The global burden of disease ...

The global burden of disease. Cambridge, MA: Harvard University Press, 1996 20.Potts SG, Bass CM Psychological morbidity in patients with chest pain and normal or nearnormal coronary arteries. Psychol. Med.1995, v.25, pp. 339-347 21. Shapiro P. A. Lidagoster L. Glassman A. H. Depression and heart disease. Psychiatr.Ann., 1997, v.27, pp.347-352 22.Sharma R., Markar HR Mortality in affective disorder. J. Affect.Dis., 1994, v.31, pp.91-96 Published with permission from Russian Medical Journal.

Safety wider category ...

Security broader category that overlaps portability. It also includes the absence of a negative effect on metabolic processes, the functions of individual organs and systems, which is particularly significant during prolonged therapy. Following the recommendations of the so-called Compliance, ie agreement, coherence patient and physician important factor for successful therapy. Usually not less than 1 / 3 therapeutic recommendations are not fully implemented, violations of regularity and precision of the prescribed purposes. Alignment is especially important in ambulatory practice, where the function of monitoring therapy largely passed, "delegate" to the patient, of course, necessarily prepared for it. References: 1. Avrutsky GY Neduva A. M. Treatment of Mental Illness: Science, 1984. 2. Report on world health 2001.Psihicheskoe Health: New Understanding, New Hope. WHO, 2001 3. Clinical Manual: Models of diagnosis and treatment of mental and behavioral rasstoroystv Ed red.V.N.Krasnova and IY Gurovich. M.: Application of the journal "Social and Clinical Psychiatry, 1999 4. KornetovN.A.Depressivnye disorder. Systematics, diagnostics, semiotics, therapy. Tomsk.: Siberian Publishing House, 2001 5. Krasnov VN The organizational model of care to those suffering from depression, in terms of territorial polikliniki.Metodicheskie rekomendatsii.M: Ministry of Health Rossii.2000. 6. Krasnov VN Psychiatric disorders in general medical praktike.Russky Medical zhurnal.2001.tom9.N 25.s.1187-1191 7. Mosolov SN Clinical use of modern antidepressants. SPb.: Medical News Agency 1995. 8. Educational Program on Depressive Disorders. Module 1. Overview and Main Aspects, World Psychiatric assotsiatsiya.Per. with angl.M.: Eli Lilly Vostok, 1999. 9. Smulevich AB Kozyrev VN Syrkin AL Depression in the medically ill. Moscow: 1997 10. Smulevich AB Depression in general medicine. M.2001 11. Federal guidelines for physicians on the use of drugs (Formulary System). Release P., 2001 12. Bech P. Pharmacological treatment of depressive disorders: A review. Depressive Disorders. Eds. M. Maj, N. Sartorius. Chichester etc: Wiley.1999, pp.89-127 13.Carney RM, Freedland KE Major depressive disorder predicts cardiac events in patients with coronary artery disease. Psychosom. Med. 1988, v.50, pp.627-633 14.Glassman AH, Pierse DW Treatment of depression in patients with heart disease. J. Pract. Psychiat.a.Behav.Health., 1998, v.4, pp.140-149 15.Katon W., Sullivan MD Depression and chronic mental illness. J. Clin. Psychiatry, 1990, v.51, pp. 3-11 16.Lesperance F. et al. Major depression before and after miocardial infartion: its nature and consequences. Psychosomatic Medicine, 1996, v. 1958, pp.99-110 17.Lyness J.M. et al. Depressive symptoms, medical illness and functional status in depressed psychiatric inpatients. Am.J. Psychiatry. 1993, v. 150, pp.910-915 18.Moeller HJ (Hrsg) Therapie psychhiatrischer Erkrankungen.Stuttgart: Enke Verlag, 1993 19.Murray Ch.JL, Lopes AD

The simultaneous use of 2 antidepressants ...

