Behandlungsmodalitäten könnten den Transfer in den Lebensalltag und die Nachhaltigkeit der Effekte fördern. Diese Modifikationen hin zu einer adaptiven KVT für Erwachsene mit Adipositas und BES, basierend auf einem patientengerechten Therapierationale, bedürfen der Absicherung durch weitere experimentelle Therapieforschung. / Obesity often co-occurs with mental comorbidity in adults, likely impacting weight loss success and indicating treatment that is not covered by standard behavioral weight loss (BWL) treatment. Using the example of binge-eating disorder (BED) as a frequent comorbid condition, this article discusses current research on etiology and intervention in case of comorbidity, in order to derive implications for research and treatment. Cognitive-behavioral therapy (CBT), the most well-established treatment for adults with BED, was more efficacious than BWL in improving binge-eating symptomatology in patients with obesity and BED, while tending to show lower weight loss effects in the short term only. Therefore, further intervention development should focus on gradual adaptations of CBT for improving weight loss. These interventions could be adapted from BWL and aim at a slight weight loss. Parallel or sequential combinations of these treatments have not consistently demonstrated improved treatment effects. Interventions based on current research could be included on an individual basis, in order to enhance efficacy for eating disorder symptomatology and body weight. New digital treatment modalities could support the transfer into daily life and boost the long-term maintenance of therapeutic gains. These modifications regarding adaptive CBT for adults with obesity and BED should be based on an individual treatment rationale and require further research in an experimental therapeutics framework.

Background: Data regarding both drug-related and non-drug-related costs in patients with Parkinson's disease (PD) are scarce, mainly due to the difficulties in data acquisition in experimental designs. Likewise, the reported impact of drug costs on total direct costs varies across different studies. In addition, the influence of comorbidities on both treatment costs and health-related quality of life has not been adequately evaluated. Methods: A sample of office-based neurologists (n = 315) in Germany was asked to examine up to five consecutive patients with PD (n = 1449) on a specified day during the study period. Patients of all ages were eligible and their evaluation was performed using standardized questionnaires. Results: PD-specific therapy costs increased with the stage of the disease, early onset of the disease and disease duration. The major costs were due to PD-related therapy, whereas other medications only resulted in minor costs. Disease stage mainly influenced direct therapy costs, with an observed increase of total daily costs from €7.3 to €11.3/day. In addition, disease onset at age < 65 years resulted in total daily costs of €11.2 compared to late onset of disease (> 75 years) with daily therapy costs of €5.3. In this patient group neuropsychiatric comorbidities such as dementia and depression were only insufficiently treated. In addition, these comorbidities severely affected health-related quality of life. Conclusion: Therapy costs were influenced by disease stage, disease onset as well as present comorbidities. Furthermore, comorbidities such as depression and dementia were diagnosed but were not adequately treated.

Objective: The paper discusses conceptual, methodological and clinical issues of comorbidity from the perspective of more recent epidemiological studies. Further the potential causal and pathogenic role of temporally primary disorders for the onset of secondary disorders is evaluated. Results: The available data suggest so far that comorbidity (a) is not an artefact of assessment strategies, sampling or design features, (b) is specific in different disorders, (c) is particularly frequent in anxiety and affective disorders, (d) affects systematically the course of the comorbid conditions and (0 might be related to symptom progression models. Conclusions: Furthermore, evidence is presented that specific forms of primary anxiety disorders affect the risk for secondary depressive disorders, increase the likelihood of non-remission as well as the number of subsequent depressive episodes. / Scopo: Lo studio affronta problemi concettuali, metodologici e clinici della comorbidità, alia luce dei piu recenti studi epidemiologici. Inoltre viene valutata la causa potenziale e il ruolo patogenetico dei disturbi temporaneamente primari per la comparsa dei disturbi secondari. Risultati: I risultati disponibili fino ad oggi suggeriscono che la comorbidità (a) non è un artefatto delle strategic di valutazione, del campionamento o del disegno, (b) è specifica nei differenti disturbi, (c) e particolarmente frequente nei disturbi affettivi e d'ansia, (d) influisce sistematicamente sull'andamento delle condizioni di comorbidita è (f) potrebbe essere correlata con modelli di evoluzione dei sintomi. Conclusioni: È inoltre evidente che forme specifiche di disturbi di ansia primaria comportano il rischio di sviluppare disturbi depressivi. secondari, aumentano la probability di non remissione cosi come il numero di successivi episodi depressivi.

