Psychiatry - O. K. Napryeyenko 2001

General Psychiatry
Treatment of the Mentally Ill

The Treatment of a mentally ill patient includes a comprehensive set of direct medical measures (examinations and Diagnostics, emergency care, active course treatment, physiotherapy, and other therapeutic Methods) and sociotherapeutic measures aimed at the socio-psychological correction and rehabilitation of the patient, the Prevention of personality defects caused by mental illness, and their compensation.

In psychiatry, depending on the intended goal, etiological, pathogenetic, and compensatory therapies are distinguished. Etiological therapy aims to eliminate the ROOT cause of the disorder. A prime example in psychiatry is the treatment of progressive paralysis with Antibiotics and pyiotherapy. Pathogenetic Therapy focuses on intervening in the mechanisms of disease development to interrupt its progression. The majority of psychiatric treatments are pathogenetic. Examples include the management of withdrawal symptoms in alcoholism and substance addiction, Shock therapy methods, course psychopharmacotherapy, and extracorporeal detoxification. Symptomatic treatment is prescribed to alleviate severe or dangerous manifestations of the disease (for example, acute anxiety is relieved using tizercin, seduxen, or phenazepam). Compensatory therapy does not target the cause or mechanism of the disease; instead, it stimulates compensatory resources. Compensatory effects can be provided by cardiovascular, dehydrating, and vitamin preparations, nonspecific psychotropic agents, general psychotherapeutic measures, etc.

When treating a mentally ill patient, it is essential to consider the specifics of psychopathology and disease progression, the premorbid constitutional-personal typology and physiological Properties of the patient's body, as well as the pharmacokinetic and pharmacodynamic factors of the medication's influence.

A distinctive feature of active therapy for mentally ill patients is prolonged course treatment, which consists of a series of stages with corresponding methods and techniques.

Capping (abortive) therapy (from French couper — to cut, to excise) consists of eliminating acute manifestations of mental disorders. It is predominantly performed in inpatient settings using parenteral administration of relatively large doses of psychotropic agents. After acute symptoms subside, the dose is reduced, and the treatment transitions to oral administration or drugs with a milder yet selective effect.

Maintenance therapy is mostly outpatient-based. Its goal is to consolidate the effects of the initial acute-stage treatment. It is crucial because complete cessation of treatment risks disease relapse. Most frequently, lower doses of the medications that proved effective are administered, or potent drugs are replaced with milder ones. For the patient's convenience, prolonged-release medications, known as depot drugs (moditen depot, clopixol depot, fluanxol depot, haloperidol decanoate, IMAP, etc.), are often used. They are administered once every 1–4 weeks. It is also advisable to use oral prolonged-release medications (pimozide, Orap, zyprexa, cipramil, etc.) taken once daily. Sudden interruption of maintenance therapy often triggers a "withdrawal reaction," manifested by both a worsening of the mental state and autonomic disturbances. Discontinuing therapy may lead to a relapse of mental disorders (not immediately, but within 2–3 days or even several weeks).

Preventive, or anti-relapse, therapy is a variant of maintenance therapy. It is administered against the Background of recovery or remission. For instance, in autumn and spring, it is advisable to use lithium salts for Affective Disorders.

Therapeutic resistance, i.e., unresponsiveness to therapeutic agents, is a very pressing issue in the treatment of mentally ill patients. It occurs particularly often in chronic disease courses and, consequently, prolonged treatment with psychotropic drugs. To overcome therapeutic resistance, various approaches are used aimed at enhancing the drug's effect (transitional parenteral administration of high doses) or increasing the body's sensitivity to them (intentional treatment breaks to provoke a "withdrawal reaction"; electroconvulsive therapy; pyiotherapy; immunomodulators, etc.). For treating patients with Schizophrenia and other psychoses showing resistance to conventional (classic) neuroleptics, it is advisable to prescribe atypical antipsychotics such as clozapine, zyprexa, risperidone, etc.

Corrective therapy, or The Use of special correctors to eliminate the side effects of psychotropic drugs (primarily in the form of neuroleptic syndrome), is determined by the genetic features of pharmacodynamics and pharmacokinetics, as well as premorbid organic cerebral insufficiency, most commonly of vascular and endocrine origin. This refers to the fact that, for example, neuroleptic drugs cause extrapyramidal disorders—gait disturbances, increased Muscle tone, tremor, general stiffness, and akathisia, which can manifest in various ways. Occasionally, muscle spasms occur in specific muscle groups—the eyeballs, Tongue, neck, face, and Mouth. Motor disorders are also accompanied by autonomic symptoms such as sweating, palpitations, and pallor or flushing of the Skin. To prevent and eliminate these neurological symptoms, oral anti-parkinsonian agents are prescribed, most frequently parkopan, cyclodol, yumex, or memantine. Parkopan or trihexyphenidyl, manufactured by the pharmaceutical company Salutas Falberg-List (Hexal), is prescribed at 2 mg 2–3 times a day (maximum daily dose is 20 mg). In cases of acute motor function disorders, tremblex is administered intramuscularly (1–3 ml per day at intervals of 2–4 days). For paroxysmal motor disorders (dyskinesias), anti-parkinsonian drugs are combined with the subcutaneous injection of caffeine-sodium benzoate (2 ml of a 20% solution) and intravenous administration of glucose with thiamine and ascorbic acid.

General strengthening (tonic) therapy is prescribed for general lethargy, weakness, decreased mental and physical performance, and other manifestations of asthenia observed in most mental and psychosomatic disorders, including those caused by a Deficiency of certain Vitamins, minerals, and other substances. In such cases, alongside general measures (work and rest regimen, dose-adjusted work therapy, therapeutic physical culture, diet therapy, etc.), preparations that replenish these deficiencies are prescribed, such as multivitamin complexes.

According to the application of methods for treating mental disorders, biological therapy and sociotherapy are distinguished, which also include rehabilitation as a system of measures for the full or partial restoration of the patient's social status. Treatment for each patient is typically comprehensive, integrating methods of both biological and sociotherapeutic influence.

Biological therapy for mental disorders refers to all therapeutic interventions acting on the body as a biological object. This includes the administration of medications, particularly psychotropic drugs, shock therapy methods when necessary, pyrogenic and restrictive-dietary therapy, detoxification, and occasionally psychosurgery, among others.

TREATMENT WITH PSYCHOTROPIC DRUGS

In 1952, French psychiatrists J. Delay and P. Deniker first reported on the therapeutic effect of chlorpromazine (largactil, aminazine) in Various Forms of mental disorders and established the specific psychotropic action of this drug. This marked the beginning of the "psychopharmacological era" in The Development of psychiatry. Over the subsequent decades, A large number of psychotropic drugs were synthesized and introduced into psychiatric practice. Today, psychopharmacotherapy has taken first place worldwide, displacing Other types of treatment. It has become the primary method, combining psychotherapy and social rehabilitation measures into a single complex. Due to the ease of use and relative safety of the medications, as well as their individual spectrum of psychotropic activity, psychopharmacotherapy has expanded the boundaries and Specificity of therapeutic impact compared to "shock" methods. Not only has the appearance of psychiatric hospitals changed, but extraordinary opportunities have also opened up for treatment in out-of-hospital (outpatient) settings. This has favorably influenced the socio-occupational readjustment of patients and the course of mental illnesses. A special mechanism of psychotropic action is characteristic of each drug. This is explained by the specific effect of medications on the Functions of various structures of the Central Nervous system (the Cerebral Cortex, limbic system, and reticular formation), as well as neurotransmitter systems (the synthesis, storage, release, binding, and biotransformation of Neurotransmitters or receptor systems).

The pathogenetic action of psychotropic drugs manifests as a general reducing effect on the mental illness, as well as a selective action on a specific spectrum of psychopathological manifestations.

The main principle of psychopharmacotherapy is the clinically grounded and correct Selection of a psychotropic drug for treating a specific patient. Therapy is conducted individually, simultaneously taking into account the Specifics of the psychopathological characteristics, the dynamics of the illness, and THE SPECTRUM OF psychotropic action of the drug used singly or in combination. This principle requires a dynamic approach to treatment, continuous analysis of changes in psychopathological and somatic symptoms occurring during psychopharmacotherapy, with appropriate correction of treatment tactics, review, selection, and dosing of psychotropic agents. The tactics of the THERAPEUTIC USE OF antipsychotics (neuroleptics) depend on the stage and character of the disease course, as well as the distinctness of psychopathological symptoms. In acute and subacute courses of mental illness with vivid symptoms, treatment begins with the parenteral administration of large doses of the drug, and after condition improvement, the dose is reduced and switched to oral administration. In cases of chronic mental disorders with indistinct symptoms, treatment begins with prescribing a small dose of the drug, which is gradually increased to the average therapeutic dose as needed. The effect in such cases manifests gradually and slowly, so one should not rush to change the prescription.

The predominance of inhibitory or stimulating action in the therapeutic effect provided the basis for classifying all psychotropic agents into psycholeptics (neuroleptics or antipsychotics, tranquilizers, normotimics) and psychoanaleptics (antidepressants, psychostimulants, nootropics), which determines clinical adequacy when choosing indications for psychopharmacotherapy. However, the sedative and activating components of psychotropic action do not always appear in pure form. Thus, among neuroleptics, tranquilizers, and antidepressants, drugs with predominantly sedative or activating action are distinguished.

ANTIPSYCHOTIC (NEUROLEPTIC) AGENTS

Antipsychotic, or neuroleptic, agents constitute a large group of psychotropic drugs and occupy a leading place in psychopharmacotherapy for acute and chronic psychoses. This group includes drugs with diverse chemical structures (phenothiazine, tocoaptene, butyrophenone, diphenylbutylpiperidine, iptol derivatives, etc.) and pharmacodynamics, the Main Properties of which were described back in 1961 by J. Delay and P. Deniker. Signs of neurolepsia ("relaxation of The Nervous System"): 1) psycholeptic action without a hypnotic effect; 2) inhibitory action regarding excitation, agitation, aggressiveness, and reduction of manic states; 3) reducing action regarding certain acute, chronic, and experimental psychoses; 4) characteristic psychomotor, neurological, and autonomic disorders; 5) predominance of action on subcortical structures.

As a result of this action, the patient's emotional tension, psychomotor agitation, and psychotic manifestations (hallucinations, delusions, etc.) are reduced. In addition to sedative and antipsychotic effects, some neuroleptic agents also possess psychostimulating, anti-autistic, behavior-correcting, and other psychotropic actions. Based on their distinct psychotropic action profiles, these drugs are divided into two groups.

Antipsychotic (neuroleptic) agents with predominantly sedative and moderate antipsychotic action.

Aminazine (plegomazin, megaphen, largactil, chlorpromazine) is the first of the psychotropic agents; psychopharmacology began its development precisely with it. Indications for the use of aminazine include various types of psychomotor agitation, especially those accompanied by fear, anxiety, and bewilderment. Against the background of a pronounced sedative (calming) effect and reduction of emotional tension, aminazine's ability to weaken hallucinatory-delusional disorders becomes apparent. However, prolonged use of aminazine can lead to the development of depression, thromboembolism, agranulocytosis, and jaundice. Following a single intravenous (50–75 mg) and intramuscular (100–150 mg) administration of the drug, ARTERIAL Blood PRESSURE may drop by 20–30 mm Hg, and collapse may develop. Therefore, after the injection, the patient must lie down for at least 1 hour. Aminazine occasionally causes allergic reactions, not only in patients but also in the personnel administering the injections. The drug is available in ampoules (2.5% in 2 ml), in dragees (25, 50, 100 mg), and largactil is also available in suppositories, drops, and as a suspension. The average daily dose is 300–500 mg.

Propazine (promazine) has properties similar to aminazine, but acts more mildly (both sedatively and antipsychotically). Due to its low toxicity, the drug is prescribed for somatogenic and exogenous-organic psychoses, in pediatric and gerontological practice.

Tizercin (levomepromazine, nozinan) has a strong antianxiety action and possesses a hypnotic effect. Unlike aminazine, it is not depressogenic. The drug can lower blood pressure and cause a collapse-like state. It is prescribed per os and parenterally. Intramuscularly, 1–6 ml of a 2.5% solution is administered; intravenously, 1–3 ml of a 2.5% solution diluted in 10–20 ml of 40% glucose. Treatment begins with a daily dose of 25–50 mg, increasing it daily by 25–50 mg up to 100–300 mg per day.

Chlorprothixene (truxal) also relieves anxiety, fear, and restlessness, but unlike tizercin, it does not cause marked lethargy and drowsiness, allowing it to be taken during the day. Along with this, chlorprothixene exerts an antipsychotic and antidepressant effect. The drug is prescribed per os and intramuscularly. Treatment begins with a dose of 25 mg per day. Subsequently, it is gradually increased to the therapeutic dose, which in an inpatient Setting is 200–400 mg orally or 150–300 mg intramuscularly. Regardless of the dose, in the first days of treatment after taking chlorprothixene, as with aminazine and tizercin, the patient must lie down for about an hour to prevent orthostatic collapse. To prevent a sharp drop in blood pressure in somatically weakened patients with vascular disorders, subcutaneous cordiamine or caffeine is prescribed.

Sonapax (thioridazine, Melleril) is used primarily for psychotic disorders—elevated affect, irritability, and anxiety. It is also indicated for obsessive-compulsive states, phobias, and hypochondriacal disorders. It suppresses sexual activity and delays the onset of orgasm. Administered orally, it is used in doses ranging from 10–30 mg up to 300 mg per day. Unlike benzodiazepine derivatives (such as Seduxen), it does not cause dependence or addiction. Melleril Retard is a sustained-release formulation. It is available in 0.2 mg tablets, with a duration of action of 24 hours.

Neuleptil is an antipsychotic medication with a pronounced sedative effect, widely known as a "behavioral corrector." It is extensively used for psychopathic disorders, including in child and adolescent psychiatry. It relieves anger, tension, excitability, aggressiveness, and disinhibition—including sexual disinhibition—and quenches affective outbursts. Treatment begins with 5–10 mg per day, gradually titrating to an individualized therapeutic dose, which typically ranges from 30–50 mg. The drug is available in 10 mg capsules and as a solution (1 mg per drop).

ANTIPSYCHOTIC (NEUROLEPTIC) AGENTS WITH PREDOMINANTLY ANTIPSYCHOTIC ACTION

Drugs in this group are characterized by a strong general and selective antipsychotic effect, as well as a more or less pronounced activating component. In low doses, they exhibit a predominantly stimulating effect, whereas in high doses, they exert a general antipsychotic influence.

Haloperidol was synthesized in 1959 at the Janssen laboratories in Belgium and for a long time was the most widely used antipsychotic medication. It rapidly alleviates psychoses, with a selective antipsychotic action targeted at hallucinations and delusions. It is indicated for both acute and chronic disorders, possessing not only antipsychotic but also pronounced calming effects. It relieves agitation (manic, catatonic, hallucinatory-delusional, etc.). In such cases, it is administered intramuscularly or via intravenous drip (0.5% solution). The starting dose is 1.5 mg, with an average daily dose of 15–20 mg. Haloperidol may cause neuroleptic malignant syndrome (spasms of the tongue, neck, and facial Muscles, etc.). It is contraindicated in organic Brain lesions, as parkinson-like disorders tend to be particularly severe and refractory even to cyclodol correction. It is available in tablets (0.5, 1.5, 3, and 5 mg), as drops (10 ml of a 0.2% solution; 0.1 mg per 1 drop), and in ampoules (1 ml of a 0.5% solution). A depot form is also available: haloperidol decanoate, 1 ml (containing 50 mg of the active substance).

Trisedyl (trifluperidol), like haloperidol, exerts an antipsychotic effect (anti-hallucinatory and anti-delusional). It is particularly indicated for persistent auditory hallucinosis. Average therapeutic doses range from 4 to 30 mg per day, administered orally or intramuscularly 2–3 times daily. The psychotropic action of Trisedyl combines features characteristic of both haloperidol and majeptil. Patients become more animated; their condition improves gradually, sometimes with a Touch of euphoria, accompanied by increased motor and mental activity. It is available in tablets (0.5 mg), vials (10 ml of a 0.1% solution), and ampoules (1 ml of a 0.25% solution).

Majeptil (thioproperazine) possesses high antipsychotic activity, showing a tropism for catatonic-hebephrenic symptomatology, arresting the progression of the process, and halting psychotic attacks and disorders resistant to other drugs. It is used in doses ranging from 1–5 mg to 60–80 mg per day. It may cause severe neuroleptic syndrome, hyperkinesia, and occasionally motor disinhibition or voracious appetite, and it can enhance sexual drive. It is available in ampoules and dragees (1 mg and 10 mg).

Piportil is an antipsychotic agent with a strongly pronounced general antipsychotic effect (similar to majeptil), as well as a reducing impact on productive hallucinatory-delusional, stuporous, substuporous, and other disorders, including deficit schizophrenic symptoms. Piportil is prescribed both for acute conditions and to curb progressive forms of chronic schizophrenia. Side effects are similar to those of other potent antipsychotics. At low doses (10–20 mg daily) it is stimulating, while at higher doses (30–40 mg daily) its antipsychotic effect increases. It is available in dragees (10 mg), ampoules (10 mg), and drops (4% solution). It also has a sustained-release formulation, Piportil Retard (1 ml contains 100 mg of the active substance), which is administered at intervals of 2–4 weeks.

Triftazine (trifluoperazine, stelazine) is most commonly prescribed for delusional disorders. Small doses activate the patient's state in cases of apathy and anergy, though initially they may sometimes intensify anxiety, delusions, and hallucinations. It is administered orally and intramuscularly. A therapeutic effect is achieved at a daily dose of 30–80 mg (reduced to 10–30 mg for intramuscular administration). It frequently causes extrapyramidal side effects, such as muscle tremor and rigidity. Therefore, treatment with triftazine is often combined with correctors (parkopan, cyclodol, etc.). It is manufactured by the domestic pharmaceutical company Darnitsa.

Fluphenazine (moditen, lyogen) exhibits not only antipsychotic action but also a "behavior-normalizing" effect. It is prescribed for psychopathy-like disorders. Sustained-release preparations are the most widely used (Lyogen Retard, Moditen Depot, fluphenazine decanoate). Following an injection of 0.5–1.0 ml of a 0.25% solution once every 2–3 weeks, a fairly high concentration of the drug is maintained in the body, which is crucial for outpatient therapy. Occasionally, the drug is prescribed in tablet form (1, 2, 5 mg). Treatment starts with 2–5 mg, gradually increasing the dose to 15–25 mg per day. Long-term treatment with fluphenazine may lead to complications such as extrapyramidal symptoms, drowsiness, and lowered blood pressure.

Etaperazine (perphenazine, trilafon) possesses antipsychotic and unique stimulating properties. It is prescribed for psychotic syndromes featuring hallucinatory-delusional symptomatology, catatonic stupor, and apico-abulic states. Among piperazine derivatives, it is one of the least toxic drugs, second only to frenolone. Extrapyramidal side effects occur only with high doses or in the presence of organic deficit. It is used in doses ranging from 5–10 mg to 50–60 mg per day. It is available in dragees (4 and 10 mg) and in a sustained-release oil-based ampoule form (1 ml containing 100 mg of the drug; Trilafon Depot, perphenazine enanthate), administered once every 1–2 weeks.

Frenolone (metaphenazine) combines stimulating, sedative-tranquilizing, and antipsychotic effects. Due to its low toxicity, it is frequently prescribed for somatically weakened patients with mental disorders, in somatogenic psychoses, and in gerontological and pediatric psychiatry. Its application is particularly valuable in treating physically debilitated patients who have refused food for extended periods, as well as in catatonic and other states. In doses of 5–15 mg, it exerts a predominantly stimulating effect, promoting the reduction of stuporous, apico-abulic, and astheno-depressive disorders. At higher doses (40–60 mg daily), frenolone affects more complex productive psychopathological symptoms. Consequently, it can be used for depressive-delusional and depressive-hypochondriacal syndromes, particularly when other antipsychotics are not tolerated. It is available in ampoules and dragees (5 mg of the drug).

Pimozide (an oral antipsychotic) is most commonly used for maintenance therapy. It provides a sustained, uniform effect characterized by mild antipsychotic activity. However, it may cause extrapyramidal disorders, tachycardia, and insomnia. It is convenient because it is taken once daily in the morning at a dose of 2 mg. It is available in 1 mg and 4 mg tablets.

Fluspirilene (an intramuscular antipsychotic) is also a sustained-action drug. Its psychopharmacological profile is similar to that of haloperidol. It is indicated for polymorphic subpsychotic symptomatology and is prescribed for maintenance therapy via weekly injections of 1–3 mg.

Penfluridol (Semap), like fluspirilene, combines weak antipsychotic action with minor sedative effects; both drugs are diphenylbutylpiperidine derivatives. The prolonged action of penfluridol is achieved by slowing its METABOLISM, whereas fluspirilene forms a microcrystalline suspension depot. Semap is taken orally once every 7 days and is available in 20 mg and 10 mg tablets.

Eglonyl (sulpiride) combines The properties of both neuroleptic and thymoleptic agents, manufactured by the pharmaceutical company Sanofi-Synthélabo. Due to its stimulating effect, Eglonyl is primarily used for lethargy, inhibition, anergy, hypochondriacal disorders, and depression, including acute and chronic psychotic and neurotic disorders, as well as psychosomatic disturbances. Because the drug lacks extrapyramidal side effects, it is also used for psychopathological states developing against the background of organic deficit or genesis. Eglonyl is prescribed for neurotic disorders at doses of 100–200 mg, and for psychotic disorders at 200–1600 mg daily. It is available in tablets (200 mg), capsules (50 mg), an oral solution (0.5%), and an injectable solution (100 mg).

Carbidine is a psychotropic drug whose action is selectively directed at the depressive-paranoid syndrome. Due to its pronounced psychostimulating properties, it is also effective for apico-abulic disorders and is used to treat depressive disorders associated with alcoholism. It is administered orally and intramuscularly in doses ranging from 12.5 to 100–150 mg per day.

CLOPIXOL (zuclopenthixol) is manufactured by Lundbeck (Denmark). A thioxanthene derivative, it promotes the rapid and clear reduction of psychotic symptoms and manic states in schizophrenia and other mental illnesses. It comes in two formulations. Clopixol AcuPhase is used for the initial treatment of acute psychoses and for exacerbations of chronic mental disorders. It is most effective in psychotic states accompanied by agitation, restlessness, hostility, or aggression. It is administered at 50 mg intramuscularly every 2–3 days, after which the patient can be switched to oral medications or depot forms. The final injection of Clopixol AcuPhase is given concurrently with Clopixol Depot. It is supplied in ampoules of 1 and 2 ml (50 mg per 1 ml). Clopixol Depot (zuclopenthixol decanoate) is used for long-term continuous antipsychotic treatment, preventing relapses, particularly in patients with poor compliance. The dosage range is 200–400 mg, administered intramuscularly every 2–4 weeks. Forms of release: 1 ml ampoules (20 mg per 1 ml); zuclopenthixol hydrochloride tablets of 2, 10, and 25 mg.

Fluanxol (depixol, flupenthixol) is manufactured by Lundbeck (Denmark). A thioxanthene derivative, it exhibits pronounced antipsychotic, activating, anxiolytic, and anti-autistic actions. It elevates mood and stimulates mental activity, transforming apathetic, unmotivated, and depressed patients into more communicative and socially active individuals. It is prescribed in the following dosages: up to 3 mg daily for depressive disorders with anxiety, asthenia, and apathy; 3 to 40 mg daily for hallucinations and delusions, including those accompanied by apathy, anergy, and autism; and over 40 mg daily for psychomotor or manic excitement and pronounced agitation.

It is available in 0.5, 1, and 5 mg tablets and as drops (100 mg per 1 ml).

Fluanxol Depot (cis-(Z)-flupenthixol decanoate) allows for continuous therapy and the prevention of relapses, including in patients with irregular compliance. Forms of release: ampoules of 1, 2, and 10 ml (20 mg per 1 ml); ampoules of 1 and 5 ml (100 mg per 1 ml).

Clozapine (leponex, azaleptine) is a dibenzodiazepine derivative and the first of the so-called atypical antipsychotics. Unlike conventional (traditional, classical) antipsychotics, they exert a minimal negative impact on the extrapyramidal system, cause virtually no neuroleptic syndrome or general suppression, and do not affect blood prolactin levels. Consequently, drugs in this group combine antipsychotic efficacy with a greater contribution to patients' social adaptation.

In addition to its antipsychotic action, clozapine possesses sedative properties and is used for various types of agitation, as well as hallucinatory-delusional and affective-Delusional syndromes. It is available in tablets (25 mg and 100 mg) and ampoules (2 ml of a 2.5% solution). The treatment regimen and dosages are nearly identical to those given for chlorpromazine.

Zyprexa (olanzapine) is a thienobenzodiazepine derivative and a novel atypical antipsychotic synthesized and manufactured by Eli Lilly. It effectively targets not only positive psychopathological symptoms (delusions, hallucinations, agitation) but also negative symptoms (blunted affect, emotional and social withdrawal, poverty of speech), as well as depressive symptoms associated with schizophrenia and other psychoses. Compared to conventional neuroleptics, it has a significantly lower incidence of neurological side effects such as extrapyramidal disorders, akathisia, dystonia, and increased muscle tone. Treatment is initiated at an optimal dose of 10 mg daily (as a single dose). The drug enhances the management of psychoses in cases of intolerance to conventional antipsychotics or resistance to them. It is available in 5 mg and 10 mg tablets.

Risperidone (risperdal, rispolept) is a benzisoxazole derivative and a new-generation atypical antipsychotic manufactured by Janssen. The drug is indicated for acute and chronic psychoses with positive symptoms (delusions, hallucinations, aggressive agitation) and anxiety-depressive disorders. It stands out among conventional neuroleptics for its superior therapeutic efficacy regarding the deficit symptoms of schizophrenia (emotional and social withdrawal, blunted affect, poverty of speech). The use of risperidone for maintenance therapy markedly reduces the risk of schizophrenic relapse. For adults, treatment begins with 1 mg twice daily, increasing by 1 mg daily as needed up to a maximum dose of 8 mg per day. It is available in 1, 2, 3, and 4 mg tablets.

Solian (amisulpride) is an antipsychotic medication developed and marketed by the pharmaceutical company SANOFI-SYNTHELABO. It is indicated for acute and schizophrenic disorders accompanied by prominent positive symptoms (e.g., delusions, hallucinations) and/or negative symptoms (emotional flattening, social withdrawal), particularly when negative symptoms predominate. It alleviates affective symptoms such as depressed mood and psychomotor retardation. For acute psychotic states, the prescribed dose ranges from 400 to 800 mg daily (maximum 1200 mg) divided into 2 doses. For patients with predominant negative symptoms, the dose ranges from 50 to 300 mg daily. It is available in 100, 200, and 400 mg tablets.

Indications for switching from a conventional antipsychotic to an atypical one include: treatment-resistance of positive or negative symptoms; persistent extrapyramidal disorders; tardive dyskinesia; exacerbation of the disease, or issues related to deficit syndromes despite strict adherence to the antipsychotic regimen.

TRANQUILIZERS (ATARACTICS)

The general psychotropic effects of tranquilizers include a calming action accompanied by a pleasant sense of relaxation and overall well-being. Tranquilizers eliminate or mitigate negative emotions such as fear, tension, and anxiety (anxiolytic effect). Their broad spectrum of psychotropic activity primarily addresses diverse symptoms associated with borderline mental disorders. Tranquilizers are widely used not only in psychiatry but also in general somatic practice, as they normalize mental status and reduce autonomic disturbances in neurotic and neurosis-like states. However, while some tranquilizers exhibit a predominantly calming and inhibitory effect, others combine this with activation and stimulation.

Tranquilizers with a Predominantly Inhibitory Component

Meprotan (meprobamate, andaxine) is one of the most effective calming agents. Treatment with this medication induces emotional tranquility, reduces reactivity to stimuli, and relieves internal tension as well as various autonomic dysfunctions. It is available in tablet form (200 mg). The prescribed doses range from 200–400 mg up to 1.5–2.5 g per day.

Chlordiazepoxide (chlozepid, elenium, librium, napoton) is a potent tranquilizer with a wide spectrum of activity. It is prescribed for all types of borderline mental disorders accompanied by increased excitability and autonomic disturbances. It is particularly indicated for obsessive, phobic, and hypochondriacal states. It is administered per os and intramuscularly. In neurotic states and somatic practice, the dosage of chlordiazepoxide ranges from 20 to 60 mg daily (1 dragee contains 5 mg).

Nozepam (oxazepam, tazepam) has a mild effect and lacks side effects, making it widely used for treating all neurotic and neurosis-like disorders characterized by increased excitability, especially in patients with severe somatic and neurological diseases, as well as in elderly patients and pediatric practice. The drug is administered orally at a dose of 10 mg 1–4 times a day.

Nitrazepam (Radedorm — AWD; Eunoctin, manufactured by Asta Medica) is a benzodiazepine derivative with a selective, pronounced hypnotic effect as well as anticonvulsant properties. The drug does not cause tolerance or dependence. It is prescribed as a hypnotic 25–40 minutes before bedtime (5–10 mg), and in pediatric practice for the complex treatment of Epilepsy (at a dose of 2.5–5 ml daily until a therapeutic effect is achieved).

Phenazepam surpasses all other tranquilizers in terms of overall tranquilizing potency. It reduces anxiety and fear even in the presence of real danger, but causes lethargy, slowed reactions, and drowsiness. It is indicated for psychotic anxiety, phobias, obsessive states, and hypochondriacal syndromes. It is prescribed for neurotic and neurosis-like disorders at doses of 3–5 mg daily. Higher doses (up to 10 mg daily) are used to relieve anxiety, agitation, and autonomic dysregulation in psychoses, as well as for the treatment of alcohol and substance withdrawal. It is available in 0.5 and 1 mg tablets.

Tranxene (dipotassium clorazepate) belongs to the benzodiazepine Class, manufactured by SANOFI—SYNTHELABO. It exhibits pronounced anxiolytic, sedative-hypnotic, anticonvulsant, and central muscle-relaxant effects. For anxiety, anxious depression, psychomotor agitation, and aggression, doses ranging from 20 to 200 mg per day are prescribed. It is administered intramuscularly or intravenously, followed by oral administration. For impending delirium and delirium tremens (including alcoholic), 50–100 mg is given every 3–4 hours. After 2–3 days, the dose is halved, and by the 5th day, it is administered per os at a dose of 150–300 mg daily. It is available in injection vials of 20, 50, and 100 mg, and in 5 and 10 mg capsules.

Stilnox (zolpidem) belongs to the imidazopyridine group. Manufactured by SANOFI—SYNTHELABO, it exhibits a pronounced sedative-hypnotic effect. It is prescribed immediately before bedtime for patients under 65 years of age at a single dose of 10 mg (maximum 15–20 mg); for patients over 65, 5 to 10 mg. It is contraindicated in children under 15, pregnant women, and during Lactation. It is available in 10 mg tablets.

Tranquilizers with a Stimulating Component

Trioxazine, unlike first-generation tranquilizers, lacks inhibitory and muscle-relaxant effects; instead, it increases activity, improves mood, and promotes a sense of vigor. At the same time, it relieves fear, anxiety, affective instability, and tension in neurotic and neurosis-like states. Trioxazine is administered orally (0.3 g 2–6 times daily) in the morning and afternoon. The average daily dose is 1.2–1.5 g.

Sibazon (diazepam, seduxen, relanium, valium) is one of the most popular tranquilizers, which is attributed to its broad spectrum of action and lack of adverse effects. Its predominant stimulating influence is harmoniously combined with a calming effect. It is prescribed orally for neurotic anxiety and depression, as well as hypochondriacal and obsessive states. Lethargy during sibazon treatment manifests only in the first few days, after which mood, activity, and working capacity improve. Prolonged use may lead to tolerance and dependence. The average daily dose is 10–15 mg. When administered intramuscularly and intravenously, it exerts an antipsychotic effect, relieves psychomotor agitation and dysphoria, and halts status epilepticus. For injections, a 0.5% solution of sibazon is used in volumes of 4–12 ml (administered slowly intravenously in 20 ml of a 40% glucose solution).

Grandaxin (tofisopam) is a "daytime" tranquilizer. Combining mild anti-anxiety, activating, and autonomic-stabilizing effects, it provides therapeutic efficacy in neurotic and neurosis-like states. It is administered orally at 50–100 mg 1–3 times daily. It is available in tablet form.

Medazepam (medazepam — AWD; Rudotel), manufactured by Asta Medica, also belongs to "daytime" tranquilizers, although its activating component is less pronounced than that of trioxazine. It does not cause drowsiness, making it suitable for patients who continue to work or engage in intellectual labor. Each tablet contains 10 mg, with an average daily dose of 40–50 mg.

NORMOTHYMIC AGENTS (MOOD STABILIZERS, LITHIUM SALTS)

Medications in this group (lithium carbonate, lithium oxybutyrate) regulate and eliminate affective disorders observed primarily in circular (manic-depressive) disorders, as well as in affectively unstable psychopathic personalities, epileptic dysphoria, and others. Long-term therapy with lithium salts prevents the recurrence of affective episodes. Properly selected dosage is crucial for effective treatment and prophylaxis with lithium salts. The concentration of the drug in Blood Plasma should be no lower than 0.6–0.8 mmol/L and no higher than 1.2 mmol/L. At the onset of therapy, blood lithium levels are determined weekly, and subsequently every 1–2 months. At lower concentrations, the therapeutic and preventive effects do not manifest, while higher concentrations may lead to lithium toxicity. Early side effects include gastrointestinal disturbances, thirst, frequent urination, and mild hand tremor; late side effects comprise progressive tremor, muscle twitching, hyperkinesia, akathisia, dysarthria, endocrine disorders, Cardiac Arrhythmias, and persistent diarrhea. Psychological side effects manifest as apathy. Upon the appearance of lithium toxicity symptoms, the medication must be discontinued, sodium chloride intake increased, and abundant fluid administration prescribed.

Lithium carbonate is available in 300 mg tablets. Treatment of manic states is recommended to start at 900 mg/day, gradually increasing the dose to 1500–2100 mg/day, and occasionally up to 3000 mg/day. For prophylaxis, it is prescribed at 900–1200 mg/day (divided into 3 doses).

