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Numerous birth-control studies, epidemiological studies, and observational studies have investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use by children, adolescents and young adults is low, even lower than for adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for a poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the interface of child and adolescent and adult psychiatry. Emerging studies show that these health-care structures are effective and efficient. Part 1 of the present review summarises the current state of mental health in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, and treatment delay with consequences.

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Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.

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BACKGROUND: Studies from several countries have by now shown the effectiveness of heroin-assisted treatment in comparison to methadone treatment. However, only few long-term results exist, and in particular data with a focus on social integration of the patients are scarce. OBJECTIVE: The study analyzes the course of long-term social integration among the patients of the German diamorphine study. METHODS: Individual changes in health, drug use and social integration among patients who had participated in a 4-year diamorphine treatment (n=156) were described and statistically tested by means of repeated measures analyses. The criteria used are based on the instruments OTI-HSS and SCL-90-R, on medical findings, urinalyses, and on variables as well as composite scores from the European Addiction Severity Index. RESULTS: In all domains significant improvements were found after long-term treatment. The percentage of patients employed or currently working had increased 3-fold up to 40% after 4 years. Moreover, the living situation and leisure behaviour improved, and criminal activities declined markedly. The main influencing factor for successful social integration after 4 years of treatment is the ability to work. CONCLUSIONS: Heroin-assisted treatment is a long-term effective treatment for severely dependent opiate addicts with respect to stabilization of health, reduction of illegal drug use and improvement of social integration. Furthermore, the results show that processes of social (re-)integration of drug users take time.

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In order to describe the patterns of use in the open drug scene in Hamburg, a study was carried out among 616 drug users in the drug scene and in or in the vicinity of low-threshold institutions close to the drug scene in summer 2000. The special focus was on the prevalence of cocaine and crack use as well as on the utilisation of help services for drug users. 80% of the interviewed persons were male, the average age was 32.6 years. They had been using drugs such as heroin or cocaine for an average of 11 years. 84% had used heroin and 74% cocaine within the last 24 h. Use was intravenous for 66%. 57% used cocaine intravenously, the percentage of crack smokers was 22%. Compared to previous studies, an increase in cocaine use can be noted among the scene users in Hamburg, mainly related to intravenous cocaine use. Crack smoking has only increased slightly over the past few years. Based on cluster analysis, four consumption pattern groups can be established. The largest group (38%) mainly uses cocaine and heroin. The second group (26%) consists of polyvalent drug consumers using methadone in addition to heroin and cocaine, as well as, partially, benzodiazepines, cannabis or alcohol. Group 3 (19%) mainly uses heroin only, some of them also using methadone and/or cannabis. The fourth group (17%) is mainly related to alcohol, the greater part of them additionally using heroin. On the whole, it appears that those users who currently do not use cocaine (or crack) are in a better health and social situation. The group using only heroin (cluster 3) also compares favourably with the other three consumption pattern groups with regard to the intensity of use, consumption in public and risk behaviour. Almost all the interviewed persons are in contact with general practitioners. However, the increasing cocaine use has not been met by sufficient intervention and treatment programmes so far.

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The goals of this study were to describe demographic variables, drinking history, and the 6-month prevalence of Axis I comorbidity among alcohol-dependent subjects in GERMANY: The variables: amount of alcohol consumption, age at onset of the first alcohol consumed, age at onset of daily alcohol consumption, age at onset of withdrawal symptoms and number of detoxifications were related to the different comorbid disorders and gender. In this study, 556 patients from 25 alcohol treatment centres were enrolled between 1 January 1999 and 30 April 1999. After a minimum of 10 days of sobriety patients who fulfilled ICD-10 and DSM-IV criteria of alcohol dependence were interviewed for data collection using the Mini-DIPS (German version of the Anxiety Disorders Interview Schedule) and a standardized psychosocial interview. The 6-month prevalence of comorbid Axis I disorders was 53.1%. Among the patients with comorbidity, affective and anxiety disorders were most frequent. Comorbid stress disorder was associated with an early start of drinking, an early beginning of withdrawal symptoms, highest number of detoxifications, and the highest amount of alcohol consumed. Female patients with anxiety disorder consumed more alcohol and started earlier than females without this comorbid disorder. The data do not answer the question of the pathogenesis of comorbid disorders and alcoholism, but indicate that stress disorders in alcoholic patients and anxiety disorders in female alcoholics influence the course and severity of alcoholism.

