1

guneba-ganwyobis (afeqturi)

aSliloba

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

2

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

`guneba-ganwyobis (afeqturi) aSliloba~ miRebulia klinikuri

praqtikis erovnuli rekomendaciebis (gaidlainebi) da

daavadebaTa marTvis saxelmwifo standartebis (protokolebi)

SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2008 wlis

5 noembris #1 sxdomaze da damtkicebulia saqarTvelos Sromis,

janmrTelobisa da socialuri dacvis ministris 2008 wlis 18

dekembris # 276/o brZanebiT.

3

guneba-ganwyobisA(afeqturi) aSliloba

1. daavadebis definicia, sinonimebi, klasifikacia da terminologia (1, 3, 5, 8, 18)

guneba-ganwyoba _ adamianis mier gancdili emociuri mdgomareoba, romelic

damokidebulia garemoebaze da sixarulis da dardis monacvleobaSi

vlindeba.

guneba-ganwyobis (afeqturi) aSliloba xasiaTdeba daTrgunvis _ depresiis

an awevis _ eiforiis, maniis paTologiuri grZnobiT da erTmaneTisagan

gancalkevebuli afeqturi (depresiuli, maniakaluri, Sereuli da a. S)

epizodebis monacvleobiT.

depresiuli epizodis klinika upiratesad depresiuli, xolo maniakaluri

epizodis _ maniakaluri sindromiTaa warmodgenili.

depresiuli sindromi (sinonimebi: depresia, melanqolia) _ daTrgunuli

guneba_ganwyoba, ideatoruli da motoruli aqtivobis retadacia (e. w.

depresiuli triada) Serwymuli somato_vegetatiur aSlilobebTan.

tipiuri depresiuli sindromis mravalferovneba ZiriTadad depresiuli

triadis ama Tu im komponentis an calkeuli simptomis dominirebazea

damokidebuli, xolo mis struqturaSi heterogenuri fsiqopaTologiuri

simptomebis aRmoceneba afarTovebs depresiul sindromTa speqtrs da

ayalibebs atipiur depresiul sindromebs.

depresiuli sindromebia:

• klasikuri depresia (,,triadiT”);

• SfoTviani, aJitirebuli depresia, agznebis pikia depresiuli raptusi _ Raptus melancholicus;

• asTeniuri depresia;

• adinamiuri depresia;

• cremliani depresia;

• disforeuli (mowuwune, boRmiani) depresia;

• apaTiuri depresia, romlis kulminaciaa depresiuli stupori;

• anesTeziuri depresia _ garTulebis SemTxvevaSi viTardeba fsiqikuri

anesTezia _ Anaesthezia psychica dolorosa; • depresia depersonalizaciiT da derealizaciiT;

• depresia akviatebebiT;

• ipoqondriuli depresia;

• SeniRbuli anu larvirebuli, latenturi, faruli, somatizirebuli,

daburuli depresia;

• depresiul _ bodviTi sindromi;

• depresiul-paranoiduli sindromi.

depresiuli sindromi aseve SeiZleba damZimdes cnobierebis oneroiduli

SecvliT, halucinaciebiT da fsevdohalucinaciebiT, fsiqikuri

avtomatizmebiT da sxva.

4

maniakaluri sindromi (sin. mania) _ aweuli guneba-ganwyoba (hiperTimia,

eiforia), ideatoruli da motoruli hiperaqtivoba (e. w. maniakaluri

triada) Serwymuli somato_vegetatiur aSlilobebTan.

depresiuli sindromis msgavsad, tipiuri maniakaluri sindromis

mravalferovneba ZiriTadad maniakaluri triadis ama Tu im komponentis an

calkeuli simptomis dominirebazea damokidebuli, xolo mis struqturaSi

heterogenuri fsiqopaTologiuri simptomebis aRmoceneba ayalibebs atipiur

maniakalur sindroms.

maniakaluri sindromebia:

• mxiaruli mania;

• mrisxane mania;

• mania abneviT;

• araproduqtiuli mania;

• Sekavebuli mania; motoruli Sekaveba, zogjer stuporis

intensivobas aRwevs;

• mania oxunjobiT;

• eqspansiuri mania;

• maniakaluri agzneba _ furor maniakalis; • maniakalur_bodviTi sindromi;

• maniakalur _ paranoiduli sindromi;

• oneroiduli maniakaluri mdgomareoba;

• moria;

• rauS _ mania;

• eqstazi.

afeqturi aSlilobis klasifikaciis momawesrigebeli RerZis rolSi

sxvadasxva parametri SeiZleba mogvevlinos: simZime _ msubuqi, saSualo da

mZime depresia an mania; mimdinareoba _ bipolaruli da unipolaruli anu

rekurentuli (Leonhard K., 1957); gamomwvev faqtorTan mimarTeba _ pirveladi

da meoradi (Robins E., Guse S.B., 1972; Lewis D.D., Smith S.E., 1983); warmomavloba _ ekzogenuri da endogenuri da sxva.

miuxedavad depresiis da maniis klasifikaciis mravalricxovnobis da

mravalferovnebisa _ struqturuli, etiopaTogenezuri, fenomenologiuri

da sxva _ srulyofilebaze pretenzias vercerTi ver acxadebs.

dReisaTvis fsiqikuri da qceviTi aSlilobis standartizebuli Sefasebisa

da diagnostirebisaTvis gamoiyeneba amerikis fsiqiatriuli asociaciis

diagnostikuri da statistikuri cnobaris me-4 gamocema _ DSM-IV da

msoflio jandacvis organizaciis mier mowodebuli, daavadebaTa

saerTaSoriso klasifikaciis me-10 gadasinjva _ dsk-10 (ICD-10; 1992);

saqarTveloSi klinikur praqtikaSi sargeblobisaTvis rekomendirebulia

dsk_10, romlis rubrikaSi ,,guneba-ganwyobis (afeqturi) aSlilobebi” (F30-F39), mowodebuli operacionaluri kriteriumebis gamoyenebiT

diagnostirebisas, garda wamyvani afeqtisa, xdeba kidev ramdenime faqtoris

erTdrouli gaTvaliswineba: mimdinareoba, mdgomareobis simZimis xarisxi,

aSlilobis struqtura, RerZuli da gamWoli sindromebis

urTierTdamokidebuleba, rac aadvilebs afeqturi aSlilobisas erTiani

5

fsiqiatriuli menejmentis SemuSavebas, mkurnalobas da SemTxvevis

prognozirebas.