Micalit (lithium-retard) is available in 400 mg ampoules. It is a sustained-release formulation of lithium carbonate. The drug dissolves gradually in Water, establishing a stable blood concentration, which allows achieving therapeutic efficacy at lower blood lithium levels (0.3–0.5 mmol/L).

Lithium oxybutyrate is a water-soluble lithium salt for intramuscular and intravenous administration, including continuous infusion. Compared to lithium carbonate, it is less toxic and more active. Lithium oxybutyrate is generally prescribed at a dose of 1600–3200 mg/day, resulting in a blood concentration of 0.4–0.8 mmol/L. This is usually sufficient to suppress manic agitation. It is available in ampoules (2 ml of a 20% solution).

Carbamazepine (finlepsin, finlepsin retard, tegretol) belongs to anticonvulsant medications, but is capable of preventing the development of manic and depressive phases. It is also prescribed in cases of resistance or contraindications to lithium therapy, as well as for dysphoria of epileptic or psychopathic origin. It is used in trigeminal neuralgia and for the prevention of seizures in alcohol withdrawal syndrome. It is available in tablets (200 mg). It is prescribed 3 times daily, with an average daily dose of 800 mg and a maximum of 1400 mg.

ANTIDEPRESSANTS

Antidepressants belong to the group of psychoanaleptics and exhibit diverse chemical structures (tricyclic and tetracyclic compounds, monoamine oxidase inhibitors) and Mechanisms of action. Through their specific psychotropic influence, they elevate pathologically depressed mood of various origins. The basis of the thymoleptic (antidepressant) effect of tricyclic antidepressants (imipramine, amitriptyline) involves blocking the reuptake of free monoamines into the presynaptic Structure and blocking presynaptic serotonin receptors, which promotes an increase in the synthesis and quantity of neurotransmitters, activating noradrenergic, dopaminergic, and serotonergic brain structures.

The MECHANISM OF ACTION of antidepressants from another group (iprasid, nialamide) involves the inhibition of monoamine oxidase (MAO) Enzymes, which similarly increases the concentration and activity of monoamines (adrenaline, noradrenaline, dopamine, serotonin) that exert excitatory and stimulating effects, thereby producing an antidepressant response in the central nervous system.

Antidepressants such as pyrazidol and incasan exhibit a dual mechanism: they selectively inhibit a specific type of monoamine oxidase while simultaneously blocking the reuptake of certain neurotransmitter monoamines.

The selection of a drug and treatment strategy for antidepressants should be guided by the General Principles of psychopharmacotherapy. The strategy for treatment-resistant depression—which occurs in 60–70% of patients—may involve combining antidepressants with each other, with neuroleptics, psychostimulants, lithium salts, carbamazepine, or other adjunctive agents (such as Tryptophan or thyroid hormone). Electroconvulsive therapy (ECT), Sleep deprivation, and sudden discontinuation of antidepressants are also utilized.

Antidepressants are categorized based on their secondary sedative or stimulating properties.

ANTIDEPRESSANTS WITH ADDITIONAL SEDATIVE EFFECTS

Amitriptyline (Saroten, Tryptizol) is a tricyclic antidepressant and a derivative of dihydrobenzocycloheptene. It combines thymoleptic activity with a pronounced calming effect. It was first introduced to the pharmaceutical market by Lundbeck under the brand names Saroten and Sarotex. Along with alleviating depressive symptoms, it relieves anxiety and agitation. Because it does not exacerbate hallucinatory-delusional symptoms, it can be used for psychotic anxiety depressions of various origins (such as involutional melancholia or schizophrenia). Due to its sedative and even hypnotic properties, it can be administered in the evening. Treatment typically begins with 25 mg three times daily. The optimal therapeutic dose ranges from 150–200 mg/day, and up to 300 mg/day or more in severe cases of depression. Afterward, the dose is tapered to 50–100 mg/day. It is available in tablets and dragees (10, 25, 50, and 75 mg), as well as in ampoules for injection (2 ml of a 1% solution).

Cipramil (citalopram) is one of the most widely used selective serotonin reuptake inhibitors (SSRIs), manufactured by Lundbeck. It is by no means inferior to classical tricyclic antidepressants; on the contrary, it surpasses them in the speed of therapeutic onset. It is well tolerated by patients because it does not impair cognitive or motor functions, exhibits minimal anticholinergic activity (thus having virtually no impact on cardiovascular function), does not potentiate the effects of alcohol, is non-toxic (allowing for prolonged use in preventing depressive relapses), and does not cause discontinuation syndrome. It shows no significant interactions with other psychotropic, cardiotropic, antihistamine, or other medications, allowing it to be administered concurrently with them (including in cases of Psychosomatic and Somatopsychic Disorders).

It is prescribed at a dose of 2 mg once daily at any time, regardless of meals. The maximum daily dose is 60 mg.

It is available in tablet form (20 mg and 40 mg).

Azafen is inferior to other antidepressants in terms of overall thymoleptic potency, yet it exhibits adequate calming and tranquilizing effects. It is indicated for depressions lacking deep psychotic or vital disorders or affective extremes, but accompanied by asthenic or other neurosis-like symptoms, emotional lability, irritability, and expansiveness. The average daily dose is 150–200 mg/day. It is available in tablets (25 mg) and ampoules (2 ml of a 1.25% solution).

Gerфонал (trimipramine, surmontil) is a tricyclic antidepressant whose psychotropic profile comprises both thymoleptic (antidepressant) and sedative effects. It is most effective in moderate psychotic anxiety depressions, as well as in neurotic, cenestopathic-hypochondriacal, and reactive depressions. It is administered per os (with an average therapeutic dose of 150–300 mg/day) or via intravenous drip infusion (75–200 mg of the drug in an isotonic sodium chloride solution). It is supplied in tablets (25 mg).

Oxylidine is a medication with mild antidepressant, sedative, and hypotensive properties. It is indicated for mild anxiety-depressive states of various origins (particularly in elderly patients) and organic central nervous system insufficiency caused by cerebrovascular disorders (such as Hypertension or cerebral atherosclerosis). The drug is administered orally (up to 300–500 mg/day) as well as intramuscularly (1–3 ml of a 2% solution twice daily).

ANTIDEPRESSANTS WITH ADDITIONAL STIMULATING EFFECTS

Imipramine (imipramine, tofranil, melipramine) possesses a potent antidepressant effect targeted primarily at vitally altered affect (endogenous depression). In addition, the drug exhibits a clearly defined stimulating effect and is therefore indicated for severe depressions accompanied by profound melancholy and inhibition. Like amitriptyline, melipramine is contraindicated in acute Liver and Kidney diseases, decompensated cardiac defects, blood disorders, glaucoma, and stage III hypertension.

Side effects may include headache, dizziness, thirst, dry mouth, tremor, insomnia, paresthesia, hyperhidrosis, and urinary retention. Most of these occur at the onset of treatment and do not require discontinuation or dose reduction. Melipramine can exacerbate anxiety, activate delusional thinking or hallucinations, and induce insomnia; therefore, it should not be administered at bedtime. In severe cases, treatment typically begins with parenteral administration (intramuscularly or via intravenous drip) of melipramine at a dose of 50–75 mg/day, gradually increasing to a therapeutic dose of 200–250 mg/day. As the patient's condition improves after 7–10 days, therapy is switched to oral administration. If necessary, it can be combined with other tricyclic antidepressants (such as amitriptyline), neuroleptics, or tranquilizers. However, concurrent administration with MAO inhibitors is strictly prohibited due to the risk of severe toxicity. If a transition to an MAO inhibitor is required, a washout period of at least 2 weeks must be observed. Melipramine (imipramine) is available as dragees (25 mg) and in ampoules (2 ml of a 1.25% solution).

Prozac (fluoxetine) is a serotonin reuptake inhibitor manufactured by Eli Lilly. It elevates mood, alleviates feelings of fear, emotional tension, and dysphoria, and lacks sedative effects.

It is prescribed for reactive and endogenous depressive states (20 mg/day), bulimia nervosa (20 mg three times daily), and obsessive-compulsive disorders (20–60 mg/day).

Contraindications include epilepsy, severe renal impairment, concurrent use with MAO inhibitors, and hypersensitivity to the active substance.

It is available in capsules (20 mg) and dispersible tablets (20 mg).

Ludiomil (maprotiline) is an active antidepressant with stimulating properties. It is used primarily for moderately severe depressions (of cyclothymic level) accompanied by adynamia and obsessive hypochondriacal disorders. The average daily therapeutic dose ranges from 150–200 mg. In severe cases, it is administered via intravenous drip at a dose of 25–150 mg/day. It is supplied in tablets (10, 25, 50, and 75 mg) and ampoules (25 mg of the active substance in 2 ml of solution).

Cphephedrine is used for various presentations of depression characterized by apathy, motor retardation, and ideational slowing. It is prescribed orally at 0.025 g/day (divided into 2–3 doses), with the dose gradually increased to 0.2–0.4 g/day.

Nialamide (niamid, nuredal) is a hydrazine derivative and an MAO inhibitor functioning as a mild stimulating antidepressant. Due to these characteristics, along with hepatotoxicity and potential food-drug interactions (such as with cheese, beer, wine, broad beans, and smoked products), drugs of this class are currently less popular. They are indicated for mild endogenous depressions with lethargy, psychomotor retardation, and abulia, as well as for cases refractory to other therapeutic methods. The average therapeutic dose is 200–350 mg/day. For prolonged episodes and severe depressive states, 500–1000 mg of the drug as a 0.1% solution is administered via intravenous drip. Intramuscular nialamide is prescribed at 250–500 mg twice daily in the first half of the day to prevent insomnia. It is available in tablet form (25 mg).

Parnate (tranylcypromine) is likewise an MAO inhibitor, though it exhibits a lower toxicity and side-effect profile. It is an antidepressant with mild antidepressant activity and a more pronounced stimulating effect, belonging to the class of minor antidepressants. It is used to treat mild depressions of various etiologies dominated by psychomotor retardation. It is prescribed in the morning and afternoon at 5–10 mg/day, with the dose gradually increased to an optimal level of 25–40 mg/day, and up to 60 mg/day or higher in severe cases. It is supplied in tablets (5 mg).

Indopan is a non-hydrazine MAO inhibitor with a pronounced stimulating action combined with mild antidepressant efficacy. It is most effective in astheno-depressive and astheno-hypochondriacal conditions. Combined with low doses of neuroleptics (such as trifluoperazine), it can be used to treat schizophrenia accompanied by apathy, abulia, and depressive symptoms. The average therapeutic dose ranges from 20–40 mg/day. It is available in tablets (5 and 10 mg).

NEUTRAL ANTIDEPRESSANTS

Zoloft is a serotonin reuptake inhibitor manufactured by the pharmaceutical company Pfizer. Indications: treatment and prevention of depression with or without anxiety, with or without a history of mania; obsessive-compulsive disorder (OCD); panic and post-traumatic stress disorders. It is prescribed once daily, starting with a dose of 25—50 mg/day. If necessary, the dose may be increased after 1 week up to a maximum of 200 mg/day.

Available in 50 mg and 100 mg tablets.

Pyrazidol is an antidepressant whose effects are similar to those of amitriptyline and imipramine. It belongs to the class of major antidepressants. It has a balanced effect on various types of depression: it is calming in cases of anxiety and stimulating in cases of inhibition. It can be used in somatic pathologies and is prescribed for physically weakened patients and the elderly. It is incompatible with MAO inhibitors. The average daily dose is 150—200 mg. Available in tablets (25 mg and 50 mg).

Antiepileptic (Anticonvulsant) Drugs

This group of medications is used to prevent and stop seizures and epileptic psychiatric equivalents. Many drugs in this group have a selective anticonvulsant effect without significantly affecting the emotional sphere (hexamidine, diphenine, ethosuximide, etc.). Other drugs (finlepsin, carbamazepine, karbasan) are also used for affective disorders. Certain barbiturates are traditionally classified as antiepileptic agents because they produce a selective anticonvulsant effect without a pronounced hypnotic effect (benzonal, etc.). Phenobarbital remains the gold standard of anticonvulsant activity for other drugs.

Phenobarbital (luminal). A barbituric acid derivative. As previously noted, it has long been a baseline treatment for epilepsy. In small doses (20—90 mg per day), it exerts a sedative and antispasmodic effect. At a dose of just 10 mg, it has a distinct hypnotic effect. In the Cytology/cytology/16.html">Early stages of epilepsy, up to 50 mg per day is prescribed. The maximum single dose for adults is 20 mg, and the daily dose is 500 mg. It is included in the antiepileptic drug mixtures of Syreysky, Vorobyov, Andreyev, Brodsky, Karmanova, etc. Formulations: powder, tablets of 50, 100, and 5 mg for children.

Benzonal. A benzodiazepine derivative. It exhibits anticonvulsant activity without a hypnotic effect. It is used for generalized, focal convulsive, Jacksonian, and adversive seizures, Kozhevnikov's epilepsy, as well as psychic and psychomotor paroxysms. Treatment begins with small doses (100—200 mg per day). The maximum daily dose is 900 mg. Available in powder form and in 50 mg and 100 mg tablets.

Hexamidine (sertan, primidone) is a barbituric acid derivative. It is indicated for major epileptic seizures and is less effective for minor ones. It has no effect on psychomotor or diencephalic seizures, or psychic paroxysms. It lacks a hypnotic effect. It is prescribed primarily for clonic seizures, starting at 125 mg per day. The dose is gradually increased to 1.5—2.0 g per day. Available in 125 mg and 250 mg tablets.

Diphenine (phenytoin, diphentoin) is a hydantoin derivative. It is most effective for major seizures with tonic convulsions. It is also prescribed for vegetative-vascular, psychomotor, and psychic paroxysms. It is ineffective for minor epileptic seizures. It is prescribed to adults at 100 mg 2—3 times a day, increasing the daily dose to 400—450 mg, most often in combination with other drugs, primarily phenobarbital.

Finlepsin (carbamazepine) is an iminostilbene derivative, manufactured by the pharmaceutical company Asta Medica (Finlepsin-200 Retard, Finlepsin-400 Retard). It is a broad-spectrum antiepileptic agent. Indications: partial epileptic seizures with complex symptomatology; major convulsive seizures, mixed forms of epilepsy, non-epileptic seizures in patients with multiple sclerosis; tonic seizures; paroxysmal dysarthria; ataxia, paresthesia, and pain attacks; psychotic conditions, especially manic-depressive psychosis (bipolar affective disorder); anxious-agitated depression; catatonic excitement; prevention of seizures in alcohol withdrawal syndrome; trigeminal neuralgia; glossopharyngeal neuralgia; pain syndrome in patients with diabetic neuropathy. The initial daily dose is 200—300 mg, which is gradually increased (individually) to 600—1200 mg. Formulations: 200 mg and 400 mg retard tablets.

Karbasam (carbamazepine). Manufactured by the pharmaceutical company Sanofi-Synthelabo. Prescribed for major epileptic seizures and epileptic psychic equivalents, partial (psychomotor) epilepsy, and typical interictal disorders: adults — 10—15 mg/kg per day; children — 10—20 mg/kg per day; for the prevention of recurrences of manic-depressive psychosis (bipolar affective disorder), especially forms resistant to lithium salts or when lithium is contraindicated — 400—800 mg per day; for the treatment of manic and hypomanic agitation — 600—1200 mg per day; Facial Nerve neuralgia — 200—400 mg. Formulations: 200 mg and 400 mg retard tablets.

Depakine contains sodium valproate. Manufactured by the pharmaceutical company SANOFI-SYNTHELABO et al. It is a broad-spectrum drug effective in all forms of epilepsy: generalized and focal — absences, myoclonic, tonic-clonic, atonic, and mixed seizures, simple or complex West and Lennox syndromes (frequently), convulsive syndrome in organic brain lesions, behavioral disorders associated with epilepsy, febrile seizures in children, and pediatric tics. It is prescribed starting with an average daily dose of 10—15 mg/kg, gradually increasing to 20—30 mg/kg or more. Special patient monitoring (blood drug concentration control) is required if the dose exceeds 50 mg/kg. For children, the dose is approximately 30 mg/kg.

Depakine Chrono has all the advantages of a retard formulation: a stable antiepileptic effect; a low risk of side effects; a convenient dosing and administration schedule (1—2 times a day) at the same daily dose of the drug. Formulations: 30 mg tablets; Depakine Chrono 30 and 50 mg; syrup (1 dosing spoon contains 20 mg of the active substance); vials with lyophilized powder for intravenous administration of 400 mg.

PSYCHOSTIMULANTS

Psychostimulants are also referred to as psychotonics, psychoenergetics, or central stimulants. They include various chemical compounds that increase activity, induce euphoria, stimulate intellect, accelerate thinking, reduce fatigue and drowsiness, and improve well-being in comorbid neurotic and neurosis-like disorders. They are prescribed to healthy individuals in extreme situations associated with mental and physical overexertion. The basis of their psychostimulating action is the enhancement of synaptic transmission through the mobilization of neurotransmitters (norepinephrine and dopamine) under The Influence of these substances.

Sydnocarb is one of the most effective drugs with a prolonged stimulating effect. It creates a sense of vigor, a surge of energy and physical strength, and increases performance. It is indicated for asthenic, psychasthenic, and apathy-abulic states characterized by lethargy, inhibition, and increased fatigability. The drug is prescribed orally 1—2 times a day at 5—10 mg. The average therapeutic dose is 25—75 mg/day. Available in tablets (5 mg and 10 mg).

Sydnophen is pharmacologically and chemically similar to sydnocarb, though it has a less pronounced psychostimulating effect. The main indications for prescribing sydnophen are lethargy, increased fatigability, and depression, including somatogenic asthenic depressions. The initial dose is 5—10 mg/day, but it can be increased to 20—30 mg/day. Available in tablet form (5 mg).

Caffeine is a central nervous system stimulant. It is prescribed per os at 50—100 mg 2—3 times daily. It is contraindicated in insomnia, hypertension, atherosclerosis, glaucoma, and organic cardiovascular diseases.

NOOTROPIC AGENTS

The name of this drug group (from the Greek *noos* — mind, intellect) first appeared in 1963 when one of the cyclic derivatives of gamma-aminobutyric acid (GABA) with a unique psychotropic profile was named Nootropil.

Nootropics stimulate neurometabolism and exhibit antihypoxic effects, activating the Bioenergetics of Nerve Cells in cerebral organic lesions or residual-organic insufficiency. Through this mechanism of action, higher mental functions are activated, mental tone is elevated, consciousness is cleared, and thinking, speech, and intellectual development are improved. Additionally, nootropics possess tranquilizing, antidepressant, vasovegetative, antiepileptic, antiparkinsonian, and antidyskinetic effects.

Due to these special properties and the absence of contraindications, nootropic agents are widely used in the course of complex treatment and rehabilitation of psychiatric patients, especially those with asthenic disorders and psycho-organic syndromes of various origins (vascular, traumatic, infectious, intoxicational, etc.).

Piracetam (nootropil) is widely used for the following pathologies: psycho-organic disorders with a predominance of asthenic, asthenohypochondriac, and asthenodepressive disorders; somatogenic asthenia; acute and residual manifestations of central nervous system organic insufficiency; consciousness disorders; alcohol withdrawal and delirium; in gerontology and pediatric practice; intellectual deficiency; schizophrenic neurosis-like and psychopath-like symptomatology; and as a corrector in neuroleptic therapy. It is administered orally, intramuscularly, and intravenously. The initial dose is 0.8—1.2 g, which can be increased up to 20—30 g/day. Manufactured by Farmak and other companies in the form of capsules (0.4 g), tablets (0.2 g), and ampoules (5 ml of a 20% solution).

Aminalon (aminalon-forte, farmalon, gamalon). It exerts a favorable effect on the energy processes of brain Tissues. It is indicated for the following conditions: cererasthenic and encephalopathic manifestations of various origins; dynamic cerebrovascular disorders; mental retardation; lethargy; adynamia; drowsiness of schizophrenic origin or caused by the use of neuroleptic drugs; and during alcohol and drug withdrawal states. It is prescribed at 0.25 g, with a daily dose of 0.5—1.5 g.

Acephen (centrophenoxine, lucidril) exhibits a mild stimulating effect and is particularly indicated for somatogenic asthenic states, vegetative dysfunctions, organic brain lesions, and intoxications. Available in tablet form (0.1 g) and vials (0.25 g). It is prescribed orally at 0.3—1.0 g, and administered intramuscularly and intravenously.

Pyritinol (Encephabol) stands out among nootropics for its pronounced stimulating and antidepressant effects. Synthesized from pyridoxine (vitamin B₆), it directly influences metabolic processes in the central nervous system (CNS). Pyritinol is primarily used for astheno-apathetic, astheno-depressive, and depressive states, neuroses, organic CNS lesions, sluggish schizophrenia, cyclothymia, and in geriatric practice. It is available in tablets (0.1 and 0.25 g) and is prescribed in courses lasting 1—3 months, with an average daily dose of 0.3—0.4 g.

Pantogam is primarily indicated for: asthenic states with "irritable weakness"; neurosis-like disorders (dyssomnic, obsessive-phobic, hypochondriacal); the treatment of extrapyramidal hyperkinesias induced by neuroleptics; and the reduction of irritability and behavioral disorders in patients with epilepsy. It is available in tablets (0.25 and 0.5 g), with a daily therapeutic dose ranging from 1.5 to 3 g.

Memantine (manufactured by Lundbeck) is a nootropic and myotonolytic agent with dopaminergic and glutamatergic properties. It enhances the release of biogenic amines, inhibits their reuptake, and improves Nerve Impulse transmission. It is prescribed for mild to moderate cognitive impairment characterized by memory loss and impaired concentration, apathy, increased fatigue, limited self-care capacity, motor disorders, depressive states (dementia syndrome), and muscle spasms caused by traumatic brain injury, stroke, multiple sclerosis, Parkinson's disease and secondary parkinsonism, as well as Alzheimer's disease. It is administered per os or intravenously at 5 to 60 mg daily (0.5 mg/kg/day for children). Available forms include tablets, drops, and injection solution.

Jumex (selegiline), manufactured by SANOFI—SYNTHELABO, enhances dopaminergic activity in the CNS and participates in the metabolism of other catecholamines. It is prescribed for Parkinson's disease and symptomatic parkinsonism at 10 mg daily in one or two doses, as well as for Alzheimer's disease at 5—10 mg daily. It is available in 5 and 10 mg tablets.

Aricept (donepezil hydrochloride), manufactured by SANOFI—SYNTHELABO, is used to treat dementia symptoms in patients with mild to moderate Alzheimer's disease. Treatment is initiated at 5 mg daily (taken once daily for 1 month), after which the dose may be increased to 10 mg daily if needed. It is available in tablets of 5 mg (equivalent to 4.56 mg of free donepezil) and 10 mg (equivalent to 9.12 mg of free donepezil).

General tonic preparations are prescribed for asthenic states, nervous strain, physical fatigue, nutritional dietary deficiencies, and excessive consumption of psychoactive substances (including alcoholic beverages).

Magnerot / Magne B₆ (magnesium lactate, pyridoxine) contains magnesium dihydroorotate (470 mg), pyridoxine (5 mg), and excipients. Manufactured by SANOFI—SYNTHELABO, it is available in tablets and an oral solution in ampoules. Indications: functional manifestations of asthenia and depression (1—2 tablets or 1 ampoule daily); magnesium deficiency (6 tablets or 3 ampoules daily); spasmophilia (4 tablets or 2 ampoules daily).

Berocca Calcium Magnesium contains seven B-group vitamins, ascorbic acid, calcium, and magnesium. These elements play a vital role in the development and functioning of nerve cells, and their deficiency may arise during mental and physical stress, alcohol abuse, etc. It is prescribed at 1—2 tablets daily, dissolved in a Glass of water.

SHOCK THERAPY

Before the advent of psychotropic drugs, shock therapy was the primary method for treating psychoses, especially schizophrenia. Today, its use is quite limited (and requires the mandatory written consent of the patient or their legal representatives).

Insulin coma therapy (ICT) was proposed in 1933 by the Austrian psychiatrist M. Sakel. Individually tailored doses of insulin are administered subcutaneously to fasting patients (usually starting at 4 IU and daily increasing the dose by 4—8 IU), inducing a hypoglycemic coma or subcomatose state, which is terminated after 20—30 minutes by the intravenous administration of 40% glucose. Insulin shock is administered daily for 10—30 days. There are two therapeutic strategies for ICT: 1) as a primary treatment method to interrupt psychosis; 2) to overcome resistance to psychopharmacotherapy. ICT is most effective in acute and subacute states of schizoaffective structure, as well as in paranoid states within the clinical picture of schizophrenia with a short duration of the process (up to 1—2 years). ICT must be preceded by a comprehensive patient evaluation. Blood glucose levels are monitored before and during treatment. Most somatic illnesses, organic neurological symptoms, and endocrine disorders are contraindications to this treatment method. ICT is not prescribed during Pregnancy or for patients over 50 years of age.

Hypoglycemia can lead to numerous complications, such as convulsive seizures, collapse-like states, cardiac arrhythmias, and recurrent hypoglycemia, particularly at night. An Exacerbation of chronic infectious diseases is also possible. A severe complication is prolonged coma that cannot be reversed by glucose administration (requiring resuscitation measures). Due to these complications and the difficulty of managing the therapeutic process, this method is used less and less frequently.

Electroconvulsive therapy (ECT) was proposed and introduced into psychiatric practice in 1938 by the Italian scientists U. Cerletti and L. Bini. In addition to paranoid schizophrenia, ECT (also known as EST — electrosuramin / electroconvulsive therapy) is effective in hypertoxic attacks of schizophrenia (febrile catatonia). It frequently yields good results in catatonic stupor; in prolonged depressions and obsessive-depressive states, ECT is also used as a means to combat resistance to psychotropic drugs. The Mechanism of action remains unclear, generally attributed to The Effect of an epileptiform seizure on subcortical brain centers and cortico-subcortical connections. The technique typically involves the symmetric placement of electrodes on both temples of the patient (bilaterally), through which an electric current of 70—120 V is passed. The exposure lasts 0.5—0.9 s (if necessary, parameters are increased by 10 V or 0.1 s, respectively, until a convulsive reaction occurs). A modified technique exists involving monopolar (unilateral) electrode placement on the nondominant hemisphere. This induces a seizure resembling a grand mal epileptic fit, lasting over a minute, accompanied by loss of consciousness, apnea, and tonic-clonic convulsions. Such sessions are conducted every other day, with a total course of 3—5, and occasionally up to 10 sessions.

ECT complications are most commonly related to The Musculoskeletal System (hairline cracks, vertebral fractures, lower jaw dislocation). Prolonged respiratory arrest and cardiac arrhythmias may also occur. Certain contraindications and restrictions apply to ECT. Therefore, to prevent complications, premedication is administered prior to the ECT session, involving sedatives or narcotics and muscle relaxants. The decision to perform ECT is made by a medical board following a thorough somatic and neurological examination of the patient.

Drug-induced convulsive therapy with intravenous administration of corazole or amidopyrine does not significantly differ from ECT in terms of indications and contraindications. In recent years, it has practically fallen out of use.

One of the general biological methods is fasting-diet therapy (FDT), which involves controlled therapeutic fasting combined with fluid intake and a special diet. It is primarily used for prolonged neuroses and sluggish schizophrenia, especially in cases of hypersensitivity to psychopharmacological agents. This technique is prescribed with the patient's consent following a comprehensive medical examination.

Detoxification methods. Hemoperfusion (hemisorption) is the most common among them. It is performed by a specially trained physician. Indications: the presence of a toxic component in the disease Pathogenesis (alcoholic and substance-induced psychoses, severe withdrawal syndrome, hypertoxic schizophrenia, etc.). This method also increases sensitivity to psychopharmacotherapy.

Sleep deprivation therapy is typically used for treatment-resistant depressions, particularly those dominated by apathy. It involves enforced wakefulness lasting from 18—20 to 36—40 hours. A course consists of 6—8 such sessions, performed 1—2 times per week. Explaining The Essence of the method and obtaining patient consent are mandatory.

Psychosurgery at the present stage is in the exploratory phase of discovering new treatment methods. Surgical Procedures (such as lobotomy or leucotomy, stereotactic methods, etc.) are not yet widely used in the Treatment of Mental Disorders.

Appendix: Selection of psychotropic drugs taking into account their impact on Psychopathological Syndromes

PSYCHOTHERAPY AND SOCIOTHERAPY

Psychotherapy is a system of direct therapeutic intervention (unlike psychopharmacological and other biological factors) targeting the patient's psyche and, through it, the entire Organism. Its goal is to alleviate morbid symptoms and alter the patient's attitude toward themselves, their condition, and their environment. Psychological tools used to influence the patient's psyche include the spoken word, non-verbal conditioned stimuli, the environment, specific activities, and so forth.

Sociotherapy is essentially a branch of psychotherapy that utilizes socio-psychological factors, namely: the Influence of the patient's immediate social environment, various forms of social engagement (such as former patients' clubs), or group activities.

Psychotherapy is applied across various fields of medicine. Every physician, regardless of specialty, should exert a positive psychological influence on the patient at all Stages of the diagnostic and treatment process. Psychotherapy is especially vital in conditions where psychological factors play a significant role (neuroses, reactive states, psychosomatic disorders), when the illness itself places the patient in stressful conditions (pre- or postoperative periods, pre-natal and labor periods, etc.), or when the illness constitutes severe psychological trauma resulting in disability. In psychiatry, psychotherapy is employed for nearly all ailments.

Among the aspects concerning the content of psychotherapy, a distinction should be made between general and special psychotherapy.

General psychotherapy is prescribed for the treatment of all patients, regardless of the medical institution's profile. It involves utilizing the entire complex of psychological factors that positively influence the patient (an optimal psychological climate, a protective regimen, etc.) to enhance their defense mechanisms in combating illness. Psychotherapy is closely linked with medical deontology and belongs to a specialized field of medical psychology that all practicing physicians need to know.

The goal of general psychotherapy is to help the patient develop an adequate attitude toward their illness and prescribed treatment; to prevent psychotraumogenic factors that exacerbate the primary ailment with Psychogenic Disorders; and to maintain the patient's hope for recovery, regardless of The Nature and severity of the disease. Crucial in shaping the doctor's general psychotherapeutic impact on the patient are the physician's authority, empathy, erudition, truthfulness, attentiveness, capacity for compassion, and ability to win the patient's trust. Throughout the diagnostic and treatment process, the clinician must maintain this trust, instill hope for successful therapy and recovery regardless of the nature and severity of the ailment, and, when necessary, correct the patient's behavior.

Special psychotherapy involves the application of specific psychological treatment methods for various disorders. They can be used independently as the primary treatment modality or adjunctively, in combination with others (for example, alongside psychopharmacotherapy).

All psychotherapeutic methods are divided into the following groups: rational, suggestive, behavioral, and psychoanalytical. Furthermore, depending on who participates in the therapeutic sessions, a distinction is made between individual, group, and family psychotherapy.

Indications for using a particular technique are not absolute. In the course of treatment, they are supplemented or substituted for one another.

Mass media (television, radio, video recordings) are also utilized for psychotherapeutic purposes.

Psychotherapy is a form of treatment based on communication between a therapist and a patient, or among several members of a psychotherapeutic group who assume these roles. This form of treatment is used to overcome emotional disorders, help patients modify maladaptive behavioral patterns and character traits, and foster improved adjustment to life conditions.

Today, there are over 140 psychotherapeutic approaches. Each is distinguished by its basic assumptions, theoretical framework, methods for analyzing therapeutic interaction, and relative emphasis on past traumas, current functioning, or future outlooks.

Despite the fact that various psychotherapeutic approaches offer patients different forms of emotional relationship with the therapist and types of tasks, there are important non-specific features common to all forms of psychotherapy. Namely:

✵ therapeutic activity takes place within the context of an emotionally charged yet trusting relationship between the psychotherapist and the patient;

✵ There is a theoretical framework adhered to by the psychotherapist and shared, to some extent, by the patient. This framework explains the conditions and approaches for transforming pathology into health;

✵ psychotherapeutic techniques involve providing new information and educating the patient through training, modeling, suggestion, persuasion, and insight.

The basis for differentiating forms of psychotherapy can be the shared goal that individual schools strive to achieve.

Psychodynamic therapy aims to improve long-term adaptation through the conscious awareness of motivations and conflicts.

Supportive therapy is directed toward the immediate alleviation of symptoms, the strengthening of conscious and unconscious defense mechanisms, the provision of emotional support to the patient, and the enhancement of self-confidence.

Behavioral (conditioned-reflex) therapy views symptoms as maladaptive habits reinforced by the environment, and directs the psychotherapist's efforts toward overcoming them.

The experiential approach in psychotherapy aims to eliminate discrepancies between thinking, feelings, and behavior by helping the patient become aware of all aspects of their life experience.

All of the above can be achieved through a range of psychotherapeutic techniques that facilitate abreaction, suppression, verbalization, role-playing, the clarification of conscious experience, or the interpretation of unconscious motivation. The therapist's role may be active or passive, directive or non-directive, rigid or flexible in behavioral style. Although the therapeutic style varies depending on the theoretical model, experienced psychotherapists tend to be significantly more active in therapy, take the initiative faster, resort to interpretation more frequently, and employ diverse techniques. As their experience accumulates and confidence grows, psychotherapists lose their fear of the patient and develop their own unique style of interaction.

Rational psychotherapy (derived from "rational" — reasonably grounded) was proposed in 1912 by the Swiss neurologist P. Dubois. The essence of the method lies in appealing to the patient's consciousness and intellect through logical persuasion. The technique of rational psychotherapy cannot be standardized. Each patient requires an individualized approach that takes into account their personality, situation, etc. The tools of this method are logical persuasion and explanations using evidence and argumentation comprehensible to the patient. Utilizing information gathered during the patient's examination, professional knowledge, and the laws of logical thinking, the physician analyzes errors in the patient's logic, traces The connection between the erroneous understanding of the causes of the illness and its course; explains the mechanisms behind the development of disease symptoms, substantiates The Need for special treatment methods, outlines a treatment plan, and determines its effectiveness. It is important to apply partnership principles, where the doctor and patient jointly evaluate the illness, treatment, and prognosis during a dialogue. This helps enlist the patient as an ally. Through such collaboration, erroneous and unfounded beliefs of the patient can be corrected so that they consciously and actively internalize the rules of logical thinking as personal convictions.

Rational (or discursive, according to I. Z. Velvovsky, 1969) psychotherapy is the most widespread method. Its elements are present in every conversation between a doctor and a patient. It is particularly suitable for patients with a "thinking type", a dominance of the second signaling system over the first, a well-developed intellect, and a capacity for Abstract thought. In psychiatry, the method is effective for somatovegetative disorders of neurotic origin, hypochondriacal states, somatogenic diseases, and in addiction treatment practice.

PSYCHOANALYTIC (PSYCHODYNAMIC) PSYCHOTHERAPY

Psychoanalysis and psychoanalytic (psychodynamic) therapy belong to forms of psychotherapy aimed at bringing about the awareness and transformation of maladaptive personality structures. More effective adjustment is achieved by gaining insight into previously unconscious conflicts, fears, or motivations.

In early historical publications, Josef Breuer and Sigmund Freud described the therapeutic technique of hypnotic catharsis (from the Greek *katharsis* — purification) for bringing repressed feelings and memories of traumatic situations into conscious awareness. Convinced of the instability of improvement following hypnotic catharsis, S. Freud began using the concentration technique: the unhypnotized patient was encouraged to recall events related to their symptoms. This technique, in turn, was replaced by the method of free association, in which the patient must verbalize everything that comes to mind without consciously concealing anything. The latter condition is the fundamental rule of psychoanalytic treatment and leads to the expression of unconscious feelings, impulses, fantasies, and ideas. It has been shown that dream analysis through free associations is an essential tool for accessing unconscious motivations—or, in S. Freud's words, the "royal road to the unconscious."

Despite the desire and attempts to use free association, the patient during therapy encounters obstacles in the associative process. Blocks and hindrances to the expression and awareness of unconscious motivations are termed resistance. A significant portion of the therapist's efforts is directed toward recognizing resistance and utilizing interpretation to help the patient achieve insight into their own symbolic behavior and psychodynamics. The analyst's interpretations may concern the patient's motivations and emotions, point out similarities between seemingly independent situations, enhance awareness of cause-and-effect relationships in their life, and uncover the hidden or symbolic meaning of behavior, emotions, and symptoms. The purpose of interpretations is not to persuade the patient of something, but to assist them in self-discovery. The analogy of the interpretation process to a mirror—in which the patient sees their unconscious motives for the first time—is widely known. What is seen may be frightening, unpleasant, or even distressing. The patient may feel a need to deny what is seen, remaining blind to this reality. Resistance to the development of insight may manifest in such patient reactions as silence, denial, avoidance, forgetting, embarrassment, and intense emotions, including anger toward the therapist.

Therapeutic progress is achieved through careful, tentative interpretations delivered with careful consideration of the patient's readiness to receive them.

The core feature distinguishing psychoanalysis from Other forms of psychotherapy is its exceptional focus on the development, analysis, and resolution of transference phenomena and the transference neurosis.

Transference is defined as a specific unconscious displacement onto the psychotherapist of emotions and relational patterns originating from significant figures in the patient's biography, such as parents or siblings. The patient treats the psychotherapist as if the latter were responsible for the initial arousal of positive, negative, or ambivalent feelings, and expects the therapist to behave just like the significant figures from their early relationships.

By re-experiencing these repressed emotions during psychotherapy, the patient unconsciously displaces feelings and desires originally tied to others onto the psychotherapist. Positive and negative feelings toward the analyst thus symbolically liberate the patient from their prior emotional baggage.

On the other hand, the analyst recognizes that their own behavior toward the patient may likewise stem from inadequate stereotypes and the displacement of unconscious feelings and motives, i.e., countertransference.

The goal of psychoanalytic therapy is to replace unconscious actions with conscious ones. By analyzing transference and resistance, and by offering interpretations, the psychotherapist helps the patient become aware of their own needs and conflicts in order to find real solutions for them.

Disorders are classified according to their accessibility to psychoanalytic therapy as follows: hysteria, compulsive and conversion neuroses, neurotic depression, character disorders, perversions, addictions, impulse neuroses, and psychoses (severe episodes of manic-depressive illness, schizophrenia). Other Factors influencing the outcomes of psychoanalytic therapy include the patient's age, intelligence, educational level, capacity to assume responsibility, ability to communicate, form trusting relationships, and cooperate effectively with the psychotherapist, as well as the skill to experience, recognize, and describe emotions and think in psychological categories.

The disadvantages of psychoanalytic therapy include its high cost, long duration (ranging from 3–4 months for short-term psychoanalytic therapy to 5–6 years for classical psychoanalysis), and a tendency to foster excessive dependence on the psychotherapist.

Psychoanalytic (psychodynamic) therapy has been profoundly influenced by the neo-Freudian analyses of Karen Horney, Erich Fromm, Harry Stack Sullivan, and Eric Berne, with their strong emphasis on the interpersonal and sociocultural dimensions that shape patients' character traits and maladaptive behavioral patterns. Today, most analysts examine the patient-therapist relationship, the patient's environmental adaptation, and the development of impaired socio-psychological patterns. While they still rely on the interpretation of dreams, transference, and resistance, they take a more active therapeutic role, conduct one-on-one sessions, and forgo the traditional psychoanalytic couch. Particular emphasis is placed on the patient-therapist relationship as a vehicle for providing a corrective emotional experience, since the therapist's response to the patient's behavior and expectations differs from the responses of parents and other figures during the patient's developmental years.

In 1941, S. L. Foulkes began using and developing the group method of analytical therapy. W. R. Bion (1961) formulated THE CONCEPT OF group dynamic therapy, according to which

the patient is viewed as the center of interpersonal relationships with other group members, and their unconscious is evaluated through statements made about both themselves and others in the group. In this process, group psychological defense mechanisms are formed (see "Group Psychotherapy").

SHORT-TERM PSYCHODYNAMIC (PSYCHOANALYTIC) THERAPY

Psychoanalytic therapy typically does not define a precise treatment duration, but for certain patients, planning a brief course of therapy aimed at achieving a single well-defined goal is preferable. Patients selected for short-term psychodynamic therapy must possess clear and strong motivation for change. This entails not only the desire to be rid of symptoms but also the patient's acknowledgment of the need for demanding psychological work. During short-term psychodynamic therapy (50-minute sessions), meetings take place individually once a week. On average, a course of dynamic therapy lasts 4 months, though treatment may sometimes be prolonged if the patient's problems are complex and adaptive capacities are low. In any case, the psychotherapist establishes clear time frames for the therapy, thereby encouraging the patient's autonomy, demonstrating trust in their capacity to adapt, and discouraging regressive behavior. By keeping the patient's core conflict in focus throughout the entire course, the psychotherapist prevents deviation and actively encourages problem-solving related to that conflict. The therapist offers frequent transference interpretations and confronts the patient with suppressed emotions and regression.

SUPPORTIVE PSYCHOTHERAPY

Supportive psychotherapy aims to reinforce the patient's psychological defenses and employs techniques that help the patient feel safe. All interventions by the psychotherapist are directed toward supporting the patient and boosting their self-confidence. Specific efforts are made to reduce stress through interventions in the patient's real-life situation, referrals for brief hospitalization, or the prescription of psychotropic medications. The physician uses all available means to encourage the patient to verbalize their consciously experienced problems, anxieties, doubts, fears, impulses, conflicts, and feelings. Such discussions—akin to a cathartic confession followed by absolution—are frequently utilized in relationships with friends and mentors. By analyzing these issues together with the patient, the psychotherapist helps them understand their underlying nature and suggests pathways to resolution.

In many cases, the therapist takes full responsibility for the direction of treatment. This approach presupposes that the psychotherapist understands the patient's problems and needs better than the patient does. Here, the doctor intervenes in the patient's life, insists on hospitalization or medication administration, uses persuasion, suggestion, and personal example. To heighten suggestibility, hypnosis, narcosis, or the administration of neutral substances disguised as highly potent medications (placebo) may be employed. Patients for whom the physician embodies prestige and authority are particularly susceptible to suggestion. Certain forms of directive supportive therapy can be characterized as repressive. They involve authoritarian firmness and commanding behavior from the psychotherapist, the dismissal of symptoms and Complaints, the extensive use of waking and hypnotic suggestion, and placebo therapy. Under this approach, the therapist acts like an omniscient, omnipotent dictator who expects nothing less than blind obedience from others.

Traumatic life situations frequently necessitate crisis interventions. Two psychotherapeutic approaches are possible. If the patient has high motivation to overcome the crisis, adequate adaptive potential, and the capacity for insight, the psychotherapist may utilize a brief form of psychodynamic therapy. The therapist's role involves collaborating with the patient to clarify the psychodynamic factors surrounding the crisis and seeking more mature ways to prevent or cope with potential future crises.

When the patient lacks the inner resources to overcome the crisis in this manner, the psychotherapist adopts a directive working style and assumes full responsibility. In such cases, all forms of supportive therapy are brought into play: suggestive techniques, mitigation of harmful environmental influences, hospitalization, prescription of psychotropic drugs, conscious persuasion, and advice. The frequency and duration of psychotherapy depend on the patient's response to the medical intervention and can range from a few meetings over several weeks to two or three sessions daily for many months. Therapy is concluded once the crisis has been resolved and symptoms have abated.

Behavioral (Behavioristic, Conditioned-Reflex) Therapy

Behavioral psychotherapy is defined as a system that applies learning principles and conditioned reflexes to analyze and treat behavioral disorders. Modern behavioral therapy places greater emphasis on clinical data rather than theoretical, hypothetical neural processes.

The first step in behavioral therapy involves a behavioral analysis, which entails:

1) a precise, objective Description of the behavioral disorders;

2) the identification of relevant external factors preceding those disorders.

The gathered material provides a basis for formulating a hypothesis regarding the variables that control and maintain the patient's altered behavior, thereby enabling the design of a treatment program.

The following forms of behavioral psychotherapy are distinguished:

1) aimed at extinguishing maladaptive behavior and reinforcing desired behavior;

2) methods of systematic desensitization of inadequate reactions through the modeling of a phobic situation;

3) forms in which undesirable behavior is combined with punishment;

4) methods of remotivation (restoration of motivation) by demonstrating the effectiveness of previously inhibited behavior.

Behavioral psychotherapy is aimed at eliminating maladaptive actions, utilizing the absence of reinforcement rather than criticism or punishment for this behavior. Simultaneously with removing factors that reinforce undesirable actions, competitive—i.e., positive—behavior is strengthened. For example, a child's stuttering may intensify as a result of excessive attention from parents who ignored fluent speech. If parents respond favorably to fluent speech while ignoring the stuttering, the latter will disappear.

Conducting psychotherapy involves the consistent application of extinction and positive reinforcement effects. A well-known technique is the "token economy," which can be used to modify The behavior of patients in inpatient psychiatric units.

Conditioned reinforcement (a token) is given to the patient for a specific behavior. Patients can accumulate tokens and exchange them for various rewards or privileges. If a patient's baseline functioning level is low (as in the case of intellectual disability), it is crucial that every correct response is reinforced using a concrete item (e.g., a cookie, a piece of candy). For individuals with a higher level of functioning, presenting a chart with points earned for good behavior is sometimes sufficient.

Systematic desensitization, as a method for overcoming neurotic anxiety and fear reactions, was introduced by J. Wolpe. According to him, the method works through reciprocal inhibition: "...if a response incompatible with anxiety can be made to occur in the presence of an anxiety-evoking stimulus so that it is accompanied by a complete or partial suppression of the anxiety response, the bond between these stimuli and the anxiety will be weakened" (Wolpe J., 1958).

