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Background: In treatment-resistant major depressive disorder (MDD), electroconvulsive therapy (ECT) is a treatment with high efficacy. While knowledge regarding changes in brain structure following ECT is growing, the effects of ECT on brain function during emotional processing are largely unknown. Objective: We investigated the effects of ECT on the activity of the anterior cingulate cortex (ACC) and amygdala during negative emotional stimuli processing and its association with clinical response. Methods: In this non-randomized longitudinal study, patients with MDD (n = 37) were assessed before and after treatment with ECT. Healthy controls (n = 37) were matched regarding age and gender. Functional magnetic resonance imaging (fMRI) was obtained twice, at baseline and after six weeks using a supraliminal face-matching paradigm. In order to evaluate effects of clinical response, additional post-hoc analyses were performed comparing responders to non-responders. Results: After ECT, patients with MDD showed a statistically significant increase in ACC activity during processing of negative emotional stimuli (pFWE = .039). This effect was driven by responders (pFWE = .023), while non-responders showed no increase. Responders also had lower pre-treatment ACC activity compared to non-responders (pFWE = .025). No significant effects in the amygdala could be observed. Conclusions: ECT leads to brain functional changes in the ACC, a relevant region for emotional regulation during processing of negative stimuli. Furthermore, baseline ACC activity might serve as a biomarker for treatment response. Findings are in accordance with recent studies highlighting properties of pre-treatment ACC to be associated with general antidepressive treatment response.
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Major depressive disorder (MDD) is associated to affected brain wiring. Little is known whether these changes are stable over time and hence might represent a biological predisposition, or whether these are state markers of current disease severity and recovery after a depressive episode. Human white matter network (“connectome”) analysis via network science is a suitable tool to investigate the association between affected brain connectivity and MDD. This study examines structural connectome topology in 464 MDD patients (mean age: 36.6 years) and 432 healthy controls (35.6 years). MDD patients were stratified categorially by current disease status (acute vs. partial remission vs. full remission) based on DSM-IV criteria. Current symptom severity was assessed continuously via the Hamilton Depression Rating Scale (HAMD). Connectome matrices were created via a combination of T1-weighted magnetic resonance imaging (MRI) and tractography methods based on diffusion-weighted imaging. Global tract-based metrics were not found to show significant differences between disease status groups, suggesting conserved global brain connectivity in MDD. In contrast, reduced global fractional anisotropy (FA) was observed specifically in acute depressed patients compared to fully remitted patients and healthy controls. Within the MDD patients, FA in a subnetwork including frontal, temporal, insular, and parietal nodes was negatively associated with HAMD, an effect remaining when correcting for lifetime disease severity. Therefore, our findings provide new evidence of MDD to be associated with structural, yet dynamic, state-dependent connectome alterations, which covary with current disease severity and remission status after a depressive episode.
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Background: Blended cognitive behavioral therapy (bCBT) — the combination of cognitive behavioral therapy and digital mental health applications — has been increasingly used to treat depression and anxiety disorders. As a resource-efficient treatment approach, bCBT appears promising for addressing the growing need for mental health care services, for example, as an early intervention before the chronification of symptoms. However, further research on the efficacy and feasibility of integrated bCBT interventions is needed. Objective: This study aimed to evaluate the efficacy of a novel bCBT program comprising short (25 min), weekly face-to-face therapy sessions combined with a smartphone-based digital health app for treating mild to moderate symptoms of depression or anxiety. Methods: This prospective uncontrolled trial comprised 2 measurement points (before and after treatment) and 2 intervention groups. We recruited university students with mild to moderate symptoms of depression or anxiety. On the basis of the primary symptoms, participants were assigned to either a depression intervention group (n=67 completers) or an anxiety intervention group (n=33 completers). Participants in each group received 6 weekly individual psychotherapy sessions via videoconference and completed modules tailored to their respective symptoms in the smartphone-based digital health app. Results: The depression group displayed medium to large improvements in the symptoms of depression (Cohen d=−0.70 to −0.90; P<.001). The anxiety group experienced significant improvements in the symptoms of generalized anxiety assessed with the Generalized Anxiety Disorder-7 scale with a large effect size (Cohen d=−0.80; P<.001) but not in symptoms of anxiety assessed with the Beck Anxiety Inventory (Cohen d=−0.35; P=.06). In addition, both groups experienced significant improvements in their perceived self-efficacy (Cohen d=0.50; P<.001 in the depression group and Cohen d=0.71; P<.001 in the anxiety group) and quality of life related to psychological health (Cohen d=0.87; P<.001 in the depression group and Cohen d=0.40; P=.03 in the anxiety group). Work and social adjustment of patients improved significantly in the depression group (Cohen d=−0.49; P<.001) but not in the anxiety group (Cohen d=−0.06; P=.72). Patients’ mental health literacy improved in the anxiety group (Cohen d=0.45; P=.02) but not in the depression group (Cohen d=0.21; P=.10). Patient satisfaction with the bCBT program and ratings of the usability of the digital app were high in both treatment groups. Conclusions: This study provides preliminary evidence for the feasibility and efficacy of a novel brief bCBT intervention. The intervention effects were generalized across a broad spectrum of patient-reported outcomes. Hence, the newly developed bCBT intervention appears promising for treating mild to moderate depression and anxiety in young adults.