2. guneba-ganwyobis aSlilobis epidemiologia (1, 3, 5, 6, 8)

• yoveli merve adamiani anu saerTo populaciaSi _ 15%, cxovrebaSi

erTxel mainc saWiroebs antidepresantebiT mkurnalobas, depresiis

gamo;

• aqedan mxolod 1/3 akiTxavs fsiqiatrs;

• aqedan mxolod 1/4¼-Si xdeba swori diagnostireba da iniSneba

adeqvaturi mkurnaloba;

• aqedan, 50% ama Tu im mizeziT wyvets mkurnalobas;

• didi depresiuli epizodis dros dasrulebuli suicidi 15-20%-ia,

rac 20-jer ufro maRalia vidre mTlian populaciaSi da 3-4-jer ufro

maRali, vidre sxva fsiqikuri aSlilobebis dros;

• SemTxvevaTa 60%-Si iRebs qronikul xasiaTs;

• pirveli depresiuli epizodis Semdeg, avdmyofebis 5-10% - Si viTardeba

maniakaluri mdgomareoba;

• genderuli Tanafardoba: SemTxvevaTa 2/3 qalia;

• srulfasovani cxovrebidan depresiis gamo dakarguli drois wili

aWarbebs Sizofreniisa da alchaimeris daavadebis gamo dakarguls

(DALY meTodi);

• depresia mosaxleobis dainvalidebis mxriv, 2020 wels daikavebs meore

adgils gul-sisxlZarRvTa daavadebebis Semdeg;

• depresias Tan axlavs SfoTva SemTxvevaTa 60_70%-Si, zogierTi

mkvlevaris azriT ki _ 42 -100% -Si (Dobson K S., Cheung E., 1990; Tollafson G. D., et. Al. 1993));

• msoflioSi mosaxleobis 5% daavadebulia depresiiT; amavdroulad

sicocxlis manZilze depresiiT daavadebis riski daaxloebiT 20%-ia

(Costa e Silva J. A. 1993); • depresiuli epizodi cxovrebaSi erTxel mainc gadaitana

_ 20-25%-ma qalma

_ 7-12% -ma mamakacma

• tipiuri SemTxvevebi, depresiuli avadmyofebis mxolod 10%-s Seadgenen.

ZiriTadad depresiuli aSliloba mimdinareobs waSlili, atipiuri,

ambulatoriuli e. w. SeniRbuli depresiis saxiT; • atipiuri depresiis gavrceleba populaciaSi 0,7%-ia da misi

manifestaciis saSualo asakia 35 weli;

• atipiuri depresiis struqturaSi panikuri aSlilobis komorbidoba _

14,4%_s, xolo toqsikomaniis _ 28,8%_s Seadgens (Horwath E. et al. 1992); • atipiuri depresiis xazebi SeimCneva rekurentuli depresiuli

aSlilobis mqone pacientebis 40%-Si; disTimiuris 60%-Si da

bipolarulis 50%-Si (Klein D.E., 1993); • sicocxlis manZilze disTimiis ganviTarebis riski 3_6%-s Seadgens

(Angst J. et. al 1994; Shader R. I., 1994; DSM _IV, 1994;). Aavadoba 2_jer metia

qalebSi;

6

• disTimia ZiriTadad gvxvdeba zogad samedicino praqtikaSi _ 2,1 _ 3,7% (Depression Guideline Panel, 1993). maT Soris, TiTqmis 50%-s uviTardebaT

tipiuri rekurentuli depresiuli aSliloba (Akiskal H.S. 1994).

3. guneba_ganwyobis aSlilobis eTiopaTogenezi (1, 3, 5, 6, 8)

A. biologiuri faqtorebi

genetikuri faqtorebi

kvlevebis umravlesoba miuTiTebs imaze, rom mZime depresiiT daavadebulTa

pirveli rigis naTesavebSi depresiuli aSlilobis ganviTarebis riski 10-

15%-ia, xolo zogadad populaciaSi 1-2%-s ar aRemateba.

monozigotur tyupebSi konkordantoba Seadgens 68%-s, xolo dizigotur

tyupebSi 23%-s (Price 1977); zogi avtoris azriTY es maCveneblebi Sesabamisad

74% da 43%-s aRwevs ( Angst 1966; Bertelsen et al. 1977).

memkvidreobiTobis albaToba ufro maRalia bipolaruli afeqturi

aSlilobisaTvis. bipolaruli aSliloba ufro xSirad gvxvdeba

bipolaruli aSlilobis mqone, vidre monopolaruli aSlilobebis mqone

probandebis ojaxebSi (Leonhard et al. 1962; Nurnberger, Gershon 1982). Tu erTi

mSobeli daavadebulia I tipis bipolaruli aSlilobiT, bavSvSi afeqturi

aSlilobis gamovlinebis albaToba 25%-s utoldeba. Tu orive mSobeli

daavadebulia I tipis bipolaruli aSlilobiT, bavSvSi aSlilobis

ganviTarebis albaToba 50_75%-mde izrdeba.

monoaminuri hipiTeza

monoaminuri hipoTezis Tanaxmad, adgili aqvs rogorc monoaminuri

receptorebis, aseve monoaminebis koncentraciis da aminebis cvlis

procesebis darRvevas. (Garver, Devis 1979).

monoaminuri hipoTezis mixedviT impulsis transmiterebis,

neiromediatorebis (noradrenalini, serotonini, dofamini) funqciuri

deficiti iwvevs depresias, siWarbe ki, manias. erTi monoaminuri sistemis

stimulireba iwvevs uSualo an mogvianebiT cvlilebebs meore monoaminur

sistemaSi. (Grahame_Smith D. G. 1992).

afeqturi impulsis gatarebaSi mniSvnelovani roli aqvs postsinafsuri

alfa_ da beta_adrenoreceptorebis (gvxvdeba Tavis tvinis sxvadasxva

struqturebSi) mgrZnobelobas, aseve neiromediatorebis destruqciasa da

maT ukumitacebaSi monawile agentis, MAO-s aqtiurobas.

neiroendokrinuli faqtorebi

endokrinuli cvlilebebi hipoTalamuri meqanizmebiT regulirdeba,

romelsac nawilobriv monoaminuri sistema akontrolebs. savaraudoa, rom

neiroendokrinuli darRvevebi hipoTalamusSi biogenuri aminebis miwodebis

regulirebis darRvevas gamoxataven. hipofizSi relizing-faqtoris

7

gamomuSavebis regulireba kontrolirdeba garkveuli neiromediatorebiT

da maT Soris, depresiis paTogenezSi monawile neiromediatorebiT

(noradrenalini, serotonini, dofamini).

depresiis dros hipoTalamo_hipofizo_adrenalinuri sistema

hiperaqtiuria, rac iwvevs kortizolis sekreciis momatebas cirkaduli

riTmis darRvevasTan erTad, saRamos da Ramis saaTebSi sekreciis gazrdis

xarjze (normaSi kortizolis sekreciis piki dilis saaTebze modis). amis

garda, darRveulia ukukavSiris makontrolebeli meqanizmic, ris gamoc

deqsametazonis _ sinTezuri glukokortikosteroidis Seyvana ar axdens

endogenuri kortizolis gamomuSavebis daTrgunvas.

