Publications by authors named "Anna Buadze"

20 Publications

  • Page 1 of 1

Evaluating the reliability of hair analysis in monitoring the compliance of ADHD patients under treatment with Lisdexamphetamine.

PLoS One 2021 30;16(3):e0248747. Epub 2021 Mar 30.

Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.

Considering the high clinical and forensic relevance of pharmaco-adherence during lisdexamphetamine (LDX) treatment for attention-deficit/hyperactivity disorder (ADHD), the aim here was to evaluate hair analysis as a tool for monitoring compliance in patients currently undergoing long term treatment with LDX, by detecting possible interruptions of medication intake or changes in dosage. For this purpose, a total of 24 patients from an outpatient clinic for ADHD were recruited. Hair and urine samples were taken after three consecutive therapy sessions over a 7-month period and analyzed for amphetamine (AMP) enantiomers and other drugs, using chiral and achiral liquid chromatography-tandem mass spectrometry (LC-MS/MS). Participants also provided information on the condition of their hair, the consumption of illegal psychotropic substances and the regularity of taking LDX. Two participants withdrew from the study early. Urine analyses were positive for D-AMP in all urine samples and therapy sessions, except in two patients who did not take LDX on a daily basis. D-AMP was detected in all hair samples; however, no correlation was found between prescribed dose/day and D-AMP concentrations in proximal hair segments. Qualitative interpretation of hair analysis showed that 18 of the 22 study completers were compliant concerning the intake of LDX without additional consumption of illegal D,L-AMP. Analysis of urine taken during the therapy sessions showed no correlation between D-AMP concentrations and prescribed dosage, with or without normalization for creatinine. In conclusion, chiral LC-MS/MS hair analysis might represent a non-invasive way to confirm LDX use within the approximate period covered by the hair segment tested, but it does not allow for quantitative therapeutic drug monitoring because of interindividual variability of concentrations in hair. Drug concentrations in hair at different stages of long-term treatment should thus be interpreted with caution by clinicians and forensic experts alike when making assessments of treatment adherence.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248747PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009440PMC
March 2021

Perceptions and Attitudes of Correctional Staff Toward ADHD-A Challenging Disorder in Everyday Prison Life.

Front Psychiatry 2020 28;11:600005. Epub 2021 Jan 28.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is associated with risk-taking behaviors, poor self-control, and interpersonal difficulties. Affected individuals have an increased probability of involvement with the criminal justice system, contributing to a higher rate of arrest, and imprisonment compared with the general population; they are also inadequately treated once sentenced. Because prison staff play a central role in the identification of inmates with mental disorders, they could well be key to improving provision of care. There is however little knowledge of the conceptions, perceptions, and attitudes of prison staff toward ADHD. Such information could help to identify starting points for awareness training and further implementation of specific ADHD treatment. To bridge this gap, we undertook a study based on a qualitatively-driven mixed methods design, combining qualitative data collection in the form of narrative interviews with 19 prison staff from a Swiss correctional facility with quantitative data collection in the form of a survey that included the Attitudes toward Prisoners scale. The interviews were analyzed with QSR NVIVO 11 and a qualitative content analysis approach was used to evaluate findings. Prison staff were generally aware of ADHD and its symptomology, believing it to a be "real," but "fashionable" disorder and favoring hereditary-genetic or biological explanatory models for its development. They viewed inmates with ADHD rather negatively, as complicating correctional efforts, and perceived them as sticking out, as tying up more resources and as frequently being involved in confrontations. Our findings suggest that difficulties in pragmatic aspects of communication and language comprehension may be perceived "as not listening or following instructions," creating additional tensions. Consequently, inmates with ADHD are more often exposed to disciplinary sanctions, such as solitary confinement-an intervention deemed "necessary" by staff. Therefore, staff training on ADHD might need to cover evidence on adverse effects. Non-pharmacological interventions for treatment were preferred and considered to be highly efficacious. Skepticism toward pharmacological treatment prevailed, even when benefits from stimulant medication were described. Interestingly, this skepticism was not the result of negative experiences with the misuse and diversion of stimulants. Acceptance of multimodal treatment among prison staff may require customized strategies.
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http://dx.doi.org/10.3389/fpsyt.2020.600005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901975PMC
January 2021

Associations of executive and functional outcomes with full-score intellectual quotient among ADHD adults.

Psychiatry Res 2020 12 22;294:113521. Epub 2020 Oct 22.

Department of Mental Health and Psychiatry, Service of Psychiatric Specialties, University Hospitals of Geneva, Geneva, Switzerland; Department of Psychiatry, University of Geneva, Geneva, Switzerland; Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada.