The simultaneous use of 2 antidepressants with different chemical structure is justified as an admission of overcoming resistance to therapy, but only after at least 2 full courses of monotherapy with different antidepressants. It should be noted that resistant depression is an indication for inpatient treatment, preferably in specialized institutions. This is due to difficulties in selecting therapy, the need for a higher than acceptable in the outpatient setting, doses of drugs, a higher risk of suicide. The real, clinically adequate duration of therapy (usually estimated by several months) is not determined by the absence of rapid onset of therapeutic outcome (it would normally be expected in 3-6 weeks) and the known laws of return of depression, the removal of the prerequisites of relapse or commit a rudimentary symptoms. Several months' use of antidepressants (already beyond the reach of the apparent improvement) also belongs to the modern principles of treatment of depression: the past, as noted above, the breaking of depression, lack of primary and secondary symptoms of depression within 2 weeks is usually considered a sufficient reason for the rapid decrease in successive doses of an antidepressant to minimum or even to stop taking it. Tolerability and safety of antidepressant drugs are particularly important in modern therapy. Portability involves no significant side effects, as is obvious to the patient (eg, dry mouth, headaches, visual disturbances, which can serve as breeding grounds for subjective intolerance), and are not always obvious changes in heart rate, blood pressure, effects of behavioral toxicity such as breach of fine motor coordination, reduced wakefulness, cognitive disorders (attention span, memory, speed of execution of logical operations, spatial orientation). Cognitive impairment is particularly important for the working person dealing with the constant intellectual component in the performance of professional functions. Modern intellectualization of labor, use of technology, particularly computer, intermediaries activities, and frequent execution of operator actions that require constant change and re-focus, communication all require a modern treatment of benign and supportive (at least not the oppressor), cognitive function properties. Recently, more attention when antidepressant therapy is justified on safety of sexual function, the lack of antidepressant side effects such as weakening of erection, delay ejaculation, repression of orgasm. Please keep in mind that sexual function (libido, especially) are in themselves suffering with depression and logical manner restored when adequate antidepressant therapy.

Need to focus on some ...

It is necessary to highlight some general principles on the use of antidepressants. Monotherapy with the basic requirement for modern treatment of depression: the appointment of a selected product and its use for at least 4 weeks, reaching the maximum tolerated therapeutic dose is desirable to 7-14 day of treatment. In this case, tolerance may allow moderately expressed transient side effects, about which the patient is warned in advance and is willing to suffer for the sake of the main therapeutic outcome, which (and this also needs to know the patient) is usually not expected before the end of the 1 st, and often at the 3 - her week of therapy. In addition to biological intolerance (cholinolytic particular expression or other side effects), it is necessary to consider the possible psychological intolerance of particular sensitivity, nevynoslivost patient to some, even quite mild side effects. Sometimes it is excused in a special (and regular) the patient's attention to the preservation and maintenance of some relevance to the daily activities of functions: the unacceptability of even a light tremor of fingers in musicians, dry mouth for teachers, etc. But often psychological intolerance associated with particular sensitivity to pain, physical discomfort, sensory, as personality traits. Recognizing the important principle of modern single-agent treatment of depression can be considered justified in some types of complementary, concurrent therapy: 1) the so-called Therapy cover, which usually precedes the main purpose of antidepressant, and 2) adjuvant therapy, join the main to enhance or stabilize the main action of antidepressant. Therapy is mainly limited to cover the somatotropic and neurometabolic drugs and is focused on mitigating or preventing the reactions of organic and somatic changes of the soil. It can be antihypertensives (preferred b-blockers), vegetostabiliziruyuschie drugs (benzodiazepines are used mainly symptomatic); cerebroprotective funds (primarily nootropics) are appointed at the expressed cognitive impairment, especially if these phenomena were detected during the previous courses of therapy and impede full remission and re-socialization patient. However, the appointment of adjuvant therapy is preferable to defer to the stage, allowing to evaluate therapeutic options (efficacy and safety) of the main therapeutic agent. In particular as it relates to cognitive impairment and psycho-vegetative manifestations (reflecting somatization of mood disorders), because in most cases, these disorders are closely linked with depression and are reduced with the reduction of its main manifestations of affective (depression, anxiety), motivational and volitional (the inducement to activity) and vital (depression and change drives). To some extent, to the adjuvant drugs can be classified timostabilizatory, in particular, carbamazepine, whose accession to the stage to achieve the effect and end the active antidepressant therapy is justified not only to smooth out the emotional and autonomic instability common to complete the main therapy, but also to the subsequent long antirelapse treatment actually prevent worsening and recurrence of depression and general mood fluctuations in the probability of their occurrence.