Carroll B. (1982)–is mier, am principze Seqmnili deqsametazonuri testis

dadebiTi Sedegi aReniSneba depresiul avdmyofTa 40-60%-s, didi depresiis

dros ki _ 80%-s. uaryofiTi deqsametazonuri testi ar SeiZleba

CaiTvalos didi depresiuli epizodis uaryofis safuZvlad, radgan yvela

avadyofSi ar xdeba kortizolis sekreciis daTrgunva, garda amisa,

deqsametazonis testi dadebiTi SeiZleba iyos sxva daavadebebis (mag.

kuSingis sindromi, nervuli bulimia, alcheimeris daavadeba, alkoholizmi,

mania) da aseve, orsulobis dros.

depresiis dros Semcirebulia Tireostimulirebadi, zrdis,

folikulostimulirebadi da luTeinizirebadi hormonis, aseve

testosteronis gamonTavisufleba. maniakaluri da depresiuli sindromebis

dros Senelebulia imunuri funqciebi.

Zilis faqtori

Zilis darRveva afeqturi aSlilobis mqone pacientebis 60-65%-s aReniSneba.

depresiis dros vlindeba swrafi Zilis fazis gazrda Zilis pirvel

periodSi da zogadad swrafi Zilis periodis gazrda (CaZinebisTanave

swrafi Zilis periodis dawyeba), Semoklebulia Zilis IV faza. maniakaluri

sindromis dros Cveulebrivi movlenaa xSiri gamoRviZebebi, zogadad Zilis

xangrZlobis Semcirebis fonze.

B. fsiqosocialuri faqtorebi

mowyvladobis faqtori

a. premorbiduli pirovnuli Taviseburebebi _ arsebobs mosazreba, rom

adamianebi piknikuri aRnagobiT da cikloTimiuri temperamentiT ufro

metad arian midrekilni bipolaruli afeqturi aSlilobisadmi, xolo

leptosomuri, fsiqasTeniuri _ unipolarulisadmi;

b. fsiqoanalitikuri faqtorebi _ fsiqoanalitikosebi amtkiceben, rom

dedis gardacvalebis an ganSorebis gamo bavSvobis asakSi dedis alersis

uqonloba, mozrdil asakSi depresiuli aSlilobebisadmi ganawyobs. mania

da aweuli guneb-ganwyoba ganixileba, rogorc dacva fonuri depresiisgan.

g. kognitiuri faqtorebi _ Beck-ma 1967 wels gamoTqva mosazreba, rom

,,depresiuli azrovneba” SeiZleba pirveladi aSliloba, an ukidures

SemTxvevaSi, am aSlilobis gamomwvevi da SemanarCunebeli Zlieri faqtori

iyos. depresiis kognituri hipoTezis sayrdenia bekis kognitiuri triada: a)

sakuTari Tavisadmi negatiuri damokidebuleba _ ,,saqmeebi cudad midis,

8

imitom rom me var cudi”; b) cxovrebiseuli gamocdilebis negatiuri

interpretacia _ ,,yovelTvis yvelaferi cudad iqneba”; g) momavlis

pesimisturi xedva _ marcxis molodini.

precipitirebadi faqtorebi

grZelvadiani, gaxangrZlivebuli da mwvave stresuli movlenebi _

mecnieruli kvlevebiT dasturdeba, rom stresuli movlenebidan eqvsi Tvis

ganmavlobaSi depresiis ganviTarebis riski 6–jer matulobs, suiciduri

mcdelobis riski ki _ 7-jer (Paykel et al. 1969, 1978; Brown, Harris 1978); stres_faqtorebidan gansakuTrebuli mniSvneloba eniWeba danakliss

ganSorebis an sikvdilis gamo, faseulobaTa rRvevas, daucvelobis gancdas

da momavlis SiSs, mkveTr cxovrebiseul cvlilebebs.

mania mTlianad biologiuri faqtorebiT ganpirobebul aSlilobad

moiazreboda, magram klinikuri gamocdileba iZleva safuZvels davuSvaT,

rom mania provocirebulia, da zogjer iseTi stresuli movlenebiTac,

romelesac sxva pirovnebaSi SeiZleba depresia gamoewvia (mag. mZime

danaklisi).

C. depresiis (da maniis) zogadi samedicino da fsiqikuri komorbiduli

faqtorebi (1, 2) cxrili 1

kardiovaskularuli

• miokardiumi infarqtis Semdeg

• CVA –s Semdeg • fitv-gulis ukmarisoba

autoimunuri aSliloba

• revmatoiduri

arTriti

• sistemuri wiTeli

mglura

qirurgiuli

• Tirkmlis

transplantacia

• koronaluri arteriebis

Suntireba

endokrinuli aSlilobebi

• hipoTireoidizmi

• Saqriani diabeti

• kuSingis daavadeba

• adisonis daavadeba

• hipopituitarizmi

• akromegalia

• hipoparaTireoidizmi

• hiperparaTireoidizmi

• dismenorea

virususuli infeqciebi

• pnevmonia

• martivi herpesi

• Sidsi • mononukleozi

aravirusuli

• brucelozi

• tifi

• neirosifilisi

• tubelkuliozi

kibo

• bronqebis

• pankreasis

• ZuZus

• nawlavebis

• sakvercxis

qimioTerapiis Semdgomi

metabolituri

• Tirkmlis qr. ukmarisoba

• dializis Semdgomi

• B12 vitaminis deficiti

dermatologiuri

• fsoriazi

• egzema

ginekologia

• histereqtomiis Semdgomi

• mSobiarobis Semdgomi

9

hematologiuri

• anemia

• perniciozuri anemia

• foliumis deficiti

nevrologiuri

aSlilobebi

• parkinsonis daavadeba

• gafantuli

sklerozi

• epilefsia

• demencia

• CV _ daavadebebi • Tavis tvinis travma

• ZilSi apnoes Seteva

• hidrocefalia

• hepatocerebruli

distrofia

samedicino mizniT daniSnuli

medikamentebi

• alfa_meTildofa

• rezerpini

• prednizoloni

• kontraceptivebi

• H2 antagonistebi_

cimetidini, ranitidini,

famotidini.

• haloperidoli

• amitriftilini

• normoTimuli saSualeba

• sxva fsiqotropuli

preparatebi (mag.

bupropioni, risperidoni

arasamedicino mizniT moxmarebuli

medikamentebi

stimulirebadi prepaparatebis moxmarebis

ukuefeqti:

• kokaini, kreki

• amfetaminebi

CNS_is depresantebis Sewyveta: • alkoholi

• benzodiazepini

fsiqikuri faqtorebi

• disTimia

• panikuri aSliloba

• tikebi

• fobiebi

• osesiur-kompulsiuri aSliloba

• nervuli anoreqsia da bulimia

• personologiuri aSlilobebi

• impulsuri aSlilobebi

• somatoformulli aSlilobebi

• SfoTviTi aSlilobebi

fsiqologiuri, socialuri da biologiuri meqanizmebi ar SeiZleba

ganvixiloT, rogorc ueWveli urTierTgamomricxavi, radgan maT SeuZliaT

erTiani paTologiuri procesis gansxvavebuli doneebi warmoadginon.

