On the issue of adequate therapy for protracted reactive depression

Among the psychogenic factors involved in the determination of reactive depressions, the leading role is assigned to bereavement, which damages the sphere of individual personal values. The sudden loss of the object of attachment (“significant other” in the terminology of psychologists) – love drama, tragic death or suicide are considered in the literature as a catastrophic stressful effect. The latter is equated in importance with events of an extreme nature with a universal property – the ability to cause distress1. Only 800,000 people experience marital loss in the modern world every year, and at least a third of them need treatment for an acute psychogenic reaction. At the same time, in half of the patients, after acute affective-shock disorders have passed, clinically outlined reactive depressions are formed, the duration of which exceeds 12 months.
Such protracted depression, denoted in psychologically oriented publications by the concept of “pathological grief reactions” (PRG), not only worsen the quality of life, but increase the suicidal risk, lower the threshold of susceptibility to recurrent affective disorders, contribute to the development of comorbid pathology (anxiety, pathocharacterological disorders, dependence on psychoactive substances).
The data obtained allowed modern researchers to come to the conclusion that protracted psychogenic depressions occurring with the picture of PRG, in contrast to the psychologically deduced phenomenon of “normal work of grief”, cannot be regarded as an “acceptable process” and should be the subject of special attention of clinicians.
However, the psychological clarity of the tragic life situation in the minds of patients (and even, unfortunately, in the judgment of some specialists) often shifts the real idea of ​​a depressive reaction as a mental disorder to its understanding exclusively in the context of a natural, inevitable and irreversible, and thus not in need of treatment for the consequence of the loss suffered.
Meanwhile, in the absence of adequate therapy, psychogenic depression with features of PRH is not only not reduced, but becomes chronic. At the same time, mental trauma becomes a maladaptive “focus” that determines, over a long period of time, violations of behavior, social functioning and the entire life structure of patients. Accordingly, the timeliness of adequate therapeutic measures in such cases is a factor of key importance.
As evidenced by the clinical experience, which is consistent with the literature data, accumulated in the department for the study of borderline mental pathology and psychosomatic disorders of the NCPZ RAMS, in a wide range of therapeutic influences (biological, psychotherapeutic, social rehabilitation) used for protracted psychogenic depressions occurring in the form of PRG , the main component is pharmacotherapy with the predominant use of antidepressants.
This position is based on a revision of the traditional concept of psychotherapy as the only effective method of treating such conditions2. With the accumulation of the results of special comparative studies, which provide statistically reasoned evidence, it became obvious that psychotherapeutic interventions in combination with placebo (i.e., the appropriate monotherapy) can achieve a positive effect in only 29% of patients with PRH [Reynolds Ch.F. et al., 1999]. At the same time, the effectiveness of antidepressant treatment is at least twice as high and can exceed 70%.
The approaches to the choice of therapeutic tactics are carried out in accordance with the concept of psychogenies, consistently developed in a series of works by A.B. Smulevich, devoted to the problem of the contribution of personality disorders to psychogenic response to stress (see, in particular, the publication in the “Journal of Neurology and Psychiatry named after SS Korsakov”, No. 6, 2000, as well as the article in this issue).