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OBJECTIVE: The present study investigates the hypothesis of a relationship between mental disorders and symptoms on the one hand and the extent of drug consumption and the addiction-related problems of opiate dependents on the other hand. METHODS: In a five-year follow-up study in Hamburg among 350 opiate dependents who, at the time of the initial survey, were in contact with the drug help system, 219 clients (63%) could be interviewed at (so far) three different times of investigation. Standardised questionnaires like the EuropASI, CIDI, SCL-90-R, STAI and BDI were used for the interviews. RESULTS: The general life situation of the surveyed persons has on the whole improved in the course of the last two to three years. Also the average drug consumption clearly decreased. Between mental disorders/disturbances and drug dependence or drug-related problems, a linear correlation could be found: An unfavourable course of mental disorders and symptoms correlates with a problematic current life situation of the client. There is also a global relationship between increased drug consumption and the emergence of mental symptoms like depressiveness and anxiety and the psychosocial functional level. CONCLUSIONS: The expected relationship between mental disturbances and the extent of drug consumption is not very marked. This is in support of the basic assumption that specific constellations of drug consumption and mental disorders do not exist isolated, but that they are related, as elements of a complex pattern, to the development of other areas of life.

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The present study investigates whether a correlation exists between mental symptoms and opiate dependency. During a 5-year follow-up study in Hamburg, of 350 opiate addicts who were in contact with the help system at the time of the initial investigation, 219 (63%) could be interviewed three times at 1-year intervals. The investigation instruments were standardized questionnaires such as EuropASI, CIDI, SCL-90-R and BDI. The general life situation of the investigated persons had, on the whole, improved in the course of the last 2-3 years. Drug consumption had markedly decreased. One third of the opiate addicts were in a comparatively good mental condition on all three survey interviews, for 17% there was a worsening of the condition, and for another 17% the negative mental condition was reinforced. A correlation can be established between mental disorders/symptoms and drug addiction or drug-related problems. The more unfavorable the course of the mental symptoms, the greater the problems of the client's current life situation. There is also an overall relationship between increased drug consumption and mental symptoms like depressivity and anxiety, and the psychosocial functioning level. However, the expected correlations between mental disorders and the extent of drug consumption are not very marked. This indicates that specific constellations of drug consumption and mental disorders are not isolated but are related, as elements of a complex behavioral pattern, to the development of other life areas of the client.

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AIMS: Outpatient maintenance treatment of opiate addicts with codeine/dihydrocodeine is a common approach in the treatment of drug addicts in Germany. This study was carried out to assess possible benefits of codeine maintenance in terms of patients' health stabilization, social rehabilitation and drug consumption. DESIGN: Three-year follow-up study. SETTING: Three practices of substituting physicians in large-city areas in Germany. PARTICIPANTS: Of a random sample of 297 people attending for opiate outpatient treatment in 1993, 199 were successfully followed up 3 years later. MEASUREMENTS: Measures of health, living conditions, employment, criminal activities and drug use were collected at baseline and follow-up. The data were based on standardized interviews and medical examinations by the attending doctors as well as on questionnaires from the patients. FINDINGS: Based on a 67%-follow-up rate, after 3 years of codeine maintenance there was improvement in general health and mental problems. The living and working situation remained more or less unchanged and stabilized at a satisfactory level. The same applies to the consumption of drugs. CONCLUSION: The patients' progress shown in this study was comparable to that achieved by methadone maintenance in similar geographical regions. Codeine has a weaker pharmacological effects and our results suggest that codeine maintenance treatment deserves more attention and controlled trials to assess the benefits compared with methadone (or other opioids).