Background: Controversy surrounds the questions whether co-occurring depression has negative effects on cognitivebehavioral therapy (CBT) outcomes in patients with panic disorder (PD) and agoraphobia (AG) and whether treatment for PD and AG (PD/AG) also reduces depressive symptomatology. Methods: Post-hoc analyses of randomized clinical trial data of 369 outpatients with primary PD/AG (DSM-IV-TR criteria) treated with a 12-session manualized CBT (n = 301) and a waitlist control group (n = 68). Patients with comorbid depression (DSM-IV-TR major depression, dysthymia, or both: 43.2% CBT, 42.7% controls) were compared to patients without depression regarding anxiety and depression outcomes (Clinical Global Impression Scale [CGI], Hamilton Anxiety Rating Scale [HAM-A], number of panic attacks, Mobility Inventory [MI], Panic and Agoraphobia Scale, Beck Depression Inventory) at post-treatment and follow-up (categorical). Further, the role of severity of depressive symptoms on anxiety/depression outcome measures was examined (dimensional). Results: Comorbid depression did not have a significant overall effect on anxiety outcomes at post-treatment and follow-up, except for slightly diminished post-treatment effect sizes for clinician-rated CGI (p = 0.03) and HAM-A (p = 0.008) when adjusting for baseline anxiety severity. In the dimensional model, higher baseline depression scores were associated with lower effect sizes at post-treatment (except for MI), but not at follow-up (except for HAM-A). Depressive symptoms improved irrespective of the presence of depression. Conclusions: Exposure-based CBT for primary PD/AG effectively reduces anxiety and depressive symptoms, irrespective of comorbid depression or depressive symptomatology. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background: Data on the impact of gender on mortality after radical cystectomy is conflicting. We investigated a large single center sample with long-term follow-up in order to determine the relationship between gender and outcome. Patients and Methods: A total of 1,184 consecutive patients who underwent radical cystectomy for high risk superficial or muscle-invasive urothelial or undifferentiated bladder cancer between 1993 and 2015 were stratified by gender. Demographic data was compared using Mann-Whitney U test, chi-square test, or Fisher exact test. Cox proportional hazard models were used for the analysis of competing risks and logit models were used for the prediction of the receipt of adjuvant cisplatin-based chemotherapy. Results: Female patients were older, healthier, less frequently current smokers and had more extravesical tumors. In the multivariate analyses, female gender was an independent predictor of (lower) non-bladder cancer (competing) mortality (hazards ratio [HR] 0.68, 95% CI 0.49–0.95, p = 0.0248) but no predictor of bladder cancer-specific mortality (HR in the full model 1.20, 95% CI 0.94–1.54, p = 0.15). Gender was no predictor of the receipt of adjuvant cisplatin-based chemotherapy. Conclusions: Female gender was associated with an increased risk of extravesical disease but was no independent predictor of bladder cancer-specific mortality. Anatomical differences might be a plausible explanation for these observations.