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Etwa 40–50 Prozent der erwachsenen Bevölkerung nimmt aktuell an legalen oder illegalen Glücksspielangeboten in Deutschland teil (Zwölf-Monats-Prävalenz, Bundeszentrale für gesundheitliche Aufklärung, 2016; Meyer, 2016; Sassen et al., 2011). Beim überwiegenden Anteil bleibt es auf der Ebene einer problemlosen Unterhaltung, während etwa 0,3–0,6 Prozent der erwachsenen Bevölkerung oder etwa 0,8–1,0 Prozent der aktiven Spieler eine pathologische Ausprägung entwickelt (Bühringer, Kotter & Kräplin, 2016; Bundeszentrale für gesundheitliche Aufklärung, 2016; Meyer, 2016; Sassen et al., 2011). Neben Beratungs- und Behandlungsmaßnahmen bestehen in vielen Ländern Sperrsysteme, die Personen davon abhalten sollen, weiter an Glücksspielen teilzunehmen, um die negativen Konsequenzen wie emotionale Störungen, erhebliche Verschuldung, das Risiko des illegalen Erwerbs von finanziellen Mitteln sowie Probleme am Arbeitsplatz und in der Familie zu vermeiden bzw. zu reduzieren. Es gibt dabei unterschiedliche Ausprägungen von Sperrsystemen, z.B. im Hinblick auf die Begründung einer Sperre (Verschuldung und/oder pathologisches Spielverhalten), ihre Initiierung (Selbst- oder Fremdsperre), die Dauer (einige Monate bis Lebenszeit), den Geltungsbereich (ein oder mehrere Glücksspielsegmente) und die Möglichkeit und Modalitäten einer Entsperrung (für einen Überblick vergleiche Gainsbury, 2014). Für eine effektive Gestaltung von Sperrsystemen ist es notwendig, die Auswirkungen und die Einschätzung einer Sperrung durch betroffene Personen vor dem Hintergrund des Wissens aus den Verhaltenswissenschaften zu analysieren. Zumindest die Fremdsperre im Sinne eines Betretungs- und Spielverbots stellt einen erheblichen Eingriff in den Freiheitsspielraum einer Person dar. Es gibt wenige ähnliche Eingriffe, wie etwa rechtlich verfügte Näherungsverbote gegenüber früheren Partnern, Kindern oder Stalking-Opfern sowie Hausverbote in Kaufhäusern und Gaststätten (die Beispiele sind unabhängig davon, ob Betroffene oder Dritte geschützt werden sollen). Es ist daher zur Einhaltung einer Spielersperre notwendig, die betroffenen Personen möglichst gut über die Notwendigkeit und den Nutzen einer Sperre zu informieren und vor allem zur Einhaltung zu motivieren. Dies gilt auch dann, wenn viele selbst- oder fremdgesperrte Spieler zunächst die Sperre verbal akzeptieren, da die Akzeptanz eines Verbots bzw. der Wunsch oder das Verlangen nach erneutem Glücksspielen im Zeitverlauf variieren kann (Ladouceur, Sylvain & Gosselin, 2007).