4. guneba-ganwyobis aSlilobis klinikuri simptomatika (1, 3, 5, 6, 8)

afeqturi aSlilobis dros ZiriTadi darRveva mdgomareobs afeqtis anu

guneba_ganwyobis daTrgunvaSi (SfoTviT an mis gareSe) an awevaSi,

romelsac umetesad Tan axlavs zogadi aqtivobis donis Secvla, xolo

danarCeni simptomebis umravlesoba meoradia, iolad gasagebi xdeba guneba-

ganwyobisa da aqtivobis Secvlis konteqstSi. am aSlilobaTa umravlesoba

xasiaTdeba ganmeorebadobiT da fsiqosocialuri funqcionirebis

gauaresebiT, xolo calkeuli epizodis dasawyisi xSirad stresuli

movlenebiTaa provocirebuli.

10

A. depresia (1, 3 – 6, 8)

depresiis klinikuri niSnebi, simptomebi, sindromebi

• garegnoba _ depresiuli avadmyofi gamoirCeva tipiuri garegnobiT.

mTlianad mouwesrigebeli, mouvlelia, Secvlilia gamometyveleba:

daSvebulia tuCis kuTxeebi, Subli SeWmuxnulia, mzera Camqrali,

quTuToebi damZimebuli, iSviaTad axamxamebs Tvalebs. mxrebi

Camovardnilia, TavCaqindruli da Tvalebdaxrilia, Jestikulacia

minimumamdea dayvanili, zogjer ki, sruli amimiaa. miuxedavad Rrma

depresiisa zogi avadyofi saxeze Rimils inarCunebs _ momRimari anu

ironiuli depresia;

• guneba-ganwyoba _ dominirebadia melanqoliuri afeqti, romelic

SeiZleba gamovlindes naRvliani, daTrguli, melanqoliuri guneba-

ganwyobiT. vitaluri komponenti SeiZleba sxvadasxva siZlieriT iyos

gamoxatuli, msubuqi modunebidan da sicocxlis tonusis daqveiTebidan

gaqvavebis da sruli umweobis gancdamde. vitaluri gancda _ ,,sulieri

tkivilis”, ,,gulze lodis”, ,,simZimis”, ,,sulis marwuxebSi moqcevis”

SegrZnebiT, romelsac zogjer Tan axlavs mosalodneli ubedurebis

dauZleveli gancda, vitaluri naRvelis gancdas ufro xSirad Tan

axlavs SfoTva da yalibdeba SfoTviT-naRvliani afeqti, xolo

emociuri gancdebis ukmarisobis, ganurCevoblobis arsebobis dros

yalibdeba apaTiuri afeqti;

• zogadi ideatoruli Sekaveba vlindeba asociaciuri procesebis

SenelebiT, yuradRebis koncentrirebis da abstragirebis unaris

daqveiTebiT, ukiduresi daurwmuneblobiT, sakuTari pirovnebis

ignorirebiT da pesimisturi SefasebiT. gamoxatulia e. w. pesimisturi,

,,depresiuli azrovneba”_ warsuli, awmyo da momavali Savbnel ferebSia.

gamoTqvams TviTdamcirebis, TviTbraldebis da TviTganadgurebis ideebs.

dakargulia emociuri rezonansi, ndoba adamianebisadmi, situacia

aRiqmeba permanentulad uimedod, yovelgvari gamonaTebisa da

gaumjobesebis gareSe. mTlianad kargavs momavalSi sakuTari Tavis

proecirebis unars. dro Senelebulia da zogjer gaCerebulic;

• motoruli Sekaveba an aJitacia _ avadmyofi uCivis sisustes, modunebas,

daRlilobas, moZraobs nela an umoZraodaa, umetesad zis an wevs,

naklebad icvlis pozas. avadmyofs didi Zalisxmeva Wirdeba nebismieri

martivi saqmis gasakeTeblad, uWirs dawyebuli saqmis bolomde miyvana.

aJitacia gamoixateba SeuCerebel motorul aqtivobaSi. msubuqi formebis

dros, avadmyofi ikvnets frCxilebs, ifSvnets xelebs, aqvs mousveneri

mzera da fexebis mousvenari moZraoba; mZime formisas ki, avadmyofi

wrialebs, dadis win da ukan, ver Cerdeba erT adgilze;

• metyveleba _ metyvelebis tempi Senelebulia, SekiTxvebze pasuxobs

mogvianebiT, xangrZlivi pauzebiT, uRimRamod, yru, daxSuli xmiT;

• anhedonia _ dakargulia interesi, sixarulis da siamovnebis miRebis

unari, interpersonaluri urTierTobebis da socialuri kontaqtebis

moTxovnileba;

11

• biologiuri anu somato-vegetatiuri simptomebi:

- guneba-ganwyobis cirkaduloba _ depresia diliT ufro mZimea;

- Zilis darRveva _ ufro xSirad iRviZebs dilaadrian, Cveulebrivze 2-3

saaTiT adre, gamouZineblobis grZnobiT, xSirad SfoTviT da

mousvenrobiT, Savbneli fiqrebiT warsulze da momavalze. SeiZleba

uWirdes CaZineba, an eZinos wyvetili ZiliT. zogjer ki piriqiT,

depresiul avadmyofs aqvs Warbi Zilianoba;

- anoreqsia da wonaSi dakleba an bulimia da simsuqne;

- Sinagani gamofitva, ioli daRla, anergia;

- libidos daqveiTeba;

- mravlobiTi somaturi Civilebi _ Tavis, saxsrebis, gulis areSi

tkivilebi, sisxlis mimoqcevis periferiuli moSla _ akrocianozi,

sicivis SegrZneba kidurebSi, arteriuli hipertenzia; intestinaluri

problemebi: hiposalivacia, kanis da lorwovanis simSrale, yabzoba;

dismenorea, mravlobiTi fsiqalgiebi, moklebuli saTanado substrats;

• asakobrivi Taviseburebebi:

- prepubertatuli periodi _ somaturi Civilebi, aJitacia, erTi da igive

xmiT warmoTqmuli smeniTi halucinaciebi, SfoTva, fobiebi;

- pubertatuli periodi _ fsiqoaqtiuri nivTierebebis Warbi moxmareba,

opoziciuri da antisocialuri qceva, daudevroba, siZneleebi

swavlaSi, skolis gacdena, SemTxveviTi nacnoboba, sibinZure, negatiuri

Sefasebisadmi aweuli mgrZnobeloba;

- sibere _ inteleqtualuri darRvevebi, yuradRebis ioli gadanacvleba,

mexsierebis daqveiTeba, dezorientireba, cnobierebis abneva,

fsevdodemencia an demencia Serwymuli depresiasTan, apaTia;

• suiciduri riski _ suiciduri azrebis, suiciduri tendenciebis da

dasrulebuli suicidis maRali sixSiris gamo aucilebelia suiciduri

riskis Sefaseba. motivacia SeiZleba iyos sruliad gansxvavebuli,

uxSiresad dauZleveli siZneleebis gadalaxvze uaris Tqma an

usasrulo, moCvenebiTi, mtanjveli suleri gancdebisaTvis wertilis

dasmis survili.