Background: Controversy surrounds the questions whether co-occurring depression has negative effects on cognitivebehavioral therapy (CBT) outcomes in patients with panic disorder (PD) and agoraphobia (AG) and whether treatment for PD and AG (PD/AG) also reduces depressive symptomatology. Methods: Post-hoc analyses of randomized clinical trial data of 369 outpatients with primary PD/AG (DSM-IV-TR criteria) treated with a 12-session manualized CBT (n = 301) and a waitlist control group (n = 68). Patients with comorbid depression (DSM-IV-TR major depression, dysthymia, or both: 43.2% CBT, 42.7% controls) were compared to patients without depression regarding anxiety and depression outcomes (Clinical Global Impression Scale [CGI], Hamilton Anxiety Rating Scale [HAM-A], number of panic attacks, Mobility Inventory [MI], Panic and Agoraphobia Scale, Beck Depression Inventory) at post-treatment and follow-up (categorical). Further, the role of severity of depressive symptoms on anxiety/depression outcome measures was examined (dimensional). Results: Comorbid depression did not have a significant overall effect on anxiety outcomes at post-treatment and follow-up, except for slightly diminished post-treatment effect sizes for clinician-rated CGI (p = 0.03) and HAM-A (p = 0.008) when adjusting for baseline anxiety severity. In the dimensional model, higher baseline depression scores were associated with lower effect sizes at post-treatment (except for MI), but not at follow-up (except for HAM-A). Depressive symptoms improved irrespective of the presence of depression. Conclusions: Exposure-based CBT for primary PD/AG effectively reduces anxiety and depressive symptoms, irrespective of comorbid depression or depressive symptomatology. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Objective: The paper discusses conceptual, methodological and clinical issues of comorbidity from the perspective of more recent epidemiological studies. Further the potential causal and pathogenic role of temporally primary disorders for the onset of secondary disorders is evaluated. Results: The available data suggest so far that comorbidity (a) is not an artefact of assessment strategies, sampling or design features, (b) is specific in different disorders, (c) is particularly frequent in anxiety and affective disorders, (d) affects systematically the course of the comorbid conditions and (0 might be related to symptom progression models. Conclusions: Furthermore, evidence is presented that specific forms of primary anxiety disorders affect the risk for secondary depressive disorders, increase the likelihood of non-remission as well as the number of subsequent depressive episodes. / Scopo: Lo studio affronta problemi concettuali, metodologici e clinici della comorbidità, alia luce dei piu recenti studi epidemiologici. Inoltre viene valutata la causa potenziale e il ruolo patogenetico dei disturbi temporaneamente primari per la comparsa dei disturbi secondari. Risultati: I risultati disponibili fino ad oggi suggeriscono che la comorbidità (a) non è un artefatto delle strategic di valutazione, del campionamento o del disegno, (b) è specifica nei differenti disturbi, (c) e particolarmente frequente nei disturbi affettivi e d'ansia, (d) influisce sistematicamente sull'andamento delle condizioni di comorbidita è (f) potrebbe essere correlata con modelli di evoluzione dei sintomi. Conclusioni: È inoltre evidente che forme specifiche di disturbi di ansia primaria comportano il rischio di sviluppare disturbi depressivi. secondari, aumentano la probability di non remissione cosi come il numero di successivi episodi depressivi.

Background: Despite an abundance of questionnaire data, the prevalence of clinically significant and medically unexplained pain syndromes in the general population has rarely been examined with a rigid personal-interview methodology. Objective To examine the prevalence of pain syndromes and DSM-IV pain disorder in the general population and the association with other mental disorders, as well as effects on disability and health-care utilization. Methods: Analyses were based on a community sample of 4.181 participants 18–65 years old; diagnostic variables were assessed with a standardized diagnostic interview (M-CIDI). Results: The 12-month prevalence for DSM-IV pain disorder in the general population was 8.1%; more than 53% showed concurrent anxiety and mood disorders. Subjects with pain disorder revealed significantly poorer quality of life, greater disability, and higher health-care utilization rates compared to cases with pain below the diagnostic threshold. The majority had more than one type of pain, with excessive headache being the most frequent type. Conclusions: Even when stringent diagnostic criteria are used, pain disorder ranks among the most prevalent conditions in the community. The joint effects of high prevalence in all age groups, substantial disability, and increased health services utilization result in a substantial total burden, exceeding that of depression and anxiety.