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Dieser Beitrag befasst sich mit der Frage, wie der Verbraucherschutz für Personen, die Glücksspielangebote in Deutschland terrestrisch oder online nutzen, möglichst effektiv umgesetzt werden kann. Hintergrund sind zum einen Forschungsergebnisse zu Entwicklung und Verlauf pathologischen Glücksspielens sowie zu den Zusammenhängen von Glücksspielangebot, Glücksspielmerkmalen und glücksspielbezogenen Störungen. Zudem wird die aktuelle Diskussion aufgrund verschiedener Gerichtsentscheidungen berücksichtigt, die zentrale Aspekte des gegenwärtigen Konzepts für den Verbraucherschutz in Deutschland infrage gestellt bzw. verworfen haben (vgl BeckOK GewO/Reeckmann, 33. Ed. 15.02.2016, GewO § 33i Rn. 6.1). In diesem Beitrag wird dafür plädiert, sehr viel stärker als bisher den Verbraucherschutz durch zwei miteinander verbundene Maßnahmen sicherzustellen: hohe Qualitätsanforderungen an Anbieter von Glücksspielen sowie hohe Qualitätskontrollen durch eine zentrale und unabhängige Regulierungsstelle. Verbraucherschutz wird dabei als übergeordneter Begriff für verschiedene Teilaspekte verstanden: Spielerschutz (vor allem die Prävention pathologischer Entwicklungen bzw. der Schutz von Personen, die bereits eine glücksspielbezogene Störung entwickelt haben), Jugendschutz (Verhinderung des Glückspielens durch Minderjährige), Vertragsrechtschutz (Einhaltung gesetzlicher Regelungen wie z. B. für Internetgeschäfte) und den Schutz vor Betrug und anderen illegalen Handlungen. Dies bedeutet auch, dass im Mittelpunkt des Beitrags die möglichst gute Sicherstellung eines risikoarmen Glücksspielens für alle erwachsenen Personen steht, die diese Angebote nutzen wollen, und nicht nur der Schutz für die Teilgruppe von Personen, die im Zusammenhang mit Glücksspielen ein pathologisches Spielverhalten entwickelt. Es bestehen unterschiedliche gesellschaftliche Wertvorstellungen, in welchem Umfang das Glückspielen in einer Gesellschaft zugelassen und reguliert werden soll (vgl. Forberger & Bühringer, 2014). Hierzu gibt es keine richtige oder falsche Antwort. Eine Entscheidung erfordert eine gesellschaftliche Diskussion, die sich letztlich in einer parlamentarischen Willensbildung ausdrückt, sowie in regelmäßigen Anpassungen aufgrund sich ändernder Wertvorstellungen und Glücksspielangebote. Diese Wertebasierung zeigt sich auch in sehr unterschiedlichen Regelungen in den Mitgliedsstaaten der Europäischen Union, von sehr liberal bis sehr restriktiv. Unabhängig von der gesellschaftlichen Diskussion und Entscheidung über das Angebot von Glücksspielen in einem Land gelten zumindest folgende Erkenntnisse: (1) Sehr extreme Einschränkungen bzw. eine komplette Prohibition führen zu Ausweichverhalten in illegale Angebote, (2) ein nicht oder wenig reguliertes Angebot führt ebenfalls zu negativen Konsequenzen, d. h. Verbraucherschutz ist notwendig und (3) es gibt kein Glücksspielangebot ohne problematische Entwicklungen des Spielverhaltens einzelner Personen. Es ist deshalb eine gemeinsame Verantwortung der Glücksspielanbieter, der Regulierungsstellen und auch der Glücksspieler selber, soweit sie Kontrolle über ihr Glücksspielverhalten haben, das Glücksspielangebot verantwortungsvoll zu steuern und zu nutzen und die Anzahl von Personen mit pathologischem Spielverhalten sowie dessen negative Auswirkungen möglichst gering zu halten.
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Although it is often regarded as obvious, the exact nature of the relationship between gambling availability and gambling behaviour or disordered gambling remains unclear. However, disordered gambling is an important public health issue and restrictions on availability are seen as an important strategy to reduce gambling- related problems in many jurisdictions. Applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we reviewed studies on the relationship between physical gambling availability and gambling behaviour, as well as disordered gambling, and focused on several currently discussed hypotheses about their relationship. We used a systematic electronic search strategy involving 12 search terms and several databases. We included 27 studies and evaluated them by applying a comprehensive quality rating and quality weighting of evidence. We found a high proportion of quality-weighted evidence for both a positive relationship (access hypothesis) and a decrease or plateau in the prevalence of gambling participation and disorders over time with increasing availability (adaptation hypothesis). However, several conceptual and methodological problems hamper final conclusions. For example, studies were often not based on precise hypotheses, only two studies had a longitudinal design, overall quality ratings varied widely, operationalizations of gambling availability were sometimes not objectively measured, follow-up periods were insufficient, and shifting behaviour was not assessed. To understand the causal role of gambling availability in the development and course of gambling disorder and to derive evidence-based prevention strategies, investigators need to perform more high-quality longitudinal research that is based on a solid theoretical framework with the corresponding statistical analyses.
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Background: Mill’s liberalism, the post-World War II German Social Market Economy (Rhine Capitalism) and modern consumer protection share the conviction that market participants have equal rights and responsibilities. Within this framework, governments and market providers are responsible for balancing the knowledge deficits of consumers in cases of “asymmetric information”. The widely discussed Reno Model for Responsible Gambling appears to be based on similar ideas by setting standards for informing participants of gambling features and procedures. Position: Based on recent research, we argue that such standard consumer protection may be adequate for social gamblers but not for vulnerable gamblers. These individuals may not benefit adequately from a rational informed choice approach to prevent harm and disordered gambling. Conclusion: Gambling providers should implement specific protections to address vulnerable gamblers, e. g., early detection procedures and limits for or exclusion from gambling.
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Efficient decoding of facial expressions and gaze direction supports reactions to social environments. Although both cues are processed fast and accurately, when and how these cues are integrated is still debated. We investigated the temporal integration of gaze and emotion cues. Participants responded to letters that were randomly presented on four faces. Two of these faces initially showed direct gaze, two showed averted gaze. Upon target presentation, two faces changed gaze direction (from averted to direct and vice versa). Simultaneously, facial expressions changed from neutral to either an approach- or an avoidance-oriented emotion expression (Experiment 1a: angry/fearful; Experiment 1b: happy/disgusted). Although angry and fearful expressions diminished any effects of gaze direction (Experiment 1a), a direct gaze advantage was found for happy and an averted gaze advantage for disgusted faces (Experiment 1b). This pattern is consistent with hypotheses suggesting a processing benefit when emotion expression and gaze information are congruent in terms of approach- or avoidance-orientation. In Experiment 2, we tracked eye movements and, again, found evidence for an approach–avoidance-congruency advantage for happy and disgusted faces both in performance and gaze behavior. Gaze behavior analyses suggested an integration of gaze and emotion information that was already visible from 300 ms after target onset. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
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To estimate the effectiveness of gambling exclusion programmes, previous research focused on changes in gambling behaviour post-exclusion. Although other mental health problems, especially co-morbid mental disorders, may be crucial for relapse and recovery of gambling-related problems, these factors have rarely been studied in excluders. Therefore, this study aimed to assess a comprehensive mental health status of excluders using well-validated diagnostic instruments. Fifty-eight casino excluders participated in face-to-face diagnostic interviews and completed several validated questionnaires (e.g. Stinchfield Questionnaire, Brief Symptom Inventory). Retrospective temporal sequences of diagnosed mental disorders, help-seeking behaviour and exclusion were examined. The majority of excluders reported impairments in mental health aspects. About three-quarters met criteria of lifetime gambling disorder, more than half in the last 12 months whereby screening and diagnostic measures correlated moderately. Other mental disorders were frequent, especially affective and substance-related disorders and typically preceded the onset of gambling disorder. Six years passed between self-awareness of gambling problems and help-seeking. Two more years passed until exclusion. Frequent mental health problems suggest the need for individually tailored support beyond exclusion programmes (e.g. psychotherapy, pharmacotherapy, counselling services). Late help-seeking and exclusion entry claim for improved early detection and intervention concepts that consider underlying mental disorders.