Associations between executive and functional impairment, intelligence, and attention deficit hyperactivity disorder (ADHD) have been scarcely investigated among adult populations and lead to inconsistent results. This study tested the impact of intellectual level on executive and functional impairment in a clinical sample of adults diagnosed with ADHD. Participants were recruited in a specialized center for the diagnosis and treatment of ADHD (n=66, mean age=27.9 ± 10.8). Measures included intellectual quotient (IQ, Wechsler Adult Intelligence Scale) categorized as ≤110 or >110, the continuous performance test (CPT3), grade retention, educational attainment, and having an activity (job or studies). Participants with a higher IQ had significantly better functional outcomes than participants with a standard IQ: higher educational attainment, lower grade retention, and often having an activity. Participants with higher IQ performed significantly better on all CPT variables assessing executive functioning. Intelligence seemed to work as a protective factor for executive and functional outcomes in a clinical population of ADHD adults and might reduce long-lasting detrimental consequences in life.
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http://dx.doi.org/10.1016/j.psychres.2020.113521DOI Listing
December 2020

Fifteen years of heroin-assisted treatment in a Swiss prison-a retrospective cohort study.

Harm Reduct J 2020 10 13;17(1):67. Epub 2020 Oct 13.

Swiss Research Institute for Public Health and Addiction ISGF, University of Zurich, Zurich, Switzerland.

Background: In the context of the current US opioid crisis and the compelling fact that a quarter to a third of all those addicted to heroin pass through its prisons and jails each year, the care of incarcerated opioid-using individuals (OUI) needs to be improved.

Aims: Little has been published on the effectiveness or outcomes of heroin-assisted treatment (HAT), a treatment option for severely dependent OUI delivered in a prison setting. The aim of this study was therefore to evaluate such treatment since its implementation. The primary objective was to investigate whether heroin-assisted treatment was associated with severe detrimental health outcomes. The secondary objective was to compare the heroin-assisted treatment group with the general prison population in terms of occupational functioning.

Design: Retrospective cohort study SETTING: An open prison with 120 places SUBJECTS: Data on 1885 male prisoners with a total of 2239 imprisonment periods between 2000 and 2015 was available. Ninety-seven inmates in heroin-assisted treatment were compared with 1788 inmates from the general prison population (reference group).

Measurements: Mortality, medical complications (including overdoses), and work performance (days worked, sick days, and monthly wages earned).

Findings: Inmates receiving HAT were on average 1 year younger (33.8 vs. 34.9 years), had longer prison stays (7.3 vs. 3.0 months), were more often of Swiss nationality (68.0% vs. 28.9%), and had committed more drug- and property-related offenses (49.5% vs. 23.2% and 63.9% vs. 38.3%, respectively) compared to the reference group. No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group.

Conclusions: This study shows that heroin-assisted treatment can be a valuable treatment option for severely dependent OUI during imprisonment, can be delivered safely by prison health staff over extended periods of time, and allows OUI in treatment to achieve work performance rates comparable to that of the general prison population.
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http://dx.doi.org/10.1186/s12954-020-00412-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552491PMC
October 2020

The Accessibility of Opioid Agonist Treatment and Its Forced Discontinuation in Swiss Prisons-Attitudes, Perceptions and Experiences of Defense Lawyers in Dealing With Detained Persons Using Opioids.

Front Psychiatry 2020 14;11:395. Epub 2020 May 14.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Background: Opioid agonist treatment (OAT) is an important pillar in the treatment of individuals using opioids and its continuation during imprisonment is recommended. Despite this knowledge access to and continuation of OAT is still limited in many countries. The forced discontinuation during pre-trial detention can cause severe withdrawal symptoms, which in turn may significantly impair the defendant's ability to exercise granted procedural participation rights. Furthermore, it can be argued that forced discontinuation of a desired treatment represents a form of a compulsory intervention.

Aims: The present study was developed against the backdrop of a recent ruling by the European Court of Human Rights (Wenner vs. Germany). It intended to examine how defense lawyers dealing with detained persons using opioids view and assess the accessibility of OAT in pre-trial detention as well as during imprisonment in different parts of Switzerland.

Methods: Using a qualitative approach, we interviewed 11 defense lawyers from three different cantons of Switzerland with multiple years of experience in providing legal representation to more than 220 defendants using heroin. The interviews were analyzed with QSR NVIVO 11 for Windows. A qualitative content analysis approach was used to evaluate findings.

