Psychiatry - G.T. Sonnyk 2003

Treatment of Mental Disorders

Over recent decades, pharmacotherapy has evolved into one of the primary Methods for treating psychiatric patients, driven by advancements in medicinal chemistry and the Introduction of a wide range of psychopharmacological agents. However, pharmacotherapy is merely one component of a clinically grounded, comprehensive approach to modern therapeutic intervention, alongside psychotherapy, Insulin coma therapy, electroconvulsive therapy, pynotherapy, and general strengthening treatments.

When treating a psychiatric patient, it is essential to consider the Specific features of their psychopathology and the course of the illness, premorbid constitutional-personal typologies, the patient's physiological profile, as well as the pharmacokinetic and pharmacodynamic Properties of the medications. A key characteristic of active psychiatric Treatment is its prolonged, course-based, and multidisciplinary nature, comprising multiple stages with tailored methods and approaches.

Psychopharmacotherapy

NEUROLEPTIC AGENTS.

Neuroleptics (major tranquilizers) hold a significant place in the treatment of mental disorders. The era of psychopharmacotherapy began in 1952 with agents from this group, when the therapeutic efficacy of chlorpromazine (largactil/aminazine) was first described. Neuroleptics encompass compounds structurally belonging to various chemical groups, which forms The basis of their Classification. They are broadly divided into predominantly sedative agents and those with primarily antipsychotic effects.

Phenothiazine derivatives.

1) Aliphatic derivatives — chlorpromazine (aminazine), levomepromazine (tezercine), propazine, alimemazine.

These agents exhibit sedative properties, inducing motor retardation and bradypsychia. They are indicated for Various Forms of psychomotor agitation accompanied by anxiety, fear, bewilderment, and insomnia. Compounds such as alimemazine and propazine are utilized as mild neuroleptics in cases of neuroses, neurosis-like states, pediatrics, gerontology, and somatic medicine.

Aminazine is available in coated tablets (25, 50, 100 mg) and as a 2.5% solution in 2 ml ampoules. The average daily dose ranges from 300 to 500 mg. Potential side effects include allergic reactions, depression, and syncopal (collapse-like) states.

Tezercine is prescribed in an average daily dose of 100-300 mg in tablets, administered intramuscularly as 1-6 ml of a 2.5% solution, or intravenously as 1-3 ml of a 2.5% solution diluted in 10-20 ml of 40% glucose. It may provoke hypotensive crises.

2) Piperazine derivatives — acetophenazine, butaperazine, imiclopazine, metofenazat, perazine, trifluoperazine (triftazine), thiopropazate/thioproperazine (majeptil), fluphenazine (moditen).

These are employed in the management of hallucinatory-delusional symptomatology and depression within major syndromes. In low doses, they exhibit a stimulating effect and are used for apico-abulic and catatonic syndromes.

The average daily dose of triftazine is 40-60 mg. It possesses pronounced antipsychotic activity and frequently induces extrapyramidal symptoms—such as rigidity and muscular tremor—necessitating pharmacocorrection with cyclodol, parkopan, or similar agents during treatment.

Majeptil is used to manage catatonic-hebephrenic symptoms and psychotic disorders resistant to other medications. It is available in 10 mg tablets and ampoules, with an average daily therapeutic dose of 30-50 mg. Irrational use of majeptil can lead to severe neuroleptic malignant syndrome (manifesting as spasms of the Tongue, neck, and facial Muscles, etc.).

In addition to its antipsychotic effects, moditen helps normalize behavior. The average daily therapeutic dose is 15-20 mg, though prolonged-release formulations (moditen depot, liogen retard) are more commonly utilized. Long-term administration may cause extrapyramidal disorders and hypotension.

3) Piperidine derivatives — mesoridazine, pecazine, perimetazine, pipamperone, piperacetazine, thioridazine (sonapax).

These agents exert a mild sedative effect, regulate mood and behavioral disturbances, and are used within the context of neurosis-like and psychopath-like syndromes.

Sonapax is prescribed for anxiety, obsessive-compulsive states, phobias, and hypochondriacal disorders. Even with prolonged use, it does not induce tolerance or physical dependence. The average daily dose is 100-300 mg per os.

Butyrophenone derivatives.

This group includes benperidol, haloperidol, droperidol, moperone, fluanisone, and trifluperidol (trisedyl).

They exhibit strong antipsychotic properties and effectively suppress psychomotor agitation, verbal hallucinosis, and all types of Delusional syndromes.

Haloperidol is administered at an average daily therapeutic dose of 15-30 mg. It is available in 1 ml ampoules of a 0.5% solution, in 0.5, 1.5, 3, and 5 mg tablets, and as drops (10 ml of a 0.2% solution). A depot formulation, haloperidol decanoate, is also used (1 ml containing 50 mg of the active substance). It may cause neuroleptic syndrome and is contraindicated in organic Brain lesions.

Trisedyl is indicated for persistent verbal hallucinosis. The average daily therapeutic dose is 5-15 mg. It is available in 0.5 mg tablets, 1 ml ampoules of a 0.25% solution, and 10 ml vials of a 0.1% solution.

Thioxanthene derivatives.

This Class comprises zuclopenthixol, thiothixene, and chlorprothixene (truxal).

In their MECHANISM OF ACTION, they are similar to aliphatic phenothiazine derivatives, exhibiting sedative and general antipsychotic effects.

Truxal is used in an average daily dose of 90–300 mg. It also possesses antidepressant activity. It does not cause drowsiness, which allows it to be prescribed during the day in outpatient treatment. It may induce hypotension.

Benzodiazepine derivatives.

Azaleptin (clozapine) is used as a potent neuroleptic for hallucinatory-paranoid and affective-paranoid disorders, as well as various forms of psychomotor agitation. It has virtually no effect on the extrapyramidal system and does not cause general depression, but requires monitoring for the risk of agranulocytosis. The average daily dose is 300–600 mg. It is available in 25 and 100 mg tablets, and 2 ml ampoules of a 2.5% solution.

Olanzapine (Zyprexa) is an atypical antipsychotic that effectively targets both positive (agitation, hallucinations, delusions) and negative (blunted affect, poverty of speech, emotional withdrawal) psychopathological symptoms. It rarely leads to pharmacotherapeutic complications. The optimal daily dose is 10 mg taken once daily. It is available in 5 and 10 mg tablets.

Phenothiazine and benzodiazepine derivatives—such as dikarbin, sulpiride (Eglonyl), clotepine, and momendone—are used in psychiatric practice for hallucinatory-paranoid disorders and depressive states within The Structure of a major syndrome.

Eglonyl is prescribed at 100–200 mg for neurotic disorders and at 200–1600 mg per day for psychotic disorders. It is available as 200 mg tablets, 50 mg capsules, 2 ml ampoules of a 0.5% solution, and 200 ml vials of a 0.5% solution.

Given the diversity and large number of neuroleptic drugs, as well as differences in their psychotropic activity profiles, their general psychotropic properties can be represented in the following series to facilitate navigation when initially selecting drugs for pharmacotherapy.

In order of increasing general antipsychotic potency:

neuleptil - thioridazine - propazine - levomepromazine - chlorprothixene - chlorpromazine - frenolone - perphenazine - meterazine - trifluoperazine - haloperidol - fluphenazine - trifluoperazine - thioproperazine.

In order of increasing calming and sedative effect:

thioridazine - neuleptil - propazine - chlorprothixene - chlorpromazine - levomepromazine.

In order of increasing activating and stimulating component in psychomotor retardation:

thioridazine - carbidine - frenolone - perphenazine - trifluoperazine - haloperidol - fluphenazine - metarazine - trifluperidol - thioproperazine.

In order of increasing selective antipsychotic efficacy against hallucinatory-paranoid disorders:

propazine - chlorpromazine - perphenazine - trifluoperazine - haloperidol - trifluperidol.

Long-acting neuroleptic agents.

Long-acting neuroleptics (depot or retard formulations) exhibit pronounced antipsychotic activity and significantly facilitate the Organization of inpatient and outpatient treatment.

Long-acting therapy can be administered over extended periods, thereby freeing patients from the daily intake of medications. An important advantage of these drugs is The ability to achieve a relatively constant concentration of the neuroleptic in the Blood, ensuring a steady pharmacological effect on the psychopathological syndrome.

The most common neuroleptics whose prolonged action is due to slowed Hydrolysis in the body into carboxylic acid (enanthic, decanoic, palmitic, and undecylenic) and the active substance include fluphenazine decanoate, pipotiazine, and trilafon depot.

In addition, neuroleptics whose prolonged action is due to slowed METABOLISM in the Body (penfluridol, pimozide) are used, as well as those with delayed absorption due to the creation of a microcrystalline depot (fluspirilene) or special formulation of tablets or capsules (Melleril Retard).

Depending on the manufacturing method of the dosage form, administration route, and dosage, the duration of the drugs' action ranges from 24 hours to 4 weeks.

These drugs are used in continuous and episodic-progredient forms of Schizophrenia. Furthermore, long-acting neuroleptics are successfully employed for maintenance therapy in outpatient settings, which has additional psychotherapeutic value as patients do not develop a sense of dependency on medications.

TRANQUILIZERS.

Tranquilizers (anxiolytics), unlike neuroleptics, lack antipsychotic properties and are grouped based on their ability to eliminate or alleviate fear, obsessions, tension, affective instability, anxiety, and other neurotic symptoms, regulate autonomic and visceral functional disorders, and induce an adequate response in patients to familiar stimuli that previously seemed overwhelming. They do not possess a direct hypnotic effect, which distinguishes them from conventional hypnotics and sedatives. In therapeutic doses, they typically do not cause the extrapyramidal and other neurological side effects characteristic of most neuroleptics. Moreover, the combined use of tranquilizers and neuroleptics alleviates undesirable neuro-vegetative adverse effects induced by the latter and enhances their therapeutic efficacy.

The tranquilizing effect of these drugs manifests not only in patients with psychopathological disorders, but also in practically healthy individuals. Therefore, The Use of tranquilizers has become widespread in general medical practice as well.

Tranquilizers are used for neurotic, neurosis-like, and psychopathy-like disorders, as well as non-psychotic psychopathological conditions dominated by asthenic, astheno-depressive, and astheno-hypochondriacal symptoms of neuro-somatic origin. They are also prescribed for mental illnesses accompanied by obsessive-compulsive phenomena, phobias, anxiety, and fear characteristic of borderline states and alcoholism, as well as for treating neurosis-like conditions in patients with organic CNS damage and diencephalic pathology, and in Epilepsy patients in combination with anticonvulsants.

Some medications exhibit a predominantly sedative effect coupled with inhibition, while in others this is combined with a stimulating effect.

Tranquilizers with a predominantly sedative effect.

Phenazepam is the most potent tranquilizer in terms of its tranquilizing efficacy. It reduces agitation and feelings of fear even in the face of real danger, though it causes lethargy, drowsiness, and slowed reactions. It is used for psychotic anxiety, obsessions, and hypochondriacal syndrome. For neurosis-like and neurotic disorders, it is prescribed at an average daily dose of 3–5 mg. To relieve agitation and anxiety, and to normalize autonomic Functions in alcohol and substance withdrawal, it is used in doses up to 10 mg per day. It is available in 0.5 and 1 mg tablets.

Elenium (librium, chlordiazepoxide) possesses a broad spectrum of activity. It is used for all variants of mental disorders accompanied by hyperexcitability and autonomic disturbances. The prescribed dosage is 20–80 mg per day. It is available in tablets, coated tablets, and capsules of 5, 10, and 25 mg.

Oxazepam (nozepam, tazepam, praxiten), owing to a minimum of side effects, is widely used in pediatrics and gerontology. It is available in 10, 15, 25, 30, and 50 mg tablets. The average daily dose is 40–80 mg.

Nitrazepam (radedorm) exhibits pronounced hypnotic and anticonvulsant effects. It is prescribed as a hypnotic at 5–10 mg taken 25–40 minutes before bedtime, as well as in pediatric practice at 2.5–5 mg for the complex treatment of epilepsy.

Meprobamate (meprotan, restenil) is available in 200 mg tablets, with an average daily dose of 600–1200 mg.

Tranquilizers with a predominantly stimulating effect.

Diazepam (sibason, seduxen, relanium, valium) is administered intravenously to manage acute anxiety, dysphoria, and seizure episodes, and to relieve drug withdrawal symptoms. Orally, it is used for obsessive states, non-psychotic depression, and neurotic anxiety. It is prescribed in doses ranging from 15 to 60 mg per day. It is available in the form of 2, 5, and 10 mg tablets, capsules, and coated tablets, as well as 2 ml ampoules of a 0.5% solution. Prolonged use leads to tolerance and dependence.

Medazepam (rudotel, mesapam) has a mild stimulating effect and does not cause drowsiness, making it widely used for daytime administration. The average daily dose is 15–40 mg. It is available in 5 and 10 mg tablets, capsules, and coated tablets.

Trimethozine (trioxazine) effectively relieves fear, anxiety, and affective instability in neurotic and neurosis-like states while simultaneously increasing activity and improving mood. It is prescribed at 1200–1800 mg per day. It is available in 300 mg tablets and capsules.

Tofisopam (grandaxin) is prescribed at 50 to 300 mg per day. It is available in 50 mg tablets.

ANTIDEPRESSANTS.

This is a group of drugs characterized by their ability to exert a thymoleptic effect—that is, to elevate pathologically depressed mood—along with an additional stimulating or sedative influence.

According to their chemical structure and mechanism of action, antidepressants are divided into several groups:

1) Tricyclic and tetracyclic antidepressants—amitriptyline, butriptyline, desipramine, imipramine, protriptyline, maprotiline, etc. Their mechanism of action consists in 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 dopaminergic, serotonergic, and noradrenergic structures of the brain. They exhibit a pronounced anticholinergic effect.

2) Monoamine oxidase (MAO) inhibitors—nialamide, benmoxin, isocarboxazid, tranylcypromine, indopan, etc. The Mechanism of action involves inhibiting The activity of monoamine oxidase Enzymes, thereby increasing the content and activity of neuromonoamines that regulate various processes in the Central Nervous system.

3) Selective serotonin reuptake inhibitors (SSRIs)—fluoxetine, fluvoxamine, citalopram, tianeptine (coaxil), sertraline, paroxetine, etc. They stimulate serotonergic transmission in the CNS, the deficiency of which is given considerable attention in the NEUROCHEMICAL MECHANISMS OF the Pathogenesis of depression. It is recommended to use drugs of this group after a course of therapy with heterocyclic antidepressants or MAO inhibitors.

The capacity to influence varying depths of depressive states underlies the conventional division of antidepressants into "major" and "minor". Major antidepressants, which are capable of affecting severe depressive states—most frequently as part of endogenous psychopathology—include amitriptyline, imipramine, butriptyline, citalopram, sertraline, etc. Minor antidepressants, such as azafen, benmoxin, tranylcypromine, coaxil, etc., are more effective in neurotic depressions, depressive states associated with vascular brain damage, and somatogenic depressions.

According to the additional influence they exert, antidepressants are divided into 3 groups.

1. Antidepressants with an additional stimulating effect.

Imipramine (melipramine, imizin, tofranil) belongs to tricyclic "major" antidepressants. It has a pronounced antidepressant effect, primarily acting on endogenous (vital) depression. It also possesses a clearly defined stimulating effect. It is prescribed for severe depressions accompanied by a sense of boundless anguish and oppression. The average daily therapeutic dose is 15–250 mg. It is available in 10, 25, and 50 mg tablets and coated tablets, and 2 ml ampoules of a 1.25% solution. Side effects include autonomic disorders that subside as treatment continues (dry mucous membranes, limb tremor, hyperhidrosis), headache, and urinary retention. An intensification of anxiety and productive symptoms (hallucinations, delusions) is possible. It is not prescribed at night to prevent The Development of insomnia. It is contraindicated in acute renal and hepatic pathology, decompensated Heart defects, blood disorders, stage III Hypertension, glaucoma, Pregnancy, and Lactation.

Maprotiline (Ludiomil), a tetracyclic "major" antidepressant, is primarily used for moderate depressions accompanied by adynamia, obsessive thoughts, and hypochondriacal disorders. It is prescribed at a mean daily dose of 100-200 mg. It is available in 10, 25, 50, and 75 mg tablets and sugar-coated pills, as well as in 2 ml ampoules of a 1.25% solution.

Fluoxetine (Adofen, Fludac, Prozac, Fontex) is a selective serotonin reuptake inhibitor. It helps elevate mood, relieves dysphoric symptoms, and alleviates feelings of anxiety. It is indicated for endogenous and neurotic depressions, bulimia nervosa, and obsessive-compulsive disorders. The mean daily dose ranges from 40 to 60 mg. It is available in 10 and 20 mg capsules.

Nialamide (Espril, Niamide, Nuredal) belongs to MAO inhibitors and "major" antidepressants. It is primarily effective for mild endogenous depressions characterized by psychomotor retardation and lethargy. The prescribed dosage is 200-350 mg per day. It should be taken in the first half of the day to prevent insomnia. It is available in 25 and 100 mg tablets. Concomitant intake with tyramine-rich foods (such as beans, cheese, and beer) may cause hepatotoxic effects.

Tranylcypromine (Parnate, Transamine), an MAO inhibitor, is classified as a "minor" antidepressant. It exhibits weak antidepressant and pronounced stimulating properties. It is used to treat mild, non-psychotic depressions with psychomotor retardation. The mean therapeutic daily dose is 30-40 mg. It is available in 5 and 10 mg tablets.

Benmoxin (Neuralex), an MAO inhibitor and "minor" antidepressant, is prescribed for depressions of neurotic origin and depressive states associated with cerebrovascular diseases. The average therapeutic dose is 50-75 mg. It is supplied in 25 mg tablets.

Indopan belongs to MAO inhibitors and "minor" antidepressants. It is most effective in asthenodepressive and asthenohypochondriacal conditions. Combined with low doses of neuroleptics, it is used to treat schizophrenia accompanied by apathy, abulia, and depressive symptoms. The prescribed dose is 20-40 mg daily. It is available in 5 and 10 mg tablets.

2. Antidepressants with additional sedative action.

Amitriptyline (Saroten, Tryptizol) belongs to the group of "major" antidepressants and has a tricyclic structure. In addition to alleviating depressive symptoms, it reduces anxiety and agitation. It is prescribed for anxious psychotic depressions of various etiologies. The optimal therapeutic dose is 150-200 mg daily, and up to 300 mg daily or more in severe depressions. It is available in 10, 25, and 50 mg tablets and sugar-coated pills, 25, 50, and 75 mg capsules, and 2 ml ampoules of 1% and 2.5% solutions. The administration of the drug does not exacerbate psychotic symptoms. Due to its sedative effect, it can be administered at bedtime. Side effects and contraindications are similar to those of imipramine.

Trimipramine (Sapilent, Surmontil, Stangyl, Herphonal) is a tricyclic antidepressant and a broad-spectrum thymoleptic agent. It is most effective for moderate anxious depressions, as well as neurotic, hypochondriacal, and reactive depressions. The mean daily dose is 150-300 mg. It is supplied in 25 and 100 mg tablets and sugar-coated pills, and 2 ml ampoules of a 1.25% solution.

Opipramol (Deprenyl, Insidon, Oprimol) has a tricyclic structure and exerts moderate antidepressant and sedative effects. It relieves anxiety and tension, exerts a regulatory effect on autonomic dysfunctions, and has antiemetic properties. It is prescribed for depressive syndromes of various origins with an anxiety component, as well as for psychosomatic and functional disorders. The mean therapeutic daily dose is 100-150 mg; it is available in 50 mg sugar-coated pills.

Azafen (Disafen), a "minor" antidepressant with a tricyclic structure, is prescribed for depressions without deep psychotic disorders, accompanied by asthenic neurosis-like symptoms. The average daily dose is 150-200 mg. It is available in 25 mg tablets and 2 ml ampoules of a 1.25% solution. It lacks anticholinergic activity and has mild side effects, making it suitable for general somatic and gerontological practice.

Cipramil (citalopram), a selective serotonin reuptake inhibitor, exhibits pronounced antidepressant and sedative effects that manifest quite rapidly. It has minimal anticholinergic and other side effects, does not potentiate the effects of alcohol, and is non-toxic. It can be used for long-term Prevention of depression relapses. The prescribed dose is 20-60 mg daily. It is available in 20 and 40 mg tablets.

3. Antidepressants without a unilateral additional effect.

Pyrazidol (pirlindole) belongs to "major" tetracyclic antidepressants. It exerts a "balancing" effect on various types of depressions: it shows sedative properties in anxious depressions and a stimulating effect in psychomotor retardation. It is prescribed for various depressive states, for alleviating depressive symptoms during withdrawal syndrome, and as part of complex therapy for cognitive impairments in senile psychoses. The mean daily dose is 150-200 mg. It is available in 25 and 50 mg tablets.

Zoloft, a selective serotonin reuptake inhibitor, is prescribed for the treatment and prevention of depression, obsessive-compulsive, panic, and post-traumatic stress disorders. The average therapeutic dose ranges from 50 to 150 mg. It is supplied in 50 and 100 mg tablets.

Fluvoxamine (Avoxin, Floxyfral, Dumirox) belongs to the group of selective serotonin reuptake inhibitors. It is used for Affective Disorders accompanied by persistent depressed mood, psychomotor disturbances, and psychosomatic symptoms.

The mean daily dose is 100-200 mg. It is available in 50 and 100 mg tablets.

Tricyclic antidepressants and some selective serotonin reuptake inhibitors are incompatible with MAO inhibitors. If MAO inhibitors are to be replaced by antidepressants from the aforementioned groups, severe complications may develop; therefore, it is recommended to wait at least 2 weeks after discontinuing MAO therapy before starting antidepressants of other groups.

MOOD STABILIZERS.

They are used to relieve manic and hypomanic states in patients with affective disorders and recurrent schizophrenia. Along with antidepressants, they are effective in treating mild to moderate depressive states. They are also used in epilepsy, psychopathy with mood fluctuations, and for the treatment of chronic alcoholism.

Regular intake prevents the recurrence of episodes (phases) in endogenous affective disorders. Lithium salt therapy over a period of 2-3 years leads to a shortening of episodes, making them milder and attenuated, and in favorable cases, they disappear completely.

In some patients, There is a reduction in the severity of affective disorders and an increase in therapeutic sensitivity, which allows episodes to be treated much faster and with lower doses of other psychotropic medications.

The concentration of the drug in Blood Plasma should not be lower than 0.6-0.8 mmol/L and higher than 1.2 mmol/L. At lower concentrations, the therapeutic and prophylactic effects are not manifested, while higher concentrations may cause lithium intoxication. Early side effects include gastrointestinal disorders, frequent urination, and thirst, whereas late side effects comprise progressive extremity tremor, Muscle twitching, hyperkinesia, dysarthria, Cardiac Arrhythmias, endocrine disorders, and diarrhea. If signs of lithium intoxication appear, the drug must be discontinued, and sodium chloride and fluid intake should be increased.

Lithium carbonate is most commonly used. For the treatment of affective states, 900 to 3000 mg per day is prescribed, while for prophylactic purposes, the dose is 900-1200 mg per day. It is available in 300 mg tablets.

A prolonged-release form, Mikalit (lithium retard), is also used. It is available in 400 mg ampoules.

Lithium oxybutyrate, which exhibits lower toxicity, is used for intravenous and intramuscular administration. It is available in 2 ml ampoules of a 20% solution.

PSYCHOTROPIC THERAPY CORRECTORS.

Psychotropic agents possess anticholinergic, hypotensive, and cataleptogenic properties, along with the ability to block adrenergic structures. Consequently, alongside the desired psychotropic effect, a range of pathological conditions induced by these drug properties—namely, side effects—may occur. Although their severity largely depends on individual bodily sensitivity and numerous other factors, they are direct consequences of drug action and typically resolve upon dose reduction or discontinuation. Side effects can be conditionally divided into 3 groups: neurological disorders (paroxysmal: acute, subacute, protracted, and chronic extrapyramidal syndromes), psychiatric disorders (transient exacerbations of psychopathology, affective inversion, neuroleptic depression, Sleep disturbances, and stuporous states), and vegetative disorders (hypotension, tachycardia, hyperhidrosis, seborrhea, accommodation disorders, mucosal dryness, as well as gastrointestinal motility and secretion disorders).

More frequently, these side effects manifest as complex symptomatology.

To mitigate adverse effects, A wide variety of pharmacological agents known as correctors are utilized. Depending on their chemical structure and clinical properties, they are classified as follows:

Propanol derivatives — trihexyphenidyl (parkopan, cyclodol), biperiden, cycrimine, pridinol. They possess a broad spectrum of activity with predominant antiparkinsonian and central anticholinergic efficacy.

Simple amino ethers — mebedrol, diphenhydramine, cogentin, rigidyl. They exhibit moderately pronounced antiparkinsonian action, central anticholinergic and antihistamine activity, as well as sleep-regulating properties.

Complex amino ethers — amizyl, metamizyl, pentaphen, spasmolytin, arpenal. Alongside a moderate antiparkinsonian effect, tranquilizing, ganglion-blocking, and spasmolytic actions are observed.

Phenothiazine derivatives — dinezine, diprasine, parsidol. They exhibit neuroleptic properties and, in combination with other drugs, are used to manage various adverse disorders.

Thioxanthene derivatives, glutaric acid derivatives, and central relaxants are used less frequently.

PSYCHOSTIMULANTS.

They stimulate the central nervous system, which manifests as the alleviation of mental and physical fatigue; however, they lack antipsychotic and antidepressant effects.

Similar to tranquilizers, psychostimulants influence mental processes even in healthy individuals. They stimulate intellectual activity and accelerate thought processes. The foundation of their psychostimulating action is the enhancement of synaptic transmission through the mobilization of neurotransmitters. Euphoria may occur, accompanied by increased activity, temporary relief from fatigue and drowsiness, and enhanced performance. They can cause sleep initiation disorders ranging from insomnia to appetite disturbances. Prolonged use leads to tolerance and psychological dependence. Certain central nervous system stimulants (amphetamine, methamphetamine, pervitin) are classified as narcotic substances.

They are prescribed for neurosis-like and neurotic disorders accompanied by asthenic, psychasthenic, and neurasthenic states, lethargy, inhibition, apathy, adynamia, and decreased performance, as well as for the treatment of stuporous, substuporous, and apathico-abulic states in schizophrenia patients. For healthy individuals, they are prescribed in extreme situations associated with mental or physical overexertion.

Caffeine is prescribed at 50-100 mg 2-3 times daily. It is contraindicated in cases of insomnia, hypertension, atherosclerosis, organic cardiovascular lesions, and glaucoma.

Sydnocarb produces a sensation of vigor and an influx of energy, and enhances performance. It is prescribed at 5-20 mg 1-2 times daily and is available in 5 and 10 mg tablets.

Sydnophen exhibits a less pronounced stimulating effect compared to sydnocarb. It is prescribed at 20-30 mg daily and is available in 5 mg tablets.

NOOTROPICS.

These agents normalize tissue metabolism processes within the central nervous system and exhibit antihypoxic action. Consequently, higher mental functions are activated, mental tone is enhanced, consciousness is cleared, and thinking and speech are improved. Nootropics possess tranquilizing, antidepressant, vegetative-stabilizing, antiepileptic, antiparkinsonian, and antidyskinetic effects.

Owing to their broad spectrum of action and absence of prominent side effects, these drugs are widely used in the therapy of asthenic states of diverse genesis, decreased overall activity, and memory impairments of vascular, traumatic, and infectious origin; post-stroke states, comas of various etiologies, intoxications, dementia, and autonomic dysfunctions.

In combination with antidepressants and tranquilizers, they are used for astheno-depressive, astheno-apathy, and depressive states, as well as for alcohol and Other types of withdrawal syndromes and alcoholic psychoses.

In geriatric psychiatry, they are used to treat various cerebroasthenic and encephalopathic disorders, memory impairments, intellectual deficits with diminished drive, and various forms of dementia.

In pediatric psychiatry, they are utilized for the treatment of acute and residual manifestations of central nervous system organic lesions, as well as in the complex therapy of oligophrenia.

Additionally, these agents are prescribed as correctors in neuroleptic therapy.

Piracetam (nootropil), a cyclic derivative of gamma-aminobutyric acid, is prescribed in doses ranging from 800 to 3000 mg daily. It is available as 400 mg capsules, 200 mg tablets, and 5 ml ampoules of a 5% solution.

Aminalon (gamalon, myelogen) is prescribed at 500–1500 mg daily. It is available in 250 mg tablets and 20 ml ampoules of a 5% solution.

Encephabol (pyrithinol, encephal, pleum) is distinguished by its pronounced stimulating and antidepressant effects. The average daily therapeutic dose ranges from 300 to 600 mg. It is produced in 100 mg and 20 mg tablets.

To normalize cerebral blood flow and neurometabolic processes, clinicians also use so-called cerebral Circulation correctors, such as cavinton, cinnarizine, nimotop, sermion, trental, vincapan, memoryplus, and others.

ANTICONVULSANTS.

These agents are used for the relief and prevention of convulsive seizures and epileptic psychiatric equivalents. Some medications have a selective anticonvulsant effect without significantly impacting the emotional sphere. Other drugs are also employed for affective disorders. Certain barbiturates are classified among antiepileptic agents as well, since they exhibit a selective antiparoxysmal action without a pronounced hypnotic effect.

Carbamazepine (finlepsin, carbapin, amizepin) is a broad-spectrum antiepileptic drug. It is prescribed for partial epileptic seizures with simple and complex symptomatology, grand mal seizures, mixed forms of epilepsy, non-epileptic seizures in multiple sclerosis patients, tonic convulsions, paroxysmal dysarthria, ataxia, pain attacks in diabetic neuropathy patients, anxiety-depressive states, catatonic excitement, and for seizure prevention in alcohol withdrawal syndrome. The average therapeutic dose is 400–1000 mg per day. It is available in 200 mg and 400 mg sustained-release tablets.

Phenytoin (diphenylin, difantoin, dilantin) is used for major seizures involving tonic convulsions. It is also effective in vegetative-vascular, psychomotor, and psychiatric paroxysms, though ineffective for absence seizures. It is prescribed in doses ranging from 200 to 450 mg daily, most often in combination with other medications. It is produced in 100 mg tablets and dragees, 30, 90, and 100 mg capsules, and 2 and 5 ml ampoules of a 5% solution.

Phenobarbital (luminal, lepynal) in small doses produces sedative and spasmolytic effects. The daily dose ranges from 20 to 500 mg. Available forms include 15, 30, 50, 60, 100, and 300 mg tablets, 60 and 90 mg capsules, and 1 mg ampoules of 4%, 20%, and 30% solutions.

Benzobarbital (benzonal) is prescribed for generalized, focal convulsive, Jacksonian, and adversive seizures, Kozhevnikov's epilepsy, as well as psychomotor and psychiatric paroxysms. The average daily dose is 400–800 mg. It is available in 50 mg and 100 mg tablets.

Primidone (hexamidine, lespiral, sertan) is used to treat major epileptic seizures, predominantly those featuring clonic convulsions. The average therapeutic dose is 1000–2000 mg per day. It is manufactured in 125 mg and 250 mg tablets.

Sodium valproate (depakine, ergenyl, convulex) is effective for generalized and focal epilepsy with absences, myoclonic, tonic-clonic, atonic, and mixed seizures, simple and complex West and Lennox syndromes, convulsive syndrome in organic brain lesions, epileptoid behavioral disorders, and febrile seizures in children. The average daily dose is 900–1800 mg. It is produced in 200 mg and 300 mg tablets and dragees.

Clonazepam (clonopin, rivotril) is prescribed for the treatment of minor seizures and polymorphic non-convulsive paroxysms (motor and psychomotor seizures, sensory, vegetative, and psychiatric paroxysms). The dosage is 4–8 mg per day. It is available as 0.5, 1, and 2 mg tablets and 1 ml ampoules of a 0.1% solution.

The use of anticonvulsants may cause a range of undesirable side effects and complications: gingival hyperplasia, stomatitis, dermatitis, leukocytosis, anemia, dyspeptic disorders, Liver and Kidney damage, drowsiness, dizziness, headache, nystagmus, diplopia, dysarthria, ataxia, finger tremor, etc.

If pronounced side effects or complications occur, the medication dosage should be reduced or the drug discontinued in favor of another antiepileptic agent.

Antiepileptic drugs are contraindicated in severe hepatic, renal, and hematopoietic system disorders. They should be prescribed with extreme caution during pregnancy.

Shock THERAPY

Prior to the advent of psychotropic medications, shock therapy was the primary treatment for psychoses. THE PRINCIPLE OF this therapy involves inducing a generalized electrical discharge that encompasses the entire central nervous system, with the biochemical changes occurring within it remaining independent of the method used to trigger the discharge. It was observed that patients suffering from both a psychotic disorder and epilepsy sometimes experienced temporary relief from emotional and cognitive disorders following epileptic convulsive seizures. Consequently, it was argued that artificially inducing a generalized discharge similar to that seen in epilepsy could be used as a treatment. The mechanism of action of shock therapy is not fully understood, but A number of hypotheses exist regarding this issue. For instance, in 1977, Modigh demonstrated that the primary effect is driven by the seizure's impact on the Brainstem, resulting in accelerated neurotransmitter release and increased sensitivity of neuraminic receptors. Today, the use of shock therapy is quite limited due to The Emergence of more effective and safer treatments. It is administered with the mandatory written consent of the patient or their legal representatives.

Insulin coma therapy has been used since 1933. Individually tailored doses of insulin are administered subcutaneously to a fasting patient, inducing hypoglycemic coma or a subcomatose state, which is terminated after 20 minutes by the intravenous administration of a 40% glucose solution. The course duration is 10–30 days. It is utilized to interrupt acute and subacute conditions of a schizoaffective structure, as well as to overcome resistance to psychopharmacotherapy. Contraindications include most somatic diseases, organic neurological symptoms, endocrine disorders, pregnancy, and age over 50. Potential complications include convulsive seizures, collapse-like states, cardiac arrhythmias, and recurrent hypoglycemia, particularly at night. A severe complication is prolonged coma that does not resolve with glucose administration, requiring immediate resuscitation measures.

Electroconvulsive therapy (ECT) was introduced into psychiatric practice by Italian scientists U. Cerletti and L. Bini in 1938. Premedication is mandatory prior to an ECT session, consisting of the administration of muscle relaxants and intravenous anesthetics or tranquilizers. As a result, the patient feels virtually nothing during the Procedure, which in no way diminishes its therapeutic efficacy. During an ECT session, electrodes are placed either bilaterally (on both of the patient's temples) or with one electrode in the center of the forehead and the other on the temple corresponding to the non-dominant cerebral hemisphere, as the latter method has been shown to reduce post-ECT confusion time. An electric current of 70–120 V is passed through the electrodes for 0.5–0.9 seconds. A total of 3–5 sessions are typically prescribed per treatment course.

ECT is most effective for severe endogenous affective disorders that are resistant to pharmacotherapy. It is also used for simple and paranoid schizophrenia, particularly in early-onset cases, and for treating catatonic stupor.

ECT complications are most frequently associated with Musculoskeletal System injuries resulting from improper premedication. Prolonged apnea and cardiac arrhythmias occasionally occur. Contraindications for ECT are similar to those for insulin coma therapy.

PSYCHOTHERAPY

This is a system of direct therapeutic intervention in a patient's psyche through speech, non-verbal stimuli, environment, specific types of activity, etc. Sociotherapy, as a subset of psychotherapy, utilizes various social factors: the Influence of the social environment on the patient, and various forms of social or collective activity.

Psychotherapy is used in nearly all psychiatric conditions, but it plays an especially vital role in the treatment of non-psychotic disorders, such as neurotic disorders, personality disorders, and reactive states.

Regarding the content of psychotherapy, a distinction is 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 a full range of psychological factors that positively influence the patient in order to enhance their defense mechanisms. Psychotherapy is closely intertwined with medical ethics and deontological principles. An important role in shaping the overall psychotherapeutic effect is played by the medical professional's authority, erudition, empathy, and ability to earn the patient's trust and instill hope for a successful outcome.

Specialized psychotherapy involves the application of specific psychological treatment methods for various disorders, either independently or in combination with other therapeutic measures.

Psychotherapy methods are classified into rational, suggestive, behavioral, psychoanalytic, and others. Depending on The Setting of the therapeutic sessions, a distinction is made between individual, group, and family psychotherapy.

Today, there are over 140 psychotherapeutic approaches, each distinguished by its core assumptions, theoretical framework, methods for analyzing therapeutic interaction, and relative emphasis on the patient's past traumatic experiences.

Common to all psychotherapeutic methods is that:

1) therapeutic activity takes place within the context of emotionally charged and simultaneously trusting relationships between the physician and the patient;

2) a theoretical foundation exists, adhered to by the psychotherapist and shared by the patient;

3) psychotherapeutic techniques involve providing new information and educating the patient through training, role-modeling, suggestion, persuasion, and insight.

Rational psychotherapy appeals to the patient's consciousness through logical persuasion and explanation using arguments the patient can easily understand. Elements of this approach are present in every conversation between the physician and the patient. It is particularly suitable for patients with a dominance of the second signaling system over the first and a well-developed intellect. The method is effective for somatovegetative disorders of neurotic origin, hypochondriacal states, addiction treatment practice, and more.

Suggestive methods utilize suggestion (hypnosis, autosuggestion) in combination with other psychotherapeutic interventions. Those most responsive to suggestion include functional tics, paralysis, amnesia, sensory disturbances, obsessive-compulsive phenomena, sleep disorders, and bad habits.

Behavioral therapy is defined as a system of learning principles and conditioned reflex formation for the analysis and treatment of behavioral disorders. The First stage is an objective Description of the behavioral disorders and the identification of external factors preceding them. Next, a hypothesis is formulated regarding the factors maintaining behavioral maladaptation and the methods for their elimination.

The following forms of behavioral therapy are distinguished:

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

2) methods of systematic desensitization to inappropriate reactions through modeling the phobic situation;

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

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

Psychoanalytic (psychodynamic) therapy aims at bringing the maladaptive personality structure into conscious awareness and modifying it. More effective adaptation is achieved by making previously unconscious conflicts, fears, or motivations conscious. The primary feature distinguishing psychoanalysis from Other forms of psychotherapy is its exceptional attention to the development, analysis, and resolution of transference—defined as a specific form of unconscious redirection onto the psychotherapist of emotions and relationships originally tied to significant figures in the patient's life (parents, siblings). Negative or positive feelings toward the analyst thus symbolically free the patient from past emotional baggage. The goal of this therapy is to replace unconscious actions with conscious ones. The drawbacks of psychoanalytic therapy include its long duration (up to 5–6 years), a tendency to foster excessive dependency on the psychotherapist, and high cost.

Gestalt therapy belongs to the empirical tradition in psychotherapy. The core idea of this method is the assertion that somatic and psychological health requires full awareness of physical sensations and emotional needs. The goal of therapy is to increase awareness of one's Physical state and repressed emotional needs by identifying perceptual blocks. Many psychotherapists incorporate this method within other psychotherapeutic frameworks.

Psychotherapeutic and sociotherapeutic methods also include: music therapy (melotherapy)—listening to specially selected musical pieces to achieve a specific emotional state; bibliotherapy—reading specially selected fiction; play therapy and art therapy—the patient's artistic creation as a way of creatively responding to their own experiences and feelings; and occupational therapy.

CONTROL QUESTIONS.

1. General Principles of treatment for psychiatric patients.

2. Classification of psychotropic medications.

3. Indications for the use of neuroleptics and their main effects.

4. Side effects of neuroleptic drugs.

5. Main effects of the most common neuroleptics.

6. Long-acting neuroleptic agents.

7. Classification of tranquilizers, their representative drugs, and main effects.

8. Indications for the use of tranquilizers and their side effects.

9. Classification of antidepressants and their main effects.

10. Indications for the use of antidepressants and their side effects.

11. Psychopharmacological profile of mood stabilizers (normotimics).

12. Indications and main effects of psychostimulants.

13. Psychopharmacological profile of nootropic agents.

14. Psychopharmacological profile of anticonvulsant drugs.

15. Methods for managing complications associated with psychotropic pharmacotherapy.

16. Indications, methods, and complications of shock therapy.

17. Principles and methods of psychotherapy for mental disorders.