Hintergrund. In klinischen und epidemiologischen Untersuchungen wurden retrospektiv Assoziationen zwischen Angst- und Alkoholstörungen bestätigt. Bei Personen, die von beiden Störungen betroffen waren, fand man restrospektiv meist einen früheren Beginn der Angststörungen im Vergleich zu den Alkoholstörungen, was kausal im Sinne der Selbstmedikationshypothese interpretiert wurde. Diese konnte bisher nicht eindeutig bestätigt werden. Zur Aufklärung notwendige prospektive Untersuchungen, die Angststörungen auf diagnostischer Ebene erfassen, zwischen verschiedenen Angststörungen unterscheiden und sich auf Jugendliche beziehen, fehlen bisher. Fragestellung. Die Bedeutung von Angststörungen für die Entwicklung von erhöhtem Alkoholkonsum und Alkoholstörungen bei Jugendlichen und jungen Erwachsenen. Methodik. Die Analysen basieren auf den Daten der prospektiv-longitudinalen EDSP-Studie (Follow-Up: insg. 4 Jahre) mit einer epidemiologischen, repräsentativen Stichprobe von 3021 Personen im Alter zwischen 14 und 24 Jahre zu T0 aus München und Umland. Zur Erhebung von DSM-IV-Diagnosen wurde das M-CIDI verwendet. Ergebnisse. Primäre Panikstörungen, Panikattacken und Soziale Phobie erwiesen sich prospektiv als spezifische Prädiktoren für Beginn und Aufrechterhaltung von Alkoholproblemen. Umgekehrt waren Alkoholprobleme mit einem erhöhten Risiko für den Beginn von Sozialer Phobie und GAS assoziiert. Bezüglich DSM-IV Diagnosekriterien fanden sich phobische Ängste sowie Episoden intensiver Angst als Risikofaktoren für den Beginn von Alkoholproblemen. Vermeidungsverhalten war mit einem verminderten Risiko für nachfolgende Alkoholprobleme verbunden. Schlussfolgerungen. Maßnahmen zur Prävention von Alkoholproblemen können sich zielgruppenorientiert an Jugendliche mit Sozialer Phobie und Paniksymptomatik richten. Bei Patienten, die sich wegen Alkoholproblemen in Behandlung begeben, ist eine umfassende Diagnostik zur Identifikation zusätzlicher Angststörungen ratsam. / Background. Many clinical and epidemiological studies have documented significant cross-sectional comorbidities between anxiety disorders and alcohol use disorders. Analysis of retrospective age-of-onset reports suggests that the anxiety disorders often start earlier than the alcohol disorders. These data have often been interpreted in terms of a self-medication-model implying a causal mechanism. Overall, in former studies this model couldn't definitely be proofed. Prospective studies that follow a sample of adolescents into adulthood assessing different anxiety disorders on an diagnostic level are needed to confirm these associations. Methods. Baseline and four-year-follow-up data from the EDSP-Study, a prospective community survey of 3021 (2548 at follow-up) adolescents and young adults aged 14 to 24 years at baseline carried out in Munich, were used. DSM-IV anxiety disorders, alcohol use and alcohol use disorders were assessed with the M-CIDI. Results. While in retrospective analyses strong associations between nearly all anxiety disorders and alcohol problems, especially harmful use and dependence, were found, prospective analyses showed that only primary panic disorder, panic attack and social phobia are specific predictors of subsequent onset and persistence of alcohol problems. Contrary, primary alcohol problems were related to subsequent onset of social phobia and GAD. Considering the different DSM-IV-criteria, phobic anxiety as well as episodes of intensive anxiety were found to be risk factors for the following onset of alcohol problems. Avoidance behavior was associated with a lower risk for subsequent alcohol problems. Conclusions. Alcohol prevention programs could be directed to target groups with social phobia and panic. Patients with alcohol problems should carefully be screened for comorbid anxiety disorders. In order to prevent relapses the treating of social phobia and panic should be part of the therapy with comorbid alcohol patients.

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