suicidis seriozul risk-faqtors warmoadgens:

- suicidis mcdeloba wina epizidis dros;

- suiciduri mcdeloba avadmyofis naTesavebs Soris;

- TviTmkvlelobis pirdapiri an arapirdapiri muqara da Semdgomi

,,avismomaswavebeli” dumili;

- suicidisaTvis mzadeba _ sucidisaTvis aucilebeli inventaris (Toki,

sawamlavi, iaraRi da a. S.) Zieba an suiciduri aqtis konstruirebis

mcdeloba da maTi letalurobis xarisxi;

- autodestruqciuli azrebi.

suicidur risks mniSvnelovnad zrdis:

- vitaluri naRveli da SfoTva;

- Zlis darRveva;

- emociuri da socialuri izolireba;

- gabrazeba agresiuli tendenciebiT;

- gamoxatuli damnaSveobis da arasrulfasovnebis gancda;

- fsiqozuri simptomebi;

12

- azrebi ganukurnebel avadmyofobaze.

suiciduri riski maRalia:

- depresiuli epizodis dasawyisSi an bolos;

- Sereuli afeqtis dros;

- biologiur krizisul periodebSi _ pubertatuli an involuciuri

periodi, menopauzis dadgoma. (Poldinger, 1984; Deniker P., Olie J.P., 1990)

depresiuli sindromis struqturaSi ama Tu im simptomis dominireba

ganapirobebs sindromul Taviseburebas da Timoanalefsiuri mkurnalobis

taqtikas.

a. asTeniuri depresia (e. s. averbuxi, 1962) _ xasiaTdeba fsiqasTeniuri

xasiaTis Civilebis siWarbiT, emociuri labilobiT, asTeniuri tipis

azrovnebiT _ upiratesad dilis saaTebSi. misi ufro mZime formaa

gamofitvis depresia (Kielholz, 1970), romelic fsiqotravmirebadi

faqtorebis zemoqmedebiT viTardeba.

asTeniuri depresiis dros ufro efeqturia mkurnaloba gamoxatuli

mastimulirebeli efeqtis mqone antidepresantebiT.

b. apaTiuri depresiis dros dominirebs motivaciis, interesebis, emociuri

reagirebis, sasicocxlo tonusis daqveiTeba, ganurCevloba, anergia,

nebelobiTi funqciebis ukmarisoba, xolo sakuTriv melanqoliuri

afeqti, suiciduri tendenciebi, somato _ vegetatiuri simptomebi,

cirkadoba naklebadaa gamoxatuli. ukanasknel wlebSi gaxSirda

depresiebi apaTo_ abuliuri simptomebis upiratesobiT, rac zogierTi

avtoris azriT medikamentozur paTomorfozTan unda iyos

dakavSirebuli da xSirad isini farmakoTerapiisadmi torpidulobiT

gamoirCevian.

depresiis apaTo_anergiuli da adinamiuri variantebis mkurnalobisas

aqcenti unda gakeTdes mastimulirebeli moqmedebis mqone

antidepresantebze, aseve mao–s Seuqcevad inhipitorebze.

g. SfoTviTi depresia. klinikuri suraTi gamoirCeva foriaqis, aJitaciis,

somato_vegetatiuri simptomebis siWarbiT. saRamos mdgomareoba

SeiZleba damZimdes. xSiria TviTdanaSaulis, TviTbraldebis ideeebi,

aseve ipoqondriuli gancdebi da fobiebi.

mkurnalobisas ZiriTadi aqcenti unda gakeTdes Zlieri

Timoanaleptiuri da sedaciuri efeqtis mqone antidepresantebis

gamoyenebaze. Terapiuli efeqti, SfoTviani depresiis adeqvaturi

mkurnalobisas, daaxloebiT 60-70%-ia.

zogi avtori Tvlis, rom SfoTviTi depresia ufro moxucebuli

asakisTvisaa damaxsiaTebeli. zogierTi mkvlevaris azriT ki es aris

depresiuli avadmyofebis gansakuTrebuli qvejgufi, daavadebis

SedarebiT adreuli asakobrivi dasawyisiT, midrekilebiT xSiri

recidivebisa da gaxangrZlivebuli mimdinareobisadmi, ufro maRali

13

suiciduri riskiT da naklebad keTilsaimedo Terapiuli da

socialuri prognoziT. (Gersh S., Fowles D. C., 1979; Fawcett J., 1988; Murphy J. M., 1993; Cassano G. B. et al. 1993).

d. cremliani depresia _ xasiaTdeba sustsulovnebiT, afeqtis labilobiTa

da SeukaveblobiT, ususurobiTa da fsiqikuri hiperesTeziiT;

e. disforiuli anu buzRuna depresia, romlisTvisac damaxasiaTebelia

gandgoma, buzRuni, ioli gamRizianebloba, yvelafrisadmi zizRi,

pirquSi ganwyoba, zogjer Tanmxlebi vitaluri naRveliT. xasiaTdeba

mdgomareobis gaxangrZlivebiT da iSviaTi cvalebadobiT, Tumca

mdgomareoba uecrad SeiZleba Seicvalos agznebiT, braziT, agresiuli

da autoagresiuli tendenciebiT. es depresia, rogorc wesi organuli

ukmarisobis fonze viTardeba.

depresiis klinikuri suraTi, simZimis xarisxis mixedviT

depresiuli epizodi SeiZleba iyos msubuqi, saSualo (zomieri) da mZime.

msubuqi, hipoTimiuri depresia ufro xSirad daavadebis dasawyisSi

gvxvdeba, SemdegSi depresiuli epizodi ufro zomierad gamoxatul, tipiur

xasiaTs iRebs, an wina planze gamodis heteronomuri an somato

vegetatiuri simptomebi.

a. msubuqi depresiis dros avadmyofi garegnulad ar gamoiyureba

daTrgunulad. uCivis guneba-ganwyobis daqveiTebas, uRonobas, siamovnebis

miRebis unaris dakargvas, momatebul gamRizianeblobas, Zilis darRvevas

_ uWirs CaZineba, Rame uwydeba Zili da mxolod gamTeniisas iZinebs.

,,biologiuri” niSnebi, rogorc wesi ar vlindeba, Tumca guneba-ganwyoba

SeiZleba icvlebodes dRis ganmavlobaSi, saRamos Cveulebriv uaresia,

vidre diliT. msubuqi depresiis dros ufro xSirad gvxvdeba e. w.