Results: Defenders who had been exposed to the opioid crisis during the course of their legal career had adopted a positive attitude towards OAT and associated it with a stabilizing influence on their clients, an improvement in criminal prognosis, and a reduction in recidivism. They were generally of the opinion that access to OAT had improved, however identified a considerable variance in different penitentiaries, which were mediated by attitudes of staff and authorities. Based on the assessments of the defense lawyers, it can be estimated that the initiation of OAT especially during pre-trial detention is challenging. The predominant aim of OAT in a variety of Swiss prisons still seems to focus on a discontinuation, mediated by a forced reduction of medication. Some of the interventions reported are not in line with the principle of equivalence and strongly contrast the recommendations of the Council of Europe.
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http://dx.doi.org/10.3389/fpsyt.2020.00395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240251PMC
May 2020

How Do Legal Experts Cope With Medical Reports and Forensic Evidence? The Experiences, Perceptions, and Narratives of Swiss Judges and Other Legal Experts.

Front Psychiatry 2019 13;10:18. Epub 2019 Feb 13.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Expert scientific knowledge, including medical knowledge, is relevant for the legal profession and can strongly influence rulings and sentencing in criminal law, civil law, and insurance law. The way in which this medical evidence is understood and evaluated thus has an impact both on individuals and on society as a whole. It enters legal procedures in various forms, for example, as expert witness statements and/or as a legal expert's own acquired medical knowledge. On the other hand, a legal expert may be confronted with expert medical opinions that differ in quality or content and thus have to decide which ones to follow. The aim of this qualitative study was to investigate legal experts' perceptions, experiences, and narratives regarding medical knowledge, particularly the skills and general knowledge used in their branch of the legal profession. A total of 51 semi-structured interviews with judges and prosecutors from different courts of law and from the public prosecutor's office in six different German-speaking (Zurich, Luzern, Aagrau, Obwalden, Nidwalden, Zug) and German/French-speaking (Bern) cantons of Switzerland were conducted, coded, and analyzed using Nvivo. We used a comparison thematic approach identifying common and new themes related to the research aims. Our findings suggest that Swiss judges and prosecutors believe that possessing and developing the skills and terminology required for processing medical information is important but complex, and time-consuming for their work. Additionally, several legal experts reported that their understanding of medical evidence was limited or even non-existent. Moreover, the acquisition of skills related to the assessment of medical reports and forensic evidence appeared to be unstructured. Participants reported having no formal instruction in how to evaluate or deal with medical knowledge. The sources they used to answer questions arising appeared to be in part problematic and non-standardized (internet, newspapers, etc.). Medical literature from peer-reviewed journals was used only rarely. The findings from this study suggest that law departments might wish to evaluate whether their graduates are sufficiently equipped with scientific literacy skills and appropriate skills to evaluate medical information for their later careers. At the same time, medical knowledge pertinent to forensics published in local legal journals may be more effective in reaching the legal expert audience than in medical journals.
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http://dx.doi.org/10.3389/fpsyt.2019.00018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381858PMC
February 2019

Status quo of German-speaking medical students' attitudes toward and knowledge about central aspects of forensic psychiatry across four European countries.

Int J Law Psychiatry 2018 May - Jun;58:9-16. Epub 2018 Mar 3.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Falkenplatz 16-18, 3012 Bern, Switzerland. Electronic address:

While forensic psychiatry is of increasing importance in mental health care, limited available evidence shows that attitudes toward the discipline are contradictory and that knowledge about it seems to be limited in medical students. We aimed to shed light on this subject by analyzing medical students' central attitudes toward and their association with knowledge about forensic psychiatry as well as with socio-demographic and education-specific predictor variables. We recruited N = 1345 medical students from 45 universities with a German language curriculum across four European countries (Germany, Switzerland, Austria and Hungary) by using an innovative approach, namely snowball sampling via Facebook. Students completed an online questionnaire, and data were analyzed descriptively and multivariably by linear mixed effects models and multinomial regression. The results showed overall neutral to positive attitudes toward forensic psychiatry, with indifferent attitudes toward the treatment of sex offenders, and forensic psychiatrists' expertise in the media. Whereas medical students knew about the term 'forensic psychiatry', they showed a lack of specific medico-legal knowledge. Multivariable models on predictor variables revealed statistically significant findings with, however, small estimates and variance explanation. Therefore, further research is required along with the development of a refined assessment instrument for medical students to explore both attitudes and knowledge in forensic psychiatry.
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http://dx.doi.org/10.1016/j.ijlp.2018.02.003DOI Listing
April 2019

Skills and compensation strategies in adult ADHD - A qualitative study.

PLoS One 2017 27;12(9):e0184964. Epub 2017 Sep 27.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Objective: The primary objectives of this study were to investigate how adult patients with ADHD coped with their symptoms prior to diagnosis and treatment, what skills and compensation strategies they had developed and what their self-perceptions of these strategies were.

Methods: We used a qualitative approach to analyze interviews with 32 outpatients of a specialty care unit at a university hospital.

Results: Patients reported frequent use of diverse compensatory strategies with varying degrees of effectiveness. These were classified into five categories (organizational, motoric, attentional, social, psychopharmacological). In certain circumstances, ADHD symptoms were even perceived as useful.

Conclusion: Before diagnosis and treatment, patients with ADHD may develop a variety of skills to cope with their symptoms. Several of these skills are perceived as helpful. Knowledge of self-generated coping strategies may help better understand patients and their histories and thus facilitate patient cooperation. Moreover, knowing ways in which such patients cope with their symptoms may help elucidate reasons for late or under-diagnosing of the disorder.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0184964PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617155PMC
October 2017

Attitudes Toward Stimulant Treatment of Offspring of Adult Patients with Attention-Deficit/Hyperactivity Disorder.

J Child Adolesc Psychopharmacol 2017 Jun 19;27(5):422-428. Epub 2017 Apr 19.

1 Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern , Bern, Switzerland .

Aim: The objective of this study was to investigate how adult patients with attention-deficit/hyperactivity disorder viewed the testing and use of stimulants in their children.

Methods: Using a qualitative approach, we interviewed 32 outpatients from a special care unit of a university hospital.

Results: Emerging themes centered around concerns about the right age to test children and opinions about stimulant treatment ranging from unreserved agreement to reluctance, as well as the need for a shared decision with the child.

Conclusions: Our results suggest that better psychoeducational programs are needed, especially for adults with attention-deficit/hyperactivity disorder, in which long-term consequences of the disorder, areas of impairment, and possible treatment effects in their children are explained and concerns about unknown side effects and the right time to test and treat are addressed.
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http://dx.doi.org/10.1089/cap.2016.0197DOI Listing
June 2017

Could Google Trends Be Used to Predict Methamphetamine-Related Crime? An Analysis of Search Volume Data in Switzerland, Germany, and Austria.

PLoS One 2016 30;11(11):e0166566. Epub 2016 Nov 30.

Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.

Objective: To compare the time trends of Google search interest in methamphetamine and criminal offences related to this drug.

Methods: Google Trends data for the search term "meth" was compared to methamphetamine-related crime statistics (incl. use, possession, and dealing) in Switzerland, Germany, and Austria for the years 2004-2016. Google data was availably monthly. Crime data was available yearly, and monthly values were imputed.

Results: On the country level, internet search trends for "meth" roughly paralleled relevant criminal activity. State-level data, which was available for Austria, showed more heterogeneity. Cross-correlations for yearly data almost always peaked at a lag time of 0 and coefficients were mostly between 0.7 and 1.0 on the country level, and between 0.5 to 1.0 on the state level. Monthly cross-correlations based on imputed values were substantially lower, ranging from 0 to 0.6.

Conclusions: These results encourage the further evaluation by law enforcement authorities of Google search activity as a possible predictor of methamphetamine-related crime. However, several limitations, in particular the crude temporal resolution of available crime data, precluded a detailed assessment of the relationship between internet search trends and the development of methamphetamine-related crime in central Europe.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166566PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5130206PMC
July 2017

High-Dose Benzodiazepine Users' Perceptions and Experiences of Anterograde Amnesia.

J Am Acad Psychiatry Law 2016 Sep;44(3):328-37

Dr. Liebrenz is Head of the Research Division, Department of Forensic Psychiatry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland. Mr. Schneider is Resident Physician, Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital, Zurich, Switzerland. Dr. Buadze is Attending Physician, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland. Ms. Gehring is a Psychologist and Head of the Residential Rehabilitation Treatment Program, Ulmenhof, Sozialtherapie, Ottenbach, Switzerland. Dr. Dube is Attending Physician, County of Santa Barbara, Department of Behavioral Wellness, Santa Barbara, California. Dr. Caflisch is Attending Physician, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland. Dr. Liebrenz was financially supported by the Prof. Dr. Max Cloëtta Foundation, Zurich, Switzerland and the Uniscientia Foundation, Vaduz, Principality of Liechtenstein.