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In a 5-year-follow-up study of 350 opiate addicts in contact with a drug help system in Hamburg, 272 clients (78%) were interviewed a second time after 1 year. The objective of the study was to examine the correlation between mental disorders and drug consumption and its relationship to clients' general life situation. In the majority of the opiate addicts, a pattern of polydrug consumption was observed, but the amount of drugs consumed was clearly lower after 1 year. In the initial survey, a mental disorder according to ICD-10 could be diagnosed for 55% of the sample. Among groups formed by the severity and course of mental disorders or their symptoms, a significant correlation was observed, particularly at the time of follow-up, between the extent of drug consumption and the course of the mental disorder. Other areas, like physical health or social problems/conflicts, were also related to comorbidity (i.e., heavy drug consumption and/or mental disorder). These interrelationships should be taken into account in treatment, care and guidance to increase the prospects for successful treatment.

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In the course of a 5-year follow-up study concerning comorbidity in opiate addicts, 350 patients were investigated initially in various addiction centres in Hamburg. More than two thirds of the participants of the study are male, with an average age of 29 years at the time of the investigation. Most of them are receiving methadone maintenance treatment (42%), about one fourth is in residential rehabilitation and another 17% in inpatient detoxification treatment. The patients have been consuming heroin for an average of 9 years. For 55% of the opiate addicts (at least) one more psychic disorder in accordance with ICD-10 has been diagnosed (lifetime prevalence). F6 personality disorders have not been taken into consideration. The 6-month prevalence is 37%, 2-week prevalence 23%. For 43% of the opiate addicts, the predominant disorders belong to the group of neurotic, endurance, and somatoform disorders (F4), and for 32% of the patients to the group of affective disorders (F3). Schizophrenic, schizotypic and delusional disorders (F2) are less frequent (5%). Another 5% of the opiate addicts suffer from eating disorders (F5). These are partly multiple diagnoses cases; there is an average of 1.3 diagnoses per patient. Women are clearly more often affected by comorbidity than men. Most disorders first occur between the age of 18 and 21 years. Therefore, (lifetime) prevalence rates are twice to three times as high as that of the average German population, according to the present state of knowledge. This underlines the great importance of specific diagnostic and explorative methods for the treatment of addiction. Psychic disorders or disturbances that might adversely affect the course of treatment should be given more consideration.

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AIM: To investigate whether the impression that prevalence rates of diseases in drug addicts undergoing detoxification could be verified empirically. In addition, to make an attempt to identify possible relationships responsible for this development. METHOD: Between 1989 and 1993, within the framework of a detoxification program, 1041 opiate addicts were investigated for the presence of somatic diseases. For this purpose, the overall sample was divided up into 3 groups corresponding to the following time periods: 1989/1990, 1991/1992, 1993. The baseline data comprised the standardised history at the time of admission, the results of the initial clinical examination, and the serological and clinico-chemical findings during the further course. RESULTS AND INTERPRETATION: A deterioration in the general state of health associated with more risky drug consumption patterns and social isolation was established. Apparently, low-threshold treatment programs and prophylactic strategies made available to almost two-thirds of the addicts in Hamburg have proved unable to prevent the deterioration of the situation of a subpopulation of addicts.

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The prevalence of suicide attempts among opioid addicts is reported to lie between 8% and 17%, with some studies reporting an even higher rate among special groups of addicts. Yet there is insufficient knowledge about which addicts have a higher risk of suicide and which other factors seem to be involved in the constellation leading to the suicide attempt; the study of different subgroups of addicts is thus necessary. This paper reports a study on suicide attempts among a sample population in a detoxification unit and another group undergoing codeine maintenance treatment. There was a high rate of suicide attempts among both groups (23% of those in the detoxification unit and 28% of those maintained on codeine), but treating physicians tended to underestimate suicidality. The results lead to the conclusion that among a subgroup of addicts suicidality plays a larger role; a greater emphasis should thus be placed on the underlying psychopathology and the treatment needed.

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The controversy caused by the debate on treatment and substitution strategies in drug addiction is unchanged. This is particularly true concerning the use of codein-based drugs in the substitution of heroin abusers. However, only a few studies on the effects of this old and widely used method of substitution have been carried out. This article presents one retrospective and prospective study on the effects of the codein-based substitution in heroin abusers (n = 416). With respect to the issues addressed by this study such as somatic and psychic health, social integration, delinquincy and consumption patterns, patients as well as clinicians report an improvement in general health and fewer of the problems usually associated with heroin abuse, similar to the results from substitution treatment elsewhere.

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