Reducing the possibility of ...

Benefits of rehabilitation therapy, as restoration of the old social role and professional abilities of the patient, actually appeared only in the last decade. This is due to the fact that, along with justified itself when expressed, severe depression, tricyclic antidepressants appeared several new pharmacological group of antidepressants. Their advantages and benefits compared with tricyclic compounds are due not so much the power of antidepressant action (here, they often yield tricyclic antidepressants), but significantly less severe side effects, respectively, more robust security. It is side effects, including cardiotoxic, hepatotoxic, neurotoxic, limit the scope of today, such high-tricyclic antidepressants as amitriptyline, imipramine, irreversible MAO inhibitors. Above all, these restrictions apply to general medical practice. However, the modern choice of antidepressants (the major ones are listed in Table. 2) is quite wide. Many of these facilities have no significant side effects and under certain conditions can be successfully applied in the general profile settings and primary care network. Affiliation antidepressant to a particular subgroup is determined by its chemical structure, but does not always correlate with its ultimate pharmacological effect. For example, antidepressants, SSRIs and SSOZS opposite effects on certain receptor systems, are considered to be associated with depression, but they both eventually have antidepressant effects. Many antidepressants are polyvalent in effects on different neurotransmitters - serotonin, norepinephrine, dopamine and related receptor systems. Scattered atypical antidepressants are sometimes referred to various groups or define as modulators of serotonin receptors - such as trazodone [12]. Preference is given to modern treatment of depression drugs with less side effects. In addition, many of today's vehicles may be taken 1-2 times per day, which is important in long-term outpatient treatment. Taken into account when choosing a drug known features of the therapeutic effect of an antidepressant: a balance of tianeptine and maprotiline, mirtazapine, milnacipran, the presence of an activating component of the antidepressant activity of selective serotonin reuptake inhibitors - fluoxetine, sertraline, paroxetine, to a lesser degree of citalopram and fluvoxamine ( the latter can be protivotrevozhnoe and action), a combination of proper antidepressant (timoanalepticheskih), anxiolytic (tranquilizing, calming) vegetostabiliziruyuschih properties of Mianserin. Well use it when expressed anxiety autonomic manifestations of depression, the presence of a soporific effect during persistent insomnia with trazodone, marked effectiveness in apathy and anergy of moclobemide.

The presence of depression in patients with cardiovascular ...