,,nevrozuli” simptomebi: fobia, SfoTva obsesiuri da isTeriuli

simptomebi, ris gamoc zogi avtori msubuq depresias nevrozul

depresias uwodebs.

fsiqosocialuri funqcionireba gaZnelebulia.

b. zomieri depresia xasiaTdeba gamoxatuli simptomebis zomierebiT da

harmoniuli depresiuli triadiT _ guneba-ganwyobis daqveiTeba,

sixarulis gancdis unaris dakargva, pesimisturi azrovneba, energiis

daqveiTeba, rac fsiqosocialuri funqcionirebis gauaresebas da Sromis

unaris daqveiTebas iwvevs.

g. mZime depresias xSirad win uZRvis hipoTimiuri depresia.

fsiqopaTologia fenomenologiurad zomieri depresiisagan bevri

arafriT ar gansxvavdeba, depresiul simptomTa ufro meti intensivobis,

ufro farTe speqtris da mdgomareobis gansakuTrebuli mdgradobis

garda.

14

DmZime depresiis dros:

• klinikur suraTSi dominirebs daTrgunuli melanqoliuri guneba-

ganwyoba (dardi, SfoTva, naRveli), interesebis dakargva,

ganurCevloba, anhedonia. darRveulia interpersonaluri

urTierTobebi da fsiqosocialuri funqcionireba. gamoxatulia

ideatoruli da motoruli Sekaveba. viTardeba adinamiuri anu

Sekavebuli depresia an zogjer fsiqikuri anesTezia;

• klinikur suraTSi aJitirebuli depresiis dominirebis dros

avadmyofi mousvenaria, wrialebs, kargavs mizanmimarTuli saqmianobis

unars. TviTbraldebis, codvianobis, TviTdanaSaulis da

ganukurneblobis zeRirebulovani ideebis fonze, msjelobs

sikvdilze, cxovrebis uazrobaze, gamoTqvams suicidur azrebs,

adgens TviTmkvlelobis gegmebs, eZebs saSualebebs.

mZime depresiuli aSlilobisaTvis damaxasiaebelia somato_vegetatiuri

gamovlinebebis mravavalferovneba da mdgradoba.

depresiis gaRrmavebis SemTxvevaSi viTardeba, ufro iSviaTi, depresiis

fsiqozuri formebi.

fsiqomotorulma Sekavebam SeiZleba miaRwios depresiuli stuporis

xarisxs _ sruli umoZraobiT, mkveTri bradifsiqizmiT, zogjer sruli

mutizmiT da cnobierebis abneviT. avadmyofi saWiroebs gansakuTrebul

mzrunvelobas da yuradRebas, mdgomareoba SeiZleba Seicvalos uecari

agznebiT an impulsuri suiciduri mcdelobiT.

mZime depresiis struqturaSi SfoTvis upiratesobisas, misi Semdgomi

gaZlirebis fonze, SesaZlebelia ganviTardes melanqoliuri raptusi an

fuga _avadmyofi oTaxSi wrialebs, oxravs, kvnesis, yviris, imtvrevs xelebs,

iyenebs travmebs, mosalodnelia suciduri mcdeloba.

zeRirebulovani depresiuli ideebi qmnis substrats damnaSaveobis,

TviTdamcirebis, codvianobis, TviTbraldebis, gaRatakebis, gansjis,

mosalodneli damsaxurebulad dasjis, ganukurneblobis da a.S. bodviTi

ideebis formirebisaTvis da yalibdeba bodviTi depresia anu bodviTi

melanqolia, roca bodviTi ideebi ZiriTadad wamyvani afeqtis Sesatyvisi _

kongruentulia. ufro iSviaTad viTardeba devnis bodva _ ,,melancholie de persecution” _ am SemTxvevaSi laparakia depresiul_paranoidul sindromze.

gaSlili depresiul-paranoiduli sindromi xasiaTdeba depresiuli

derealizaciiT da depersonalizaciiT, mwvave grZnobadi,

intermetamorfozis da miniSnebis bodviT, mcdari SecnobebiT,

iluzorul_bodviTi aRqmiT. bodvis fabula, rogorc wesi, dakavSirebulia

danaSaulis, gansjis, dasjis moaxloebuli katastrofis ideebTan. am

simptomatikas SeiZleba Tan axldes verbaluri halucinaciebi.

halucinaciuri gancdebis dominirebis SemTxvevaSi calke gamoyofen

depresiis halucinaciur formas.

depresiuli afeqtis da bodviTi ideebis Semdgomi damZimeba iwvevs

melanqoliuri parafreniis anu fantastikuri melanqoliis ganviTarebas.

depresiis fsiqozuri formebis dros SesaZlebelia afeqtis

arakongruentuli bodvis da halucinaciis, anu heteronomuli

procesualuri simptomebis _ fsiqikuri avtomatizmebi,

15

katatonur_hebefrenuli simptomebi, devnis, zemoqmedebis bodva, azrovnebis

specifiuri darRvevebi da sxva _ aRmoceneba.

atipiuri depresia

garda martivi da bodviTi depresiebisa, bolo dros klinikur praqtikaSi

xSirad gvxvdeba depresiis gansakuTrebuli sindromaluri variantebi

waSlili, disharmoniuli, disociaciuri simptomatikiT.

a. anesTeziuri depresia, romelic ayalibebs depresias

depersonalizaciiTa da derealizaciiT, xasiaTdeba emociuri

gaucxovebis gancdiT, avadmyofebi uCivian ara imdenad guneba-ganwyobis

daqveiTebas, dards an SfoTvas, ramedenadac gancdis da emociis,

TanagrZnobis unaris uqonlobas. aRniSnaven, rom dakarges raRac kavSiri

samyarosTan, rom Seicvala samyaros aRqma, garemom dakarga Cveuli

feradovneba, umoZrao, usicocxlo da uRimRamo gaxda. xmebi daxSuli

da monotonuria. gamoxatulia anhedonia. ufro mkveTrad gamoxatuli

depresiuli derealizaciisas avadmyofebs euflebaT gancda, rom

imyofebian burusSi, samyaro Tejirs miRmaa, itanjebian emociuri

siClungis, garemosTan emociuri rezonansis dakargvis gamo. vitaluri

komponenti warmodgenilia gulis areSi da TavSi gaxevebis, gaqvavebis,

sicarielis gancdiT. fiqomotoruli Sekaveba sustadaa gamoxatuli an

saerTod ar arsebobs. sakmaod xSirad gvxvdeba somatofsiqikuri

depersonalizacia _ dakargulia Zilis, SimSilis, tkivilis da a.S.

