In classical psychotic depression with a characteristic triad of symptoms, antidepressants with a stimulating effect are shown: imizin (melipramine), anafranil, pyrazidol. With a large depth of depressive disorders, it is preferable to administer them intravenously. It is recommended to quickly (within 3-5 days) increase the dose to 300-400 mg per day (initial dose of 100-150 mg), as otherwise the patient’s body gets used to the drug. Due to the weaker antidepressant effect of pyrazidol and the practical absence of side effects during its use, this drug can be prescribed in higher doses than tricyclic antidepressants. The most effective drug among the above is anafranil, which has a faster resolving effect on the symptoms of depression. In the treatment with anafranil, the percentage of positive results is higher than when using melipramine. According to the data of Yu. L. Nuller (1981), amitriptyline also has a pronounced effect in melancholic depression. The author recommends that the antidepressants be distributed evenly throughout the day, since a stable level of the drug in the blood is more important therapeutically than possible sleep disturbances that are easily stopped by sleeping pills. Doses are reduced gradually, while always monitoring the mental condition of patients.
Tricyclic antidepressants often cause side effects that can be eliminated by parenteral administration of oxazil (5-10 to 60 mg) or proserin (30-45 mg to 135 mg), galantamine up to 5-10 mg.
In the case of the development of symptoms of classical depression at a non-psychotic level (cyclotymic melancholy depression), it is more advisable to gradually prescribe small and medium doses of imizin (melipramine) and anafranil (50-100 mg per day) or pyrazidol. If severe somatic and autonomic symptoms occur, the treatment is supplemented with tranquilizers with a vegetotropic effect – sibazon (seduxen), grandaxin.
For anxiety depression, sedative drugs are used: amitriptyline (tryptisol), insidone, synequan.
In addition to antidepressants, antipsychotics are widely used: levomepromazine (tizercin), chlorprotixen, thioridazine (meleryl) and tranquilizers: sibazon (seduxen), phenazepam, nozepam (tazepam).
With an alarming component, azafen or amitriptyline is prescribed in combination with small doses of sleeping pills (nitrazepam, or radedorm, eunoktin) at night and tranquilizers in the daytime (sibazon or seduxen; nozepam or tazepam), as well as antipsychotics with a sedative effect: lev (tizercin) 25-100 mg.
It must be borne in mind that anxiety in the structure of depression most often appears in patients after 40-50 years. In patients with manic-depressive psychosis, the phenomena of vascular pathology are often observed. Such patients are contraindicated for the rapid increase in doses of antidepressants and antipsychotics, as well as the use of large initial doses.
In depressive states with delusions and individual perceptual impairments (verbal illusions corresponding to the topic of delirium by auditory hallucinations), antidepressants with a stimulating effect and monoamine oxidase inhibitors are contraindicated, which lead to a sharp exacerbation of delusional symptoms and an increase in suicidal tendencies. Prescribe either antidepressants that have a strong anxiolytic effect (amitriptyline, synequan, insidone), or drugs with a predominant balancing effect (pyrazidol, anafranil), enhancing their action with sedatives if necessary, as well as haloperidol (15-30 mg), triftazine (up to 60 mg), clozapine (leponex).
Patients with nonpsychotic depressive-hypochondriac disorders are shown to have drugs with a weak antidepressant effect (azafen, pyrazidol), or amitriptyline, anafranil in small doses in combination with tranquilizers: chlozepide (elenium), sibazone (seduxenamaz, nomez), or with antipsychotics: thioridazine (meleryl), alimemazine (teralen). Small doses of insulin, fortifying therapy, B vitamins, especially pyridoxine and psychotherapy give a good effect.
With hypochondriacal depression of the psychotic register (depression with delirium of an incurable disease), the principles of therapy are the same as with delusional depression.
Phenazepam (from 3-6 to 20-30 mg per day) and clozapine, or leponex (from 150 to 600 mg per day or intramuscularly) give a positive effect in some patients with depersonalization depression, less often a combination of imizine (melipramine) and chlorazizin. Prescribing antidepressants with a stimulating effect (melipramine, anafranil) is impractical, since they increase the anxiety observed in patients.
Positive results were obtained in the treatment of patients with depression with tryptophan in combination with monoamine oxidase inhibitors and madopar (G.V. Stolyarov et al., 1984). In the treatment of melancholic depression, cyclodol (16-24 mg per day), methylmethionine (150-600 mg per day) give a positive effect. In the treatment of patients with sleep deprivation, consisting of 36-hour deprivation (day, night, day) of its deprivation, the best results after 6-8 treatment sessions were achieved in patients with a typical melancholic syndrome.
Reduced resistance in protracted depressive phases, as well as in depression that is not treatable by known methods, is achieved using ECT (if there are no contraindications). In our clinic, insulin in hypoglycemic doses (or 2-3 insulin shock) and sulfosine (2-4 injections of 0.5-3 ml) are successfully used for these purposes with success. The method of simultaneous withdrawal of therapy was also spread. Positive results are noted in the transition from intramuscular and oral administration of antidepressants to intravenous drip and replacement of the drug with an antidepressant of a different chemical structure.
Psychotherapy is indicated not only in the protracted, but also in the normal course of the depressive phase, when improvement in some patients is accompanied by a “personal shock of the disease” – an anxiety about belonging to a mentally ill patient, fear due to treatment in a psychiatric hospital. At the first stage of treatment, patients with latent depression are prescribed antidepressants in minimal doses: 12.5 mg of pyrazidol or 6.25 mg (1D tablet) of imizine (melipramine) in the morning for the first 3 days. The use of large doses of antidepressants and their accelerated increase lead to a deterioration in the patient’s condition due to the addition of side effects of antidepressants to somatovegetative disorders (dry mucous membranes, tachycardia, sweating, arterial hypotension). It is advisable to take tranquilizers in the evening, which have a vegetotropic effect: 0.5 mg of phenazepam, 5-10 mg of sibazon (seduxen). In the next 10-12 days, doses of antidepressants (up to 50-60 mg) and tranquilizers are increased: up to 10 mg of sibazon (seduxen) or 1.5 mg of phenazepam. With insufficient treatment effectiveness, small doses of insulin, pyridoxine (up to 150-200 mg per day), iron and potassium preparations, pyriditol (encephabol) are prescribed.
After reducing somatovegetative disorders, leading to the unmasking of latent depression, they proceed to the 2nd stage of treatment (therapy of the actual depressive disorders) – the choice of antidepressants: for sluggish, adynamic, asthenic forms of depression, antidepressants with a stimulating effect – imizine (melipramine) are recommended to 75-100 mg per day; for depression with anxiety, anxiety, antidepressants with a sedative effect are prescribed – amitriptyline up to 50-75 mg per day.
After normalization of the affective sphere, they proceed to the 3rd stage of treatment, the purpose of which is the elimination of somatovegetative “traces” of latent depression. To do this, continue treatment for 9-10 weeks, gradually (every 5-7 days) reducing the dose of antidepressant by 6.25-12.5 mg and small tranquilizers. It is impossible to sharply reduce the dose, as this can lead to an exacerbation of the condition. 12.5-25 mg of pyrazidol or amitriptyline at night for 6 months are prescribed to patients who fixate their attention on bodily sensations and patients with increased anxiety. In the bipolar course of latent depression and clearly defined phases, lithium salts (up to 0.6-0.9 g per day) are used prophylactically with monthly monitoring of its blood level.
The severity of the “personality shock of the disease” is greater in primary cases, especially in those cases when the first depressive phase occurs after the manic. In this regard, rational psychotherapy is of great importance for the prevention of suicidal tendencies and improving the quality of social and rehabilitation measures.
When conducting psychotherapeutic work with people who have undergone depressive phases, it should be borne in mind that the state of “personal shock of the disease” can be repeated before discharge from the hospital and in the first days of stay at home. Therefore, it is necessary to carry out appropriate work among family members and representatives of the labor collective.
P.V. Biryukovich and co-authors (1979) proposed a system of pathogenetic prophylaxis of manic-depressive psychosis based on the results of a study of metabolism and indicators of somato-vegetative state. It boils down to the elimination of somatic disorders developing during the period of remission or in the period before the onset, and consists in the medical correction of metabolic disorders. Patients are prescribed 20-30 IU of insulin, 25-30 mg of thiamine, 0.3 g of lipocaine per day, sodium salts of citric, succinic and acetic acids, thyroidin. For prevention, lithium salts are used with a control of its concentration in the blood and side effects.
The working capacity of patients is determined individually: with long-term and pronounced psychopathological manifestations, they are transferred to disability, and with sub-depressive and hypomanic, they are recognized as temporarily incapable of work. Persons with severe psychotic manifestations are considered insane and incompetent.
In the system of measures for social and labor rehabilitation, it is necessary, along with periodic periodic anti-relapse treatment and the use of lithium preparations for this purpose, to pay special attention to providing patients with a rational mode of work and rest, psychotherapeutic conditions at home and at work, maintaining their working capacity and normal relationships with others. Psychotherapeutic support is important for preventing relapse of the disease and suicidal tendencies, maintaining a rational attitude to your illness and life