The presence of depression in patients with cardiovascular diseases not only complicates the course and therapy of these disorders, but also reduces the life expectancy of patients. For example, depression, developing immediately after myocardial infarction, 3,5 times increased risk of dying of the disease [14.22]. In modern medicine, there is no other more dramatic and almost simultaneously changing group of disorders, what are the depression and cardiovascular disease. In recent years, they are distinguished by certain tendency to increase the rating burden amongst other forms of pathology. This is clearly confirmed by indicators of medical statistics and predictive models of the prevalence of different forms of pathology. Deserve special attention by WHO and the World Bank, based on predictions of the Harvard School of Public Health [2.19]. According to the criteria DALY (reduction of operational, sotsialnopolnotsennoy life), the most unfavorable dynamics of c early 90s and in the coming decades, characterized by 3 clinical forms: unipolar depression, coronary heart disease, cerebrovascular disease. In 1990, these diseases (or more precisely, the burden of these diseases) held on 4, 5, 6 seats. By 2020, the burden of these diseases will increase, and coronary heart disease becomes the leading cause of reducing the full-fledged human life, unipolar depression will be second place, and cerebrovascular disease will take 4 position (on the third will go traffic injuries). Clinical (and therapeutic) importance of a combination of depression with somatic pathology and more frequent detection of depression in primary care networks require close cooperation between psychiatrists and internists, search for new effective forms of such interaction with the organization of care to patients with depression outside of traditional mental health facilities. Such attempts are taken [4,5,9], but are still limited. However, the general concept of treatment of depression in recent years and is modified to a large extent based on the change of generations of antidepressants, the emergence of various non-drug treatments for depressed patients [1,3,7,8,11,12,18]. New therapeutic agents induce another to assess the opportunities and the organizational forms of treatment of depression, rather than 20-30 years ago. In this context, it seems reasonable shorthand for the stages of formation of the modern strategy of treatment of depression is a strategy, because it is not only and not on specific Zoloft to improve their pharmacological properties and effectiveness as a change of their relations with other methods of therapy in the general system of treatment suffering from depression. Finally, we are talking about and a certain change in the content of the concept of therapy, which today includes not only the methods of biological therapy (primarily drug therapy), but also forms of psychological and psychosocial effects (Table 1) Restorative therapy involves the deployment of Multiprofessional activity in clinical practice, including primary care network, providing maximum availability of assistance for persons with depression.

Intensive treatment with vitamins ...

Intensive treatment with vitamins and nootropics must be at least 23 months. Only in this case it is possible to observe a reduction of memory impairment and other manifestations of psychoorganic syndrome. In some cases, memory disturbances disappear completely, as well as other manifestations of this syndrome. Patients become active enough, there is criticism. However, this result may be achieved infrequently. Most rapidly disappearing manifestations of alcoholic polyneuropathy. In connection with gross violations of memory and the phenomena of dementia in most cases, patients recognize the disabled (disabilities of the second group). After graduating from acute alcoholic psychoses, as well as in protracted and chronic forms, there should be temperance therapy. So, a month after the end of the delirium, hallucinosis, and acute paranoia may tend to holding temperance therapy in full. Its aim to prevent re-occurrence of alcohol psychosis. Published with permission from Russian Medical Journal.

Current approaches to the treatment of depression

Prof. VN Krasnov Institute of Psychiatry, Ministry of Health, Moscow In the current epidemiological situation of depressive disorders attracted attention as a clinical and social phenomenon and as an object of therapeutic research. In a recent publication in breast cancer (№ 25, 2001) [6] we presented some evidence of high prevalence of depression worldwide, and that significant social and economic burden that carries with it a disease. Public health planning for the coming decades can not be done without taking into account the scale of the problems of depression, their relationship not only with psychiatric practice, but with many areas of somatic medicine [2]. To date, there are a number of institutional, social, and proper medical prerequisites for significant changes in helping people suffering from depression and the prevention of severe, chronic, disabling form of depression. Meanwhile, modern therapeutic agents used to treat depression is not enough or not quite adequately, without complying with the established scientific and preferences, and address the adverse effects and drug interactions. Depressive and anxiety disorders often manifest themselves exclusively somatic (somatovegetative) symptoms and are in the same way as somatic, as well as a mental disorder. Along with it there and is becoming increasingly pressing problem of conjugation of various forms of somatic and neurological disorders and depression. This primarily refers to the so-called psychosomatic diseases. Moreover, current projections suggest similar trends in the prevalence of depression and certain systemic diseases. In this case, confirmed particularly close relationship of depression and cardiovascular disease. Comorbidity of depression and hypertension is about 30% [17] and in patients in myocardial infarction depression are found in 16-45% of cases [10,16,21].

Only long antialcoholic ...

Only antialcoholic prolonged treatment, which patients are completely stopped drinking alcohol, may help in some cases, the gradual reduction of verbal hallucinosis and the disappearance of the perception of deception. Acute alcoholic paranoid docked as well as acute alcoholic hallucinosis. To eliminate the fear and the normalization of behavior might slow intravenous injection of 50 mg of chlorpromazine. This leads to the onset of sleep. On waking affect of fear is much less pronounced. Possible and intramuscular 1015 mg haloperidol concurrently with parenteral administration of 2,040 mg of diazepam. Neuroleptic therapy should continue for as long as patients pobredovomu interpret the behavior of others. If, after the abolition of neuroleptics reappears acute sensory delusions of persecution, it is necessary to exclude the presence of endogenous disease. Treatment of patients with alcoholic delusions of jealousy by using drugs with antipsychotic activity. Can be assigned to chlorpromazine 150 mg / day, haloperidol 15 mg per day, etc. Treatment of antipsychotic drugs continues as long as the tensions affect anger, a willingness to aggressive actions. In cases where the delirium of jealousy, combined with low mood, together with neuroleptics appointed antidepressants (amitriptyline). Success of therapy is dezaktualizatsiya delirium, loss of aggressive tendencies. Only upon reaching this result the patient may be discharged from the hospital. Highly desirable to conduct long temperance therapy, as well as the resumption of alcohol abuse rather quickly leads to the actualization of the ideas of jealousy. In some cases, during the delirium tremens becomes protracted. For several weeks in the evenings there are hallucinatory stupor, disorientation, restlessness. It always indicates the presence of alcoholic encephalopathy or associated systemic diseases. Most often cited a combination of alcoholic encephalopathy with serious medical conditions (pneumonia, pulmonary tuberculosis, cirrhosis of the liver). In these cases, treatment with B vitamins and piracetam. To combat insomnia, and excitation used diazepam, oxybutyrate sodium, low doses of haloperidol in combination with diazepam. Treatment of patients with Korsakov's psychosis and alcoholic dementia by taking into account the stage of the disease. In all cases we are talking about alcohol entselofalopatii, the initial phase of which takes place in a delirious stupor. At this stage treatment is the same as in relieving delirium tremens. In the second stage, when the detected gross memory impairment and multiple cognitive disorders, the intensive vitamin therapy. Doses of vitamin B1 can be as high as 300,400 mg per day. At the same time introduce vitamins B6, C, nicotinic acid. Must be appointed nootropics. Of paramount importance was the introduction of sufficiently large doses of piracetam (812 g / day).

Thiamine is introduced at a daily dose of ...

Thiamine is introduced at a daily dosage of 5001000 mg. It was at these doses using thiamine can increase the level of oxidative processes and reduce the severity of cerebral hypoxia. In addition, we introduce vitamins C, B6, PP. The range of prescribed drugs must include ethyl alcohol. Using alcohol to arrest severe delirium tremens is impossible, but ethanol helps stabilize the situation and buy time for intensive care. Sustained hyperthermia eliminated by introducing 2 ml of 50% of metamizol sodium in the great vessels are superimposed bubbles with ice. Extremely helpful is the introduction of a day to 30 g piracetam. Infusion therapy is conducted over 1,236 hours. It stops when the normal physical condition and sleep comes. In the coming days after arresting severe delirium tremens marked drowsiness, severe fatigue with increased exhaustibility. At this stage lasts vitamin, is introduced nootropil to 812 grams per day. It is best to carry out treatment of patients with severe delirium tremens in the intensive care unit, where there are opportunities for long-term infusion therapy under laboratory control. Therapy of patients with acute alcoholic hallucinosis constructed taking into account the fact that this psychosis, there is no significant violations of homeostasis. To eliminate the affect of fear and the normalization of behaviors were successfully used chlorpromazine (50 mg 3 times daily), levomepromazine. It later turned out that it is safer to use drugs such as haloperidol, triftazin, zuklopentiksol. Usually introduced by intramuscular injection 1015 mg and 2040 mg haloperidol diazepam. Sometimes combined with haloperidol hlorprotiksenu (15 mg 3 times a day). Antipsychotic drugs administered to until disappear verbal hallucinations. Seeking to normalize sleep. If, after the abolition of antipsychotics renewed verbal hallucinosis is necessary to exclude the presence of endogenous mental illness. All the patients underwent vitamin. Since 30% of the typical delirium tremens begins with the appearance of abundant auditory illusions of perception, the construction of therapy always take into account neurological disorders. In the presence of generalized tremor, ataxia, a rough, profuse sweating therapy is the same as in case of delirium. If alcoholic hallucinosis takes a protracted course, it is necessary to continue antipsychotic treatment. In some cases it is expedient to attach hypoglycemic insulin. Then in the morning, inject insulin, a second antipsychotic. In some cases prolonged hallucinosis accompanied by a decline in mood and appearance of more or less pronounced depressive symptoms. In these cases, can be attached to antidepressants. Appointment of antipsychotics patients with chronic alcoholic hallucinosis does not lead to the disappearance of verbal hallucinations. Neuroleptics can only eliminate the aggravation of symptoms caused by another alcoholic excesses.

Unfavorable for expressed ...

Unfavorable change over expressed in a typical hyperkinetic delirium, mussitiruyuschim, hyperthermia occurs sopor and coma. Death occurs during the collapse, which may arise during mussitiruyuschego delirium. Case-fatality rate reaches 1,015%. Usually have to deal with two variants tyazheloprotekayuschego delirium. For the first characterized by progressive dehydration and hypovolemia. Having decompensated metabolic acidosis, hypovolemia politsitemicheskaya, the concentration of sodium in blood plasma and decreases its concentration in red blood cells, drops of potassium in plasma and erythrocytes. The second option is accompanied by hyperhydration, increased politsitemicheskoy hypervolemia. There is decompensated metabolic acidosis. Increased potassium content in blood plasma and sodium in erythrocytes decreases the concentration of potassium in erythrocytes and plasma sodium levels. On the severity of the condition can be judged not only by the depth of confusion and progression of neurologic symptoms, but the content of sodium and potassium ions. In a typical delirium tremens sodium content was 2024 umol / L, potassium 6580 micromoles per liter. In severe delirium tremens sodium content (erythrocyte) above 24 micromol / l and potassium 3.5 mmol / liter. With such a violation of hypokalemia and the ratio of potassium and sodium, edema of the brain. When dehydration and hypovolemia skin is dry, hot, facial features, sharp, there is cyanosis of lips, noted wears neck veins, inhibition of reflexes. Arises serchechnososudistaya and respiratory failure. Necessary to conduct rehydration. Introduced more fluid than urine. Treatment is effective if the urine output increased to 400,500 ml. Used 5% glucose, Ringer's solution, isotonic sodium chloride solution, gemodez, reopoliglyukin, dextran. Blood volume filled by the introduction of 14 liters of fluid. Be sure to introduce the ions of potassium, sodium, and tachyarrhythmias, magnesium sulfate, sodium chloride, propranolol, novokainamid. When hyperhydration overcrowding neck veins, peripheral edema, signs of cerebral edema. Used by 1,020% glucose with insulin, 30% solution of potassium chloride, furosemide, mannitol. Woo to the amount of urine on 10% higher than the amount of fluid infused. To combat the metabolic acidosis arising during that and the other variant tyazheloprotekayuschego delirium on the basis of laboratory parameters are introduced 5% sodium bicarbonate, Cocarboxylase, disol, potassium chloride. To increase the level of blood pressure and normalization of vascular permeability using hydrocortisone and prednisolone. With the trend towards lower blood pressure dose of prednisolone is 80 mg, when a kollaptoidnyh states simultaneously introduced no less than 120 mg prednisolone. Of particular importance is the introduction of vitamins complex B. It is believed that in many developed severe delirium tremens, as well as acute encephalopathy GayeVernike due to deficiency of vitamin B1.