SegrZneba. rTul SemTxvevebSi viTardeba anaesthesia psychica dolorosa. zogjer SeiZleba ganviTardes uecari motoruli agzneba, rac zrdis

suicidis risks;

b. depresia akviatebebiT xasiaTdeba klinikur suraTSi obsesiuri,

kompulsiuri an fobikuri simptomebis upiratesobiT. ufro xSirad

akviatebebi uviTardebaT pirebs premorbiduli fsiqasTeniuri xazebiT

xasiaTSi. depresiis struqturaSi akviatebuli mdgomareoba SeiZleba

iyos ipoqondriuli fobiis (kancerofobia, kardiofobiis, nozofobiis

da sxva), kontrastuli akviatebis (pirovnebis Seusabamo

moralur_eTikuri faseulobebis), akviatebuli meryeobis da

indiferentuli Sinaarsis ideatoruli akviatebebis saxiT. iSviaTia

akviatebuli moqmedebebi da rTuli ritualebi. sakuTriv depresiuli

afeqti zomierd an sustad aris gamoxatuli;

g. SeniRbuli (larvirebuli, latenturi, faruli, somatizirebuli)

depresia xasiaTdeba klinikur suraTSi somaturi da vegetatiuri

simptomebis an sxva fsiqopaTologiuri registris aSlilobisaTvis

damaxasiaTebeli darRvevebis upiratesobiT, xolo tipiuri depresiuli

afeqti waSlilia an saerTod ar aris, am ukanasknels zogjer uwodeben

,,depresias depresiis gareSe” an ,,depresiul ekvivalents”.

bolo wlebSi SeniRbuli depresiis calke gamoyofa fenomenologiuri

fsiqiatriis erT_erT mniSvnelovan warmatebad unda CaiTvalos.

avtorTa umravlesoba (Kielholz P., 1973; Lopez-Ibor J., 1973; Less S., 1983; da sxv.) SeniRbuli depresias viwro gansazRvrebas iZleva da mas miakuTvnebs,

mxolod endogenuri depresiis somatizirebul formebs. depresias

16

mkveTrad gamoxatuli somato-vegetatiuri funqciuri darRvevebiT da

ipoqondriul depresias Cveulebriv ganixilavs SeniRbuli depresiis

farglebSi.

SeniRbuli depresiis klinikuri niSnebia:

• momatebuli SfoTva sakuTari janmrTelobis gamo;

• warmosaxvebi gansakuTrebiT mZime daavadebebze;

• mravlobiTi somaturi da vegetatiuri aSliloba _ taqikardia,

wnevis meryeoba, oflianoba, dismnezia, gulisreva, gulis areSi

SeteviTi xasiaTis tkivili, myari Tavbrusxveva, kuW-nawlavis

traqtis aSliloba, mravalricxvovani fsiqalgia da paresTezia,

SedarebiT iSviaTad, Civilebi sayrden_mamoZravebeli sistemis

da sunTqvis organoebis mxriv da sxva.

_ warmoadgens depresiis niRabs.

• ukiduresad ucnauri xasiaTis vitaluri gancda, dilis saaTebSi

somaturi Civilebis saxiT;

• dauzustebeli lokalizaciis senestopaTiebi;

• klinikur substrats moklebuli somaturi Civilebi;

• dausrulebeli vizitebi sxvadasxva profilis eqimebTan

damatebiTi gamokvlevebis moTxovniT, miuxedavad somaturi

darRvevebis ararsebobisa;

• guneba-ganwyobis umniSvnelo daqveiTeba. SesaZlebelia SesamCnevi

iyos depresiuli afeqtis niSnebi _ gaRaribebuli moZraobebi,

SeSfoTebuli mzera, damaxasiaTebeli mobuzuli poza da saxis

naRvliani gamometyveleba;

• depresiis somaturi niSnebi _ libidos, Zilisa da madis

darRveva, anhedonia an vitaluri gancdebi moWeris, dabuJebis,

simZimis SegrZnebiT gulis an epigastriumis areSi;

• umniSvnelo inteleqtualuri Sekaveba;

• ukmayofileba fsiqiatrTan gaSvebiT _ is daiRala ara marto

Tavis daavadebiT, aramed eqimebiTac;

am darRvevebis depresiisaTvis mikuTvneba SesaZlebelia:

• memkvidruli mowyvladobis;

• simptomebis sezonurobis da cirkadobis;

• anamnezSi ufro tipiuri afeqturi _ depresiuli da

ganasakuTrebiT hipomaniakaluri periodebis arsebobis;

• xSiri suiciduri tendenciebis;

• Timoanaleptiuri mkurnalobis kargi efeqtis gamo;

guneba-ganwyobis (afeqturi) qronikuli aSliloba

a. disTimia

disTima warmoadgens qronikul depresiul aSlilobas. gamoyofen pirvelad

da meorad disTimiebs, aseve disTimiebs adreuli da mogvianebiTi

dasawyisiT. pirveladi anu ,,sufTa” disTimia Cveulebriv viTardeba

17

TandaTanobiT, bavSvobis an pubertatul asakSi, swrafad iRebs qronikul

xasiaTs (21 w-mde) da ar aris dakavSirebuli raime winamorbed fsiqikur

aSlilobasTan. meoradi disTimia iwyeba mogvianebiT, ukve arsebuli

fsiqikuri an somaturi daavadebis fonze. disTimiis es forma pirvelad

aRwera H.Weitbrecht_ma (1954) endoreaqtiuli disTimiis saxeliT. misi azriT

aSliloba uviTardebaT emociurad arastabilur, sensitiur pirebs

fsiqotravmirebad situaciaSi. zogierT avadmyofs disTimiuri aSlilobis

fonze ufro mkveTrad gamoxatuli depresiuli epizodi e. w. ,,ormagi

depresia” uviTardeba (Keller M.B., Shapiro R.W., 1982; Keller M.B. 1994 da sxv.), romelic aseve gamoirCeva qronikuli mimdinareobiT, didi depresiuli

epizodebis recidivebis sixSiriT da Timoanaleptiuri mkurnalobisadmi

rezistentobiT. DSM_IV–is monacemebiT, rekurentuli depresiuli

aSlilobis 20_25%-s Seadgens avadmyofebi ,,ormagi depresiiT”, aqedan

srulyofili remisia viTardeba avadmyofebis 3%_Si, sxva SemTxvevebSi

remisiebs Soris yovelTvis rCeba ama Tu im xarisxis disTimiuri

simptomebi.

disTimiis ZiriTadi maxasiaTebelia:

• aSlilobis TandaTanobiTi dasawyisi da qronikuli mimdinareoba;

• TiTqmis mudmivad arsebuli an remitirebadi ara Rrma depresiuli

simptomebi, romelic ar warmoadgens rezidualurs depresiuli

epizodis Semdeg;

• Tanmxlebi pirovnuli paTologia, romelic pirdapir ar monawileobs

simptomebis formirebaSi;

• socialuri funqcionirebis SedarebiTi stabiluroba;

• depresia ufro subieqturia, vidre obieqturi.

disTimiis ZiriTadi klinikuri simptomebia:

• madis daqveiTeba an gaumaZRroba;

• uZiliba an Warbi Zilianoba;

• anergiuloba an daRliloba;

• daqveiTebuli TviTSefaseba;

• yuradRebis koncentrirebis gaZneleba;

• gadawyvetilebis miRebis gaZneleba;

• uimedobis grZnoba.

ufro iSviaTad gvxvdeba:

• sakuTari ugergilobis grZnoba;

• anhedonia;

• interesebis dakargva;

• gulCaTxrobiloba;

• mwuxareba an danaSaulis gancda warsulis gamo;

• gamRizianebloba an brazi;

• aqtivobisa da produqtulobis daqveiTeba.

Zalze iSviaTia:

• tipiuri somato-vegetatiuri darRvevebi;

18

• melanqoliuri depresiis cirkadul_vitaluri niSnebi;

• gamoxatuli fsiqomotoruli Sekaveba;

• suiciduri azrebi;

• bodviTi aSliloba.

G

b. cikloTimia

cikloTimia xasiaTdeba qronikuli fluqtuirebadi mimdinareobiT da

mravlobiTi hipomaniakaluri da msubuqad an zomierad gamoxatuli

depresiuli epizodebiT. cikloTimiis klinikaSi ar gvxvdeba fsiqozuri

simptomebi. qalebSi da mamakacebSi Tanabari sixSiriT viTardeba, rogorc

wesi mozardobis an ymawvilobis asakSi iwyeba da Tan axlavs alkoholis

da fsiqoaqtiuri nivTierebebis Warbi gamoyeneba. depresiuli aSliloba

ufro xSiria pirdapir naTesavebSi, vidre populaciaSi. emociuri

aSlilobis rekurentulobam SeiZleba gamoiwvios fsiqosocialuri

funqcionirebis gauareseba.

B. maniakaluri epizodis klinika (1, 3, 6, 8)

maniis klinikuri niSnebi, simptomebi da sindromebi

• garegnoba _ avdmyofi gamoiyureba gaaxlgazrdavebuli, gabrwyinebuli

TvalebiT da Sefakluli loyebiT, yovelmxriv cdilibs yuradRebis

centrSi moqcevas _ Warbad iyenebens kosmetikas, icvams gamomwvevad,

eqscentrulad, zedmetad mkveTr ferebSi, Seuxameblad;

• aweuli guneba-ganwyoba _ avadmyofi optimisturi, eqspansiuri da

eiforiulia, romlis realuri mizezi ara Tu ar arsebobs, aramed

SeiZleba avadmyofis cxovrebasTan groteskulad Seusabamoc ki iyos.

aweuli guneba-ganwyobis xarjze yvela movlens dadebiTad aRiqvams.

SeiZleba gamovlindes momatebuli gamRizianebloba, brazi, agresia;

• azrovnebis darRveva _ vlindeba tempis aCqarebaSi. asociaciuri

procesebis aCqarebuli da daukavSirebelia, viTardeba ,,ideaTa rbola”.

zogjer gvxvdeba Sinarsobrivi darRvevac _ avadmyofi axdens sakuTari

SesaZleblobebis gadafasebas, aRmocendeba gandidebis zeRirebulovani

ideebi. yuradRebis koncentrireba gaZnelebulia, SesaZlebelia

hipermnezia;

• motoruli aqtivoba _ momatebulia qmediToba _ erTdroulad iwyebs

uamrav saqmes, romelic bolomde ver mihyavs. saqmianoba xdeba umizno da

uSedego, vlindeba garTobisadmi, azartuli TamaSebisadmi, alkoholisa

da narkotikebis moxmarebisadmi midrekileba. avadmyofi flangavs fuls,

qonebas, xSirad debs wamgebian da moufiqrebel xelSekrulebebs;

• metyveleba _ avadmyofi laparakobs swrafad, xmamaRla, dramatulad,

Teatralurad, CaxleCili xmiT. asociaciuri procesebis Zlieri

aCqarebis gamo, metyveleba nakadis xasiaTs atarebs da SeiZleba

daukavSirebelic gaxdes;

19

• vegetatiuri funqciebi energia mozRvavebulia, pulsi aCqarebulia,

daqveiTebulia Zilis moTxovnileba. aweulia libido, rac xSirad

SemTxveviTi seqsuluri kavSirebis da arasasurveli orsulobis mizezi

xdeba. mada ufro xSirad momatebulia, magram motoruli agznebisa da

uZilobis gamo ikleben wonaSi. mkurnalobis gareSe, TandaTanobiT

viTardeba sruli gamofitva;

• adeqvaturi Sefasebis da daskvnis gakeTebis, racionaluri

gadawyvetilebis miRebis unari daqveiTebulia, xdeba sakuTari

avadmyofobis sruli uaryofa.

maniakaluri epizodis klinikur suraTSi, rogori simZimisac ar unda iyos

is, wamyvani yovelTvis aris afeqturi fonis da vitalur _ energetikuli

tonusis momateba. maniis struqturaSi am ori komponentis gamovlineba

faravs somatovegetatiur darRvevebs. ama Tu im simptomis dominirebis

mixedviT gamoyofen maniis sxvadasxva sindromul variantebs:

• mxiaruli mania _ optimisturi guneba-ganwyoba, zomieri metyvelebiTi da

motoruli agznebiT; es varianti Seesabameba K. Leonhard (1957)–is aRweril ,,sufTa manias”, romelic xasiaTdeba eiforiuli guneba-

ganwyobiT, dadebiTi vitaluri TviTgrZnobiT da sakuTari

SesaZleblobebis gadafasebiT, aseTi qceva avadmyofs dabrkolebas ar

uqmnis socialuri funqcionirebisas;

• disforiuli mania _ aweuli guneba-ganwyoba ukmayofilebiT,

modaveobiTa da gamRizianeblobiT; xasiaTdeba fsiqikuri funqciebis

aCqarebiT, gandidebis zeRirebulovani ideebiT, fsiqomotoruli

agznebiT, braziT, rasac SesaZloa agresiuli qceva moyhves;

• eqspansiuri mania _ fsiqikuri procesebis aCqarebas Tan axlavs

gandidebis zeRirebulovani ideebi, saqmianobisadmi uzomo ltolva _

sistematurad problemebis mogvarebaSia, flangaven fuls da qonebas,

debs realurad Seusrulebel pirobebs da xelSekrulebebs, ris

Sedegadac xSirad gakotrebamde midis da kargavs socialur statuss;

• mania abneviT anu mania ,,ideaTa rboliT”_ aweuli guneba-ganwyobis

fonze, asociaciebis aCqareba, dawyveta, daukavSirebeli metyveleba da

uwesrgo motoruli agzneba;

• araproduqtiuli mania _aweuli guneba-ganwyoba da motoruli agzneba

araproduqtiul metyvelebasTan erTad;

• bodviTi mania _ aweuli guneba-ganwyoba, fobikur warmonaqmnebsa da

iSviaTad, interpretaciul bodvasTan erTad. xSiria gandidebis da

devnis bodva, iSviaTad _ damokidebulebis. SesaZlebelia

halucinaciebis CarTvac;

• Sekavebuli mania _ aweuli guneba-ganwyoba da metyvelebiTi agzneba

motoruli Sekavebis fonze, romelic zogjer stuporis intensivobas

aRwevs;

• mania oxunjobiT _ aweuli guneba-ganwyoba motoruli da metyvelebiTi

agznebiT, manerulobiT, bavSvurobiT, jambazobiT, briyvuli xumrobebiT;

20

• maniakaluri agzneba _ furor maniakalis _ mdgomareoba mkveTrad

gamoxatuli fsiqomotoruli agznