Exposition in der Versorgungspraxis: Zur Frage der Umsetzbarkeit und Prädiktion früher Veränderungen
(2018)
Ziel der vorliegenden Arbeit war die Beantwortung folgender Fragestellungen: 1. Wie wirksam ist ein evidenzbasiertes Expositionsmanuals bei Panikstörung mit Agoraphobie in der Routineversorgung? 2. Was sind mögliche Barrieren und Hindernisse bei der Umsetzung der Exposition? 3. Was sind Prädiktoren früher Veränderungen im Therapieverlauf?
Methode: Im Rahmen einer prospektiven Längsschnittstudie wurden die Daten der vorliegenden Studie mit denen der Multicenter-Studie von Gloster et al. (2011) mittels Effektstärken und Testung auf Äquivalenz verglichen. Grundlage war das Manual von Lang, Helbig-Lang, Westphal, Gloster und Wittchen (2011). Die Patientinnen und Patienten und Therapeutinnen und Therapeuten wurden zu den Hausaufgaben, der Umsetzung im Alltag und der therapeutischen Beziehung befragt. Zusätzlich wurde die wechselseitige Beeinflussung von therapeutischer Allianz und dem Behandlungserfolg im Therapieverlauf untersucht. In Anlehnung an Westra, Marcus und Dozois (2007) wurde getestet, ob bei es Patientinnen und Patienten mit einer hohen Hausaufgaben-Compliance und einer positiven Behandlungserwartung vor Beginn der Therapie zu einer frühen Reduktion der Panik-Symptomatik kommt und ob frühe Veränderungen durch die Compliance und die Behandlungserwartung beeinflusst werden.
Ergebnisse: 1. Die Behandlung war in der Versorgungspraxis nicht weniger effektiv als in der Multicenter-Studie. 2. Die Abbrecherquote lag bei 20.59%. Die meisten Behandelten gaben an, ihre Hausaufgaben wie besprochen erledigt zu haben und schätzten sie nicht übermäßig schwer ein. Die Umsetzbarkeit der Anforderungen im Alltag wurde von den Patientinnen und Patienten sehr hoch eingeschätzt. Die meisten Therapeutinnen und Therapeuten stimmten der Aussage, die Umsetzung der massierten Exposition sei im therapeutischen Alltag nicht praktikabel eher nicht oder gar nicht zu. Je negativer die Einschätzungen der therapeutischen Beziehung durch die Behandelten war, umso höher waren die Panikwerte am Ende der Therapie. Der HAQ-S korrelierte mit dem Outcome zu r = .21, der HAQ-F zu r = .37. 3. Die beiden Mediator-Hypothesen von Westra et al. (2007) konnten nicht bestätigt werden.
Diskussion: Die Behandlung ist in der Routineversorgung wirksam und praktikabel. Die Hausaufgaben scheinen frühe Veränderungen nicht zu prädizieren. In späteren Arbeiten des Forschungsprojektes wird notwendig sein, zudem die differentielle Wirksamkeit des angepassten Manuals zu untersuchen, und zwar mittels drei aktiver Vergleichsgruppen: massierte Exposition versus prolongierte Exposition versus die Kombination beider.
The transport of pesticides from agricultural land into surface waters via diffuse entry pathways such as runoff is a major threat to aquatic ecosystems and their communities. Although certain risk mitigation measures are currently stipulated during pesticide product authorisation, further approaches might be needed to manage hot spots of pesticide exposure. Such a management is, for example, required by the European Union- directive for the sustainable use pesticides (2009/128/EC).
The need for mitigation measures was investigated within the present thesis at stream sites draining an arable and a vineyard region in Germany by characterising pesticide exposure following edge-of-field runoff and (expected) effects on the aquatic macroinvertebrates. The results of these field studies showed, that streams in both regions were exposed to pesticide concentrations suggesting effects on the macroinvertebrate community. In the arable region the observed toxicity was mainly attributed to the insecticides lambda-cyhalothrin (in the water-phase samples) and alpha-cypermethrin (in the suspended particle samples), whereas in the vineyard region fungicides were most important. Furthermore stream water and suspended particles sampled in the vineyard region showed critical copper concentrations, which might cause ecotoxicological effects in the field. In addition to pesticide exposure, in the arable region also the effects on aquatic macroinvertebrates were assessed in the field. Generally, invertebrate fauna was dominated by pesticide-tolerant species, which suggested a high pesticide exposure at almost all sites. The elevated levels of suspended particle contamination in terms of maximum toxic units per sample (logTUMax > -2) reflect also this result. At two sites that received high aqueous-phase entries of the insecticide lambda-cyhalothrin (logTUMax > -0.6), the abundance and number of sensitive species (indicated by the SPEcies At Risk index) decreased during the pesticide application period. In contrast, at sites characterised by low water-phase toxicity (logTUMax < -3.5), no acute significant negative effects on macroinvertebrates were observed. In conclusion these data showed that in both regions the implementation of risk mitigation measures is needed to protect the aquatic communities.
To mitigate runoff-related pesticide entries, riparian buffer strips are often recommended. However, the mitigating influence with increasing buffer strip width could not be demonstrated for riparian buffers which were already present in the arable and vineyard region. This result was attributed in the vineyard region to the high number of paved field paths associated with artificial erosion rills, which concentrate and rapidly transport receiving edge-of-field runoff in stream direction. Consequently the pesticide reduction efficiency of buffer strips is considerably reduced. We assumed that a similar process occurred in the arable region, due to a high number of erosion rills, which complicate a laminar sheet flow of edge-of-field runoff through the riparian buffer strip. Additionally also the presence of ephemeral drainage ditches, which led surface runoff from the agricultural fields to the streams may have contributed to observed pesticide entries despite wide buffers.
Effective risk mitigation measures should address these identified most important input pathways in the study areas. As possible measures the implementation of grassed field paths and vegetated ditches or wetlands were suggested. In general also the improvement of currently present riparian buffer strips regarding their efficiency to reduce pesticide runoff entries should be taken into account. In conclusion the results of the field studies underline the importance that risk mitigation measures are identified specifically for the respective pollution situation in stream catchments. To facilitate this process, a user guide was developed within the present thesis for identifying appropriate mitigation measures at high-risk sites. Based on a survey of exposure relevant landscape parameter a set of risk mitigation measures is suggested that focus on the specific pollution situation. Currently the guide includes 12 landscape- and six application-related measures and presents an overview of these measures" efficiency to reduce pesticide entries via runoff and spray drift, their feasibility and expected acceptability to farmers. Based on this information the user can finally choose the mitigation measures for implementation. The present guide promotes the practical implementation of appropriate risk mitigation measures in pesticide-polluted streams, and thus the protection of aquatic stream communities against pesticide entries.