Psychopharmacotherapy of prolonged depression with a picture of PRH is carried out taking into account the general principles of treatment of affective disorders: the volume and power of the drug effect are consistent with the severity of the condition. Accordingly, in the treatment of deep depression, the use of a high activity of psychotropic drugs of a wide spectrum is shown, while mild hypothymic disorders require the prescription of drugs with a differentiated effect on psychopathological manifestations (a narrow spectrum of psychotropic activity). However, these provisions are applicable to the conditions under discussion only in part, as evidenced by the already well-known fact that, despite the dominance of hypothetical manifestations in the picture of depressive reactions with features of PRH, the set of drugs used in the treatment, as a rule, is not limited to antidepressants.
The need for complex therapy, as follows from the results of a number of studies, correlates with a special characteristic of psychogenic depression – their clinical manifestations depend on the structure of comorbid relationships of affective disorders with personality disorders. In cases of the formation of protracted depressions with a picture of PRG (this will be shown below), we are talking about a mandatory complicity in the structure and dynamics of the depressive reaction of personality disorders (PD) or even disorders of an endogenous procedural nature3.
The ultimate goal of treatment is the most timely impact not only on the pathologically altered affect, but also on the pathocharacterological manifestations.
Initially, the choice of the psychopharmacotherapy technique depends on the belonging of the clinical manifestations of psychogenia to one of the following levels of personal response to stress, reflecting the stages of the dynamics of the disorder:
1 – the level of “deep personality” with polymorphic undifferentiated affective disorders (acute period);
2 – constitutional characterological / pathocharacterological level with differentiation and modification of affective disorders according to the patterns of post-traumatic comorbidity (subacute period, stabilization period).
For disorders of the first level, as shown in the figure, urgent intensive psychopharmacotherapy is shown, which in severe cases is advisable to be carried out in a hospital setting. Therapeutic tactics are determined by the peculiarities of the clinical picture of affective-shock reactions with abrupt (like rapid hysterical states of raptoid) changes in affect (from confusion, anxiety with a feeling of unacceptability of the catastrophe, despair with demonstration of suicidal intentions to ecstatic “fascination” with visions of a happy past) and dissociative disorders (psychogenically narrowed consciousness, fugiform agitation or stupor, seizures, hallucinations of the imagination).
The primary task of therapy is the timely relief of all components of the syndrome: affective imbalance, signs of hysterically clouded consciousness and psychomotor agitation. This problem is solved using parenteral (intramuscular, intravenous jet or drip) administration of tranquilizers prescribed in high daily doses (30-50 mg of diazepam) from the moment of admission to the hospital. (It should be borne in mind that “classic” affective-shock reactions are not always observed – the state at first may correspond not to an acute reaction to stress, but to an adaptation reaction, i.e., shallow psychogenic depression. This does not exclude the possibility of the formation of prolonged depression with features of the PRG, although there is no need for hospitalization immediately after the loss). It should be noted that stationing not only provides the possibility of intensive medication, but also has a psychotherapeutic meaning. Placing the patient in a hospital setting at least partially shifts attention and alleviates the burden of traumatic memories.
As clinically delineated depression forms, which indicates the possibility of the development of protracted psychogenia with a picture of PRH, antidepressants of the 1st generation in adequate daily doses (250-300 mg of tricyclic antidepressants – TCAs) are added to tranquilizers. The latter, if necessary, are also used parenterally, including intravenous drip. In complex therapy, the antidepressant properties of TCAs can be enhanced by the addition of medium and high (3-6 mg) daily doses of alprazolam (Xanax), a triazolebenzodiazepine derivative, the tricyclic structure of which is not directly related to antidepressants, but radically distinguishes this tranquilizer from other benzodiazepine derivatives. If signs of behavioral toxicity characteristic of benzodiazepines are identified, it is advisable to use non-benzodiazepine tranquilizers (hydroxyzine-atarax – 50-100 mg / day, buspar-buspirone – 20-30 mg / day). Less often (with the predominance of psychogenic deceptions of perception or arousal phenomena), neuroleptics of a wide spectrum of action in low doses are prescribed (aminazine – 100-150 mg / day, haloperidol – 5-10 mg / day, azaleptin-leponex – 50-100 mg / day). Such tactics in a significant part of cases allows achieving a complete reduction of psychogenic disorders.
In the part of cases when the desired therapeutic effect cannot be achieved, i.e. when the transition to the second level of psychogenic response with the formation of subacute affective disorders is registered, the issues of constructing optimal treatment programs acquire special significance.
It should be immediately emphasized that in case of second-level disorders, adequate therapy requires not only the differentiated use of medications, taking into account the spectrum of their psychotropic activity, but also the choice of various methods in which these drugs (antidepressants and drugs of other classes), as well as other biological effects included in very different proportions. The rationale for this strategy is its compliance with clinical reality – the therapy technique is consistent with the nature of comorbid connections between psychopathological formations and PD, which determine the characteristics of the observed manifestations of psychogenia. Differentiation of approaches to the choice of one method or another is carried out on the basis of the typology of protracted psychogenic depression with a picture of the PRG, subdivided, according to A.B. Smulevich (2000), into two options.
The first option is protracted psychogenic depression of the type of characterological dysthymia. As the severity of the condition decreases, clear signs of post-traumatic personality development are revealed. As a result of the interaction of affective disorders with personality patterns by the amalgamation mechanism (literally merger), a gradual transformation of affective disorders into pathocharacterological ones occurs. The persistently lowered mood takes on the character of a gloomy “basic tone” inseparable from the pessimistic outlook of the victim of an unhappy fate. Catatimically charged, mastering representations of the acute period are transformed into persistent overvalued formations with idealization and embellishment of the lifetime virtues of the object of loss and the cultic activity of perpetuating his memory (obsession with grief), less often – with the struggle (up to litigation and even paranoid tendencies) for “just punishment »Perpetrators of misfortune (often imaginary).
Treatment with this variant of comorbid relationships pursues two goals: it is aimed at the fullest possible elimination of depressive symptoms with minimization of the risk of exacerbations in the form of “double depression” and at the same time – at compensation for pathocharacterological manifestations – a decrease in the “emotional charge” of overvalued formations and associated abnormalities. behavior. The amount of drug exposure in this variant of comorbid ratios is rather limited due to the shallow level of affective disorders proper. At the same time, despite the blurring of dysthymic phenomena inseparable from PD, they are distinguished by the pathological resistance inherent in residual states. It is not necessary to expect rapid success from the use of drugs, which would manifest itself as a complete reduction of symptoms; it makes no sense to intensify therapy for this purpose. It should be borne in mind that the regression of psychopathological formations occurs very slowly, and their disappearance is possible after many years. This implies the need for long-term treatment with the prescription of new generation antidepressants (atypical TCAs – selective serotonin reuptake stimulants – SSOZS – tianeptine-coaxil at doses of 25-37.5 mg / day; selective serotonin reuptake inhibitors (SSRIs) bicyclic – citalopram-cypramypram-cypramine -40 mg / day, paroxetine-paxil 20-40 mg / day, sertralin-zoloft 50-100 mg / day; monocyclic SSRIs – fluoxetine-Prozac 20-40 mg / day, fluvoxamine-fevarin 20-40 mg / day; selective serotonin and norepinephrine reuptake inhibitor – SNRIs – milnacipran-ixel 50-100 mg / day, etc.).
An equally important prerequisite for the success of therapy is the use of modern atypical antipsychotics (risperidone-rispolept 2-4 mg / day, olanzapine-zyprexa 5-15 mg / day, flupentixol-fluanksol 1-3 mg / day, sulpiride-eglonil 200-400 mg / days). The preference for such a choice is quite justified, since psychotropic drugs of the latest generations, along with the main effect, have a high safety and tolerability index, are convenient to use, and do not require careful dose titration.
In conditions of the reverse development of hypothymia, a transition to monotherapy with atypical antipsychotics in doses sufficient for the correction of pathocharacterological disorders is shown.
This technique helps to level the signs of exacerbation in the structure of pathologically altered affect (dysphoric outbursts, “anniversary reactions”) and to gradually deactualize litigious and paranoid tendencies.
Of particular importance in conditions of long-term treatment, in which patients often do not see the need, are informational strategies that make it possible to create the necessary and effective medical alliance between the doctor and the patient, to achieve his interested participation in the therapy process, which minimizes violations of the prescribed recommendations. This interaction, according to the concept of completeness of adherence to the treatment regimen (compliance), is greatly facilitated by the expansion of knowledge of medical personnel at all levels, coverage of the current state of the problem. The
second option is protracted PRGs of the type of endogenomorphic depression. Affective disorders interacting with pathocharacterological formations by the integration mechanism (literally unification) reveal features of constitutional reactive lability (“dynamics of susceptibility”). In contrast to the manifestations of characterological dysthymia (option 1), in which each of the components (hypothymia, PD) in the picture of depression loses its independence, with this option their connection is expressed by the generalization of the elements forming the depressive syndrome and the worsening of the clinical picture. Vital disorders (insomnia, anorexia, circadian rhythm) dominate, ideas of self-accusation are strengthened, true suicidal thoughts are formed. This worsening of depression can reach the level of PD-associated quasi-psychosis (signs of dissociative alienation and / or sensitive paranoia and / or basic anxiety with fear of new loss transferred to the substitute).
The clinically substantiated amount of necessary medical care in accordance with the nature and severity of psychopathological manifestations includes active complex effects that reduce the level of generalization of the disorder and thereby – the therapeutic effect.
Treatment begins with the use of newer generation antidepressants; in the absence of an effect, antidepressants of a wide spectrum of action are prescribed with universal psychotropic activity (TCAs – imipramine-melipramine, amitriptyline, clomipramine-anafranil 250-300 mg / day in combination with high-potential tranquilizers of the benzodiazepine series and, less often – traditional neuroleptics / butyrophenerazines – haloperidol 10-20 mg / day, trifluoperazine-stelazine 10-15 mg / day).
When signs of aggravation of the condition or resistance are identified, strategies of intravenous drip of psychotropic drugs are used.
In the absence of a positive response to psychopharmacotherapy, it is advisable to conduct a course of electroconvulsive therapy. The main indication for prescribing ECT is the severity of the affective component of PRH, when the manifestations of hypothymia approach the picture of a severe depressive episode without psychotic symptoms (psychomotor retardation or agitation, consciousness of worthlessness, guilt, high suicidal risk, sleep and appetite disorders) or with psychotic symptoms (delusional ideas of sinfulness, signs of sensitive paranoia). It is clear that intravenous infusions of psychotropic drugs, as well as shock methods, are possible only in a specialized hospital.

1This term (English distress – grief, suffering, severe malaise, exhaustion) denotes stress (“stress stress” in Russian literature), which has a negative, disorganizing effect on the body, activity and behavior; the result of this influence may be psychopathological disorders.

2In modern balanced strategies with the exclusion of alternative approaches opposing pharmaco and psychotherapy, the latter remains an important part of the treatment process. It is assumed that the community of psychiatrists and psychotherapists provides the possibility of active use of targeted psychotherapeutic influences (rational, cognitive-behavioral, suggestive, family psychotherapy, the tactics of “therapeutic crisis intervention” – an intensive individual psychocorrectional intervention that helps to prevent suicidal intentions). Treatment is differentiated depending on the stage of development of the disorder (see article by A.V. Andryushchenko in this issue). If in the acute period of the psychogenic reaction psychotherapy in the form of adequate support is needed, then in the subsequent treatment techniques include an increasingly subtle study of the traumatic experience aimed at reducing the psychogenic complex, a realistic, distant reassessment by the patient of the loss suffered instead of its pathological denial, building adequate relationships with the environment and modeling of adaptive behavior in general.

3 This aspect of the problem, which requires coverage of the issues of psychogenic provocation of affective diseases (“depressive illness” by modern French authors) and / or “true psychogenies” in schizophrenia, is beyond the scope of this report.

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