Associations between criminal activity and the use of psychotropic substances are well established. Flunitrazepam, specifically, has been suspected of triggering, per se, violent criminal behavior and severe memory disturbances in the form of anterograde amnesia. However, data from investigations of this relationship are scarce and have been primarily derived from forensic institutions, where there may be a reporting bias. This study was a qualitative exploration of high-dose benzodiazepine users' experiences of anterograde amnesia symptoms and their beliefs about their behavior during the phases of memory impairment in a nonforensic setting. Users subjectively reported experiencing symptoms of anterograde amnesia, especially after combining short-acting benzodiazepines with alcohol, but only rarely when using slow-onset, long-acting compounds. They perceived their experiences as unpleasurable, unpredictable, and embarrassing. Their awareness developed with time, triggered by descriptions of disinhibited and erratic behavior by others. Users described being victimized during phases of anterograde amnesia in addition to engaging in violent and criminal activities themselves. Although unable to recall, many participants believed that they had been able to make rational decisions while intoxicated with flunitrazepam, disregarding notions of diminished insight. In light of the varying terminology used for the phases of memory disturbance and these findings, we suggest that forensic experts additionally explore evaluees' beliefs about amnestic periods and their self-perceptions about their behaviors during these episodes, when evaluating high-dose benzodiazepine-dependent patients.
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September 2016

Adult attention-deficit/hyperactivity disorder and nicotine withdrawal: a qualitative study of patient perceptions.

BMC Psychiatry 2016 07 4;16:208. Epub 2016 Jul 4.

Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.

Background: Nicotine use has been reported to ameliorate symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). Furthermore, adults with ADHD have a relatively high prevalence of cigarette smoking and greater difficulty abstaining from smoking. Overall, though, there is scant literature investigating the beliefs, perceptions and experiences of smokers with ADHD regarding smoking cessation and withdrawal.

Methods: Our participants (n = 20) fulfilling criteria for ADHD and a past or current dependence from nicotine were recruited from the in- and outpatient clinic of the Zurich University Psychiatric Hospital and the Psychiatric Services Aargau (Switzerland). We conducted in-depth interviews to explore their motivations to quit, past experiences with and expectations about quitting using a purposeful sampling plan. The sample was selected to provide diversity in relation to level of nicotine dependence, participation in a smoking-cessation program, gender, age, martial status and social class. Mayring's qualitative content analysis approach was used to evaluate findings.

Results: Adult smokers with ADHD had made several attempts to quit, experienced intense withdrawal symptoms, and relapsed early and often. They also often perceived a worsening of ADHD symptoms with nicotine abstinence. We identified three motives to quit smoking: 1) health concerns, 2) the feeling of being addicted, and 3) social factors. Most participants favored a smoking cessation program specifically designed for individuals with ADHD because they thought ADHD complicated their nicotine withdrawal and that an ADHD-specific smoking cessation program should address specific symptoms of this disorder.

Conclusions: Since treatment initiation and adherence associate closely with perception, we hope these findings will result in better cessation interventions for the vulnerable subgroup of smokers with ADHD.
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http://dx.doi.org/10.1186/s12888-016-0911-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932755PMC
July 2016

Attitudes towards a maintenance (-agonist) treatment approach in high-dose benzodiazepine-dependent patients: a qualitative study.

Harm Reduct J 2016 Jan 8;13. Epub 2016 Jan 8.

Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.

Background: High-dose benzodiazepine dependence constitutes a major clinical concern. Although withdrawal treatment is recommended, it is unsuccessful for a significant proportion of affected patients. More recently, a benzodiazepine maintenance approach has been suggested as an alternative for patients' failing discontinuation treatment. While there is some data supporting its effectiveness, patients' perceptions of such an intervention have not been investigated.

Methods: An exploratory qualitative study was conducted among a sample of 41 high-dose benzodiazepine (BZD)-dependent patients, with long-term use defined as doses equivalent to more than 40 mg diazepam per day and/or otherwise problematic use, such as mixing substances, dose escalation, recreational use, or obtainment by illegal means. A qualitative content analysis approach was used to evaluate findings.

Results: Participants generally favored a treatment discontinuation approach with abstinence from BZD as its ultimate aim, despite repeated failed attempts at withdrawal. A maintenance treatment approach with continued prescription of a slow-onset, long-acting agonist was viewed ambivalently, with responses ranging from positive and welcoming to rejection. Three overlapping themes of maintenance treatment were identified: "Only if I can try to discontinue…and please don't call it that," "More stability and less criminal activity…and that is why I would try it," and "No cure, no brain and no flash…and thus, just for everybody else!"

Conclusions: Some patients experienced slow-onset, long-acting BZDs as having stabilized their symptoms and viewed these BZDs as having helped avoid uncontrolled withdrawal and abstain from criminal activity. We therefore encourage clinicians to consider treatment alternatives if discontinuation strategies fail.
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http://dx.doi.org/10.1186/s12954-015-0090-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4705614PMC
January 2016

High-Dose Benzodiazepine Dependence: A Qualitative Study of Patients' Perceptions on Initiation, Reasons for Use, and Obtainment.

PLoS One 2015 10;10(11):e0142057. Epub 2015 Nov 10.

Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.

Background: High-dose benzodiazepine (BZD) dependence is associated with a wide variety of negative health consequences. Affected individuals are reported to suffer from severe mental disorders and are often unable to achieve long-term abstinence via recommended discontinuation strategies. Although it is increasingly understood that treatment interventions should take subjective experiences and beliefs into account, the perceptions of this group of individuals remain under-investigated.

Methods: We conducted an exploratory qualitative study with 41 adult subjects meeting criteria for (high-dose) BZD-dependence, as defined by ICD-10. One-on-one in-depth interviews allowed for an exploration of this group's views on the reasons behind their initial and then continued use of BZDs, as well as their procurement strategies. Mayring's qualitative content analysis was used to evaluate our data.

Results: In this sample, all participants had developed explanatory models for why they began using BZDs. We identified a multitude of reasons that we grouped into four broad categories, as explaining continued BZD use: (1) to cope with symptoms of psychological distress or mental disorder other than substance use, (2) to manage symptoms of physical or psychological discomfort associated with somatic disorder, (3) to alleviate symptoms of substance-related disorders, and (4) for recreational purposes, that is, sensation-seeking and other social reasons. Subjects often considered BZDs less dangerous than other substances and associated their use more often with harm reduction than as recreational. Specific obtainment strategies varied widely: the majority of participants oscillated between legal and illegal methods, often relying on the black market when faced with treatment termination.

Conclusions: Irrespective of comorbidity, participants expressed a clear preference for medically related explanatory models for their BZD use. We therefore suggest that clinicians consider patients' motives for long-term, high-dose BZD use when formulating treatment plans for this patient group, especially since it is known that individuals are more compliant with approaches they perceive to be manageable, tolerable, and effective.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0142057PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640837PMC
July 2016

Adult attention-deficit/hyperactivity disorder: Associations between subtype and lifetime substance use - a clinical study.

F1000Res 2015 28;4:407. Epub 2015 Jul 28.

Psychiatric University Hospital, Research Group on ADHD, Zurich, 8032, Switzerland.

ADHD is the one of the most prevalent childhood disorders and has been associated with impairments persisting into adulthood. Specifically, childhood ADHD is an independent clinical risk factor for the development of later substance use disorders (SUD). Moreover, adults who meet diagnostic criteria for ADHD have shown high rates of comorbid SUDs. Few studies, however, have reported on the relationship between ADHD subtypes and SUD in adult samples. The purpose of this study was to characterize a clinical sample of adults with ADHD and to identify possible associations between ADHD subtypes, lifetime substance use, and if ADHD subtypes may be preferentially associated with specific substances of abuse. We recruited 413 adult ADHD patients, performed an evaluation of their ADHD and conducted an interview on their use of psychotropic substances. Complete data was obtained for 349 patients. Lifetime substance abuse or dependence was 26% and occasional use was 57% in this sample. The inattentive subtype was significantly less likely to abuse or be dependent on cocaine than the combined subtype. Our findings underscore the high rate of comorbidity between substance use and ADHD in adults. The more frequent abuse/dependence of cocaine by adult patients with hyperactive-impulsive symptoms should be kept in mind when treating this patient group.
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http://dx.doi.org/10.12688/f1000research.6780.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089146PMC
July 2015

High-dose benzodiazepine dependence: a qualitative study of patients' perception on cessation and withdrawal.

BMC Psychiatry 2015 May 13;15:116. Epub 2015 May 13.

Psychiatric University Hospital, Lenggstrasse 31, 8032, Zurich, Switzerland.

Background: Benzodiazepine withdrawal syndrome has been reported following attempts to withdraw even from low or therapeutic doses and has been compared to barbiturate and alcohol withdrawal. This experience is known to deter patients from future cessation attempts. Research on other psychotropic substances shows that the reasons and motivations for withdrawal attempts - as well as the experiences surrounding those attempts - at least partially predict future efforts at discontinuation as well as relapse. We therefore aimed to qualitatively explore what motivates patients to discontinue this medication as well as to examine their experiences surrounding previous and current withdrawal attempts and treatment interventions in order to positively influence future help-seeking behavior and compliance.

Methods: To understand these patients better, we conducted a series of 41 unstructured, narrative, in-depth interviews among adult Swiss patients with a long-term dependent use of benzodiazepines in doses equivalent to more than 40 mg diazepam per day and/or otherwise problematic use (mixing benzodiazepines, escalating dosage, recreational use or illegal purchase). Mayring's qualitative content analysis was used to evaluate findings.

Results: These high-dose benzodiazepine-dependent patients decision to change consumption patterns were affected by health concerns, the feeling of being addicted and social factors. Discontinuation attempts were frequent and not very successful with fast relapse. Withdrawal was perceived to be a difficult, complicated, and highly unpredictable process. The first attempt at withdrawal occurred at home and typically felt better than at the clinic. Inpatient treatment was believed to be more effective with long term treatment (approaches) than short term. Patients preferred gradual reduction of usage to abrupt cessation (and had experienced both). While no clear preferences for withdrawal were found for benzodiazepines with specific pharmacokinetic properties, participants frequently based their decision to participate in treatment on the availability of their preferred brand name and furthermore discarding equivalent dosage rationales.

Conclusions: Our findings provide greater understanding of the factors that motivate high-dose benzodiazepine-dependent individuals to stop taking these medications, and how they experience withdrawal and treatment strategies. They underscore how patients' perceptions of treatment approaches contribute to compliant or non-compliant behavior.
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http://dx.doi.org/10.1186/s12888-015-0493-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443548PMC
May 2015

Adult attention-deficit/hyperactivity disorder and nicotine use: a qualitative study of patient perceptions.

BMC Psychiatry 2014 May 16;14:141. Epub 2014 May 16.

Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Drive, New York, NY 10032, USA.

Background: Adult Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with high rates of comorbid substance use disorders, and cigarette smoking has a particularly high prevalence in this population. However, there is an ongoing debate as to whether this tobacco use is an attempt at "self-medication" or due to behavioral disinhibition. There is a surprising lack of qualitative studies that investigate the subjective perceptions of adults with ADHD regarding cigarette smoking. The present study was designed to fill this gap in the literature.

Methods: We recruited twelve adult patients with ADHD and comorbid tobacco use from our ADHD consultation service, an outpatient facility of the Zurich University Psychiatric Hospital. Subjects were interviewed using qualitative methodology, and Mayring's qualitative content analysis was used to evaluate findings.

Results: We identified two explanatory models linking ADHD and tobacco use: smoking as an attempt at self-medication and "smoking as a social behavior". On one hand, subjects considered tobacco a therapeutic aid, reporting positive effects on "inner tension" and cognitive function, and noted possible antidepressant properties as well. On the other hand, subjects considered smoking to enhance social functioning and to have a positive impact on interpersonal relationships. The majority believed that stimulant medications offered only a transient decrease in patterns of tobacco use because their ability to reduce nicotine cravings wore off quickly. Others believed that stimulants had no effect or even reinforced cigarette use.

Conclusions: Participants had different views about the link between cigarette smoking and ADHD. While the majority thought of nicotine as a sort of therapy, viewing smoking as a way to self-medicate symptoms of ADHD, motivations for nicotine use were also related to self-image, desire to belong to a peer-group, and a drive to undermine perceived social norms. Ultimately, these findings can be used by clinicians to improve treatment alliance and collaboration.
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http://dx.doi.org/10.1186/1471-244X-14-141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4037284PMC
May 2014

Patient's perceptions of the cannabis-psychosis link--a systematic review.

Curr Pharm Des 2012 ;18(32):5105-12

University of Zurich, Clinic of Affective Disorders and General Psychiatry, Lenggstrasse 31, 8032 Zurich, Switzerland.

Over the past years a growing research effort has investigated the relation between cannabis use and schizophrenia at a neurobiological, epidemiological and clinical level. A number of systematic reviews and meta analyses have summarized the available evidence in the field. Conversely the patient's perception of the link between cannabis use and psychosis has been under investigation. Since patient's beliefs and attitudes strongly correlate with adherence to all forms of treatment, we conducted a systematic PUBMED database search for any English and German-language articles published until January 2012 that addressed patient's perception of a cannabis psychosis link. Six studies including psychotic subjects met inclusion criteria yielding a total sample of 97. The vast majority of patients with either schizophrenia or a recent psychosis disagreed with a causal link between cannabis use and their mental illness. We qualitatively reviewed the explanatory models underlying their views, which were multi-factorial, psychological, social, biological, esoteric and irrational factors. Most patient's believed that the temporal sequence of events did not clearly indicate a causal relationship for them. They thus discarded the hypothesis of a causal link between cannabis use and psychosis. Despite the heterogeneity of the included studies, findings are comparable and support the robustness of this review. Limitations and implications for clinicians and psychosis research are discussed.
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http://dx.doi.org/10.2174/138161212802884645DOI Listing
March 2013

High dose methylphenidate treatment in adult attention deficit hyperactivity disorder: a case report.

J Med Case Rep 2012 May 14;6:125. Epub 2012 May 14.

Psychiatric University Hospital, Research Group on Substance Use Disorders, Selnaustrasse 9, 8001, Zurich, Switzerland.

Introduction: Stimulant medication improves hyperactivity, inattention, and impulsivity in both pediatric and adult populations with Attention Deficit Hyperactivity Disorder (ADHD). However, data regarding the optimal dosage in adults is still limited.

Case Presentation: We report the case of a 38-year-old Caucasian patient who was diagnosed with Attention Deficit Hyperactivity Disorder when he was nine years old. He then received up to 10 mg methylphenidate (Ritalin®) and 20 mg sustained-release methylphenidate (Ritalin SR®) daily. When he was 13, his medication was changed to desipramine (Norpramin®), and both Ritalin® and Ritalin SR® were discontinued; and at age 18, when he developed obsessive-compulsive symptoms, his medication was changed to clomipramine (Anafranil®) 75 mg daily. Still suffering from inattention and hyperactivity, the patient began college when he was 19, but did not receive stimulant medication until three years later, when Ritalin® 60 mg daily was re-established. During the 14 months that followed, he began to use Ritalin® excessively, both orally and rectally, in dosages from 4800-6000 mg daily. Four years ago, he was referred to our outpatient service, where his Attention Deficit Hyperactivity Disorder was re-evaluated. At that point, the patient's daily Ritalin® dosage was reduced to 200 mg daily orally, but he still experienced pronounced symptoms of, Attention Deficit Hyperactivity Disorder so this dosage was raised again. The patient's plasma levels consistently remained between 60-187 nmol/l-within the recommended range-and signs of his obsessive-compulsive symptoms diminished with fluoxetine 40 mg daily. Finally, on a dosage of 378 mg extended-release methylphenidate (Concerta®), his symptoms of Attention Deficit Hyperactivity Disorder have improved dramatically and no further use of methylphenidate has been recorded during the 24 months preceding this report.

Conclusions: Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) in this adult patient, who also manifested a co-occurring obsessive compulsive disorder, dramatically improved only after application of a higher-than-normal dose of methylphenidate. We therefore suggest that clinicians consider these findings in relation to their adherence to current therapeutic guidelines.
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http://dx.doi.org/10.1186/1752-1947-6-125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3407707PMC
May 2012

Do patients think cannabis causes schizophrenia? - A qualitative study on the causal beliefs of cannabis using patients with schizophrenia.

Harm Reduct J 2010 Sep 28;7:22. Epub 2010 Sep 28.

Psychiatric University Hospital, Research Group on Substance Use Disorders, Selnaustrasse 9, 8001 Zurich, Switzerland.

Background: There has been a considerable amount of debate among the research community whether cannabis use may cause schizophrenia and whether cannabis use of patients with schizophrenia is associated with earlier and more frequent relapses. Considering that studies exploring patients' view on controversial topics have contributed to our understanding of important clinical issues, it is surprising how little these views have been explored to add to our understanding of the link between cannabis and psychosis. The present study was designed to elucidate whether patients with schizophrenia who use cannabis believe that its use has caused their schizophrenia and to explore these patients other beliefs and perceptions about the effects of the drug.

Methods: We recruited ten consecutive patients fulfilling criteria for paranoid schizophrenia and for a harmful use of/dependence from cannabis (ICD-10 F20.0 + F12.1 or F12.2) from the in- and outpatient clinic of the Psychiatric University Hospital Zurich. They were interviewed using qualitative methodology. Furthermore, information on amount, frequency, and effects of use was obtained. A grounded theory approach to data analysis was taken to evaluate findings.

Results: None of the patients described a causal link between the use of cannabis and their schizophrenia. Disease models included upbringing under difficult circumstances (5) or use of substances other than cannabis (e. g. hallucinogens, 3). Two patients gave other reasons. Four patients considered cannabis a therapeutic aid and reported that positive effects (reduction of anxiety and tension) prevailed over its possible disadvantages (exacerbation of positive symptoms).

Conclusions: Patients with schizophrenia did not establish a causal link between schizophrenia and the use of cannabis. We suggest that clinicians consider our findings in their work with patients suffering from these co-occurring disorders. Withholding treatment or excluding patients from certain treatment settings like day-care facilities or in patient care because of their use of cannabis, may cause additional harm to this already heavily burdened patient group.
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http://dx.doi.org/10.1186/1477-7517-7-22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2954921PMC
September 2010