Systematic desensitization is carried out in several stages, namely:

✵ teaching the patient deep muscle relaxation;

✵ compiling a list of anxiety-provoking situations, starting from times when such anxiety did not yet exist, and subsequently moving on to situations associated with the highest level of anxiety;

✵ starting with the least anxiety-provoking situations and progressing to those that provoke the most anxiety, the therapist helps the patient vividly imagine the state causing the anxiety, while simultaneously helping the patient achieve maximum relaxation;

✵ as therapy progresses, the physician advises the patient to actually confront the situations that were the subject of the psychotherapeutic sessions.

Conditioned reflex (aversive) therapy is aimed at treating chronic alcoholism. All variants of this methodology involve combining alcohol consumption with emetics. By "punishing" the intake of alcohol, a motivational conflict is induced between the desire to drink and the fear of extremely unpleasant consequences. On the other hand, with this form of treatment, the desire to consume alcohol is suppressed only temporarily; the patient requires repeated therapy because the conditioned reflex quickly extinguishes without reinforcement.

Attempts are being made to apply conditioned reflex therapy to Sexual deviations. These methodologies involve combining aversive stimuli with deviant behavior while simultaneously providing positive reinforcement for socially approved sexual patterns. Similar techniques are used in the West in attempts to modify the antisocial behavior of criminals. However, the use of such methods encounters public opposition, as individuals have the right to refuse treatment and determine their own destiny.

Psychotherapeutic remotivation techniques are used by psychotherapists of various schools. The best-known approach involves conducting group therapy to stimulate communication and interests in chronically ill patients.

There are varying opinions regarding the efficacy and developmental Prospects of behavioral psychotherapy. It is built on scientific principles, but their application is limited by the complexities of human behavior and interpersonal relationships. On the other hand, knowing behavioral therapy techniques does not mean one should be confined within the framework of this approach alone.

GROUP PSYCHOTHERAPY

Group psychotherapy involves the use of various psychotherapeutic techniques during the treatment of a group of patients. Nearly all psychotherapeutic orientations utilize group-based therapy. Group approaches can be used in inpatient and outpatient settings to treat patients with neuroses, psychoses, and behavioral disorders. Group psychotherapy has gained widespread popularity due to:

a) the desire to include a larger number of patients in psychotherapy;

b) the conviction that better therapeutic effects can be achieved through group interactions;

c) the recognition of the influence of social-dynamic factors on human behavior.

At the same time, group psychotherapy does not replace individual therapy—patients may participate in both forms simultaneously, often with different psychotherapists. Group psychotherapy is particularly effective

for patients who are unsure of their ability to communicate with others, as well as for delinquent and paranoid individuals who are more inclined to trust peers similar to themselves rather than a psychotherapist. The main advantage of the group approach is that the patient can interact with a variety of people. Identification can occur with each of them, and emotions and expectations—which lie at the core of the patient's conflict—can be unconsciously transferred onto each member.

The optimal size for a psychotherapeutic group is 6–12 individuals. A session typically lasts 90 minutes. A group is considered open if its membership changes continually (some patients finish therapy while others begin). The composition of a closed group remains unchanged from the beginning to the end of treatment. Psychotherapeutic groups aimed at personality reconstruction are usually closed, with a limited number of members (from 4 to 12) and relative homogeneity (in terms of age, gender, and type of problems). Meetings are held frequently (up to 3–4 times per week) over a prolonged period. Three developmental phases are distinguished in such groups:

✵ unification through the development of group identity and a sense of belonging;

✵ interactions involving the observation and analysis of group relationship dynamics;

✵ fostering understanding and resolution through heightened self-awareness (insight) and more adaptive behavior.

As with individual psychotherapy, the goals of group therapy can be limited or specifically defined; however, this results in an open group format where therapeutic sessions are held less frequently.

A distinctive form of group therapy proposed by J. Moreno, known as psychodrama, incorporates role-playing, Discussion, and interpretation. In sensitivity groups, patients strive to heighten self-awareness and understand group interaction dynamics. Encounter groups emphasize confrontation as a tool for achieving insight. T-groups (sensitivity training groups, typically intended for beginning psychotherapists) meet to learn more about themselves, interpersonal relationships, group processes, and social systems. Group marathon therapy involves a single, highly extended session (8–72 hours) aimed at fostering trust and the free expression of feelings.

FAMILY PSYCHOTHERAPY

Psychotherapy that encompasses more than one family member during a single session is known as family therapy. It is founded on the premise that the family functions as the structural unit wherein psychological disorders develop, and therefore, therapeutic interventions must be directed toward the family system. For a long time, the concept of family therapy existed exclusively within the framework of child and adolescent psychiatry, where individual psychotherapy was traditionally combined with family support (counseling or therapy involving one or both parents).

Family therapists conduct sessions with multiple family members. Family groups may consist of a married couple, parents and children, or, occasionally, three generations. Although family psychotherapy utilizes certain techniques borrowed from group therapy, it should not be viewed merely as a variant of the latter. Each family constitutes a unique subculture characterized by specific role distributions and a distinct family mythology. In many families, a primary function of the family myth is to deny the existence of conflicts among its members. By observing interactions, the family therapist identifies factors leading to maladaptation in one or more family members, provides interpretations, offers support, employs confrontation, or issues directives. Therapeutic progress in the functioning of a single family member influences the relational dynamics of the entire household, thereby modifying the behavior of every member.

HYPNOTHERAPY

The use of hypnosis alone is rarely regarded as sufficient or adequate psychotherapy. Nevertheless, hypnosis enhances a patient's susceptibility to suggestion (which can be utilized in supportive psychotherapy) and reduces repression (which is desirable during reconstructive psychotherapy). An example of utilizing hypnotic suggestion is the alleviation of disabling neurotic symptoms. Those most susceptible to suggestion include functional tics, paralysis, amnesia, various sensory disturbances, obsessive-compulsive phenomena, sleep disorders, and bad habits.

During reconstructive psychotherapy, hypnosis can be employed to overcome resistance. Occasionally, merely inducing a hypnotic state in a patient is sufficient to bring repressed thoughts into conscious awareness. A range of specialized techniques applied in a trance state—such as free association, dramatization with abreaction, automatic writing and drawing, and controlled regression—can help patients achieve insight. However, not everyone can be hypnotized to the requisite depth. Furthermore, material obtained under hypnosis can sometimes be a fantasy rather than a genuine memory that needs to be integrated into the patient's conscious experience. Some patients perceive hypnosis as magic, which diminishes their motivation for other forms of therapeutic work or is experienced as threatening.

CLIENT-CENTERED THERAPY

This form of non-directive psychotherapy was developed by the American psychologist Carl Rogers, who posited that therapeutic progress requires the therapist to embody three core conditions:

✵ congruence, which entails an authentic awareness of one's own personality and experience;

✵ unconditional positive regard for the patient;

✵ an accurately attuned, empathetic understanding of the patient.

During client-centered therapy, the therapist avoids making diagnoses, expressing categorical judgments, sharing personal opinions, or introducing any element of inequality into the relationship. The therapist's efforts are directed toward helping the patient achieve authenticity in relationships with others and maximum openness to experience. The therapeutic technique includes reflecting the patient's expressed emotions, paraphrasing key statements, and clarifying conscious experience. The therapist avoids techniques that carry even a minimal degree of threat to the patient, such as interpretations, confrontations, or efforts to overcome resistance.

Due to its democratic ethos, client-centered therapy is highly popular and effective in treating mild-to-moderate disorders.

Critics of this therapeutic approach emphasize that maintaining unconditional positive regard toward certain aspects of a patient's behavior may be impossible, and that the meaning of the relationship and therapy must vary significantly depending on whether the patient presents with neurotic, psychotic, or antisocial traits.

COGNITIVE-BEHAVIORAL MODIFICATION

This approach integrates psychodynamic and behavioral psychotherapy and is utilized in the treatment of depressive disorders. The method was developed by the psychoanalyst A. Beck, who believed that the primary cause of emotional disturbances lies in the patient's misinterpretation of themselves and their environment. The central goal of cognitive-behavioral modification is to alter maladaptive thinking patterns. This is achieved by identifying the problem area and implementing Therapeutic Exercises aimed at correcting the thought processes associated with it. The psychotherapy encompasses the following phases:

✵ training the patient to become aware of their own thoughts;

✵ identifying distorted and irrational thinking;

✵ providing feedback and reinforcement to facilitate cognitive restructuring;

✵ replacing irrational, distorted thinking with more objective judgments.

As with many forms of behavioral therapy, patients are assigned homework tasks. Special techniques are employed, notably: drawing up an activity schedule for the patient; cognitive testing with alternative explanations of experiences; mastery and pleasure therapy; and cognitive rehearsal.

GESTALT THERAPY

This psychotherapeutic approach was developed by psychoanalyst F. Perls, who applied the principles of Gestalt psychology to explain human motivation. The core idea of Gestalt therapy is the assertion that somatic and psychological health requires full awareness of physical sensations and emotional needs. Such awareness triggers genetically inherited behavior aimed at satisfying the need and appropriately expressing (releasing) the affect. Once a need is satisfied, other needs and affects take their place in consciousness. Interference with this natural process disrupts the integrity of functioning and threatens the individual's health. Just as the inability to quench thirst leads to dehydration and potential death, the repression of unexpressed emotions causes mental disorders.

Gestalt therapy belongs to the experiential direction in psychotherapy, which emphasizes emotional release (abreast/abreaction). Intellectual understanding of a neurotic conflict is considered unimportant, since only current behavior, not past behavior, can be changed. The Gestalt therapist insists on exploring the situation "here and now," focusing on feelings rather than thoughts. The goal of therapy is to increase awareness of the Physical state and repressed emotional needs by identifying perceptual blocks that blind the patient to their real feelings. Techniques of Gestalt therapy include variations of sensorimotor exercises to increase awareness of physical stimuli, psychological exercises to reduce repression, and procedures to enhance emotional response. An example of the latter is the "empty chair" technique, where the patient is asked to imagine that a significant person is present and to voice thoughts and feelings that were previously avoided or unrecognized. Typical exercises also include a "dialogue" between different aspects of the patient's personality, and role-playing involving people and objects from dreams.

Although Gestalt therapy is sometimes criticized as a set of techniques with inadequately formulated goals, many psychotherapists utilize this method within the framework of other psychotherapeutic approaches.

Psychotherapeutic and sociotherapeutic methods also include music therapy (achieving a specific emotional state through listening to specially selected musical compositions and choral singing), bibliotherapy (reading specially selected fiction to evoke a specific emotional state; mirroring situations from the lives of literary characters also helps patients find solutions, adjust their plans, etc.), play therapy for children, and art therapy (creative artistic activity through which patients can "act out" and process their experiences).

OCCUPATIONAL THERAPY

Occupational therapy is a system of processes ranging from the simplest activities that distract from painful experiences and help pass the time (occupational therapy in the sense of engagement), to acquiring a new profession if required by the illness. Occupational therapy is a crucial method of sociotherapy.

Review Questions

1. General Principles and stages of mental illness therapy.

2. Biological therapy: treatment with psychotropic drugs. Shock therapy.

3. Antipsychotic drugs (neuroleptics): examples, indications for use. Spectrum of psychotropic action, side effects, complications, and management methods.

4. Application of new atypical antipsychotics. What are their advantages? Name specific medications.

5. Antidepressants: Classification and clinical use.

6. Tranquilizers (ataractics): General characteristics of their clinical action. Provide examples of medications and the spectrum of syndromes for their use.

7. Mood stabilizers (normothymics), psychostimulants, and nootropics in the treatment of mental disorders.

8. Electroconvulsive and insulin coma therapy. Indications and procedures. BIOLOGICALLY ACTIVE SUBSTANCES.

9. Definition, concept, goal, and Main methods of psychotherapy, techniques, and indications for use. The concept of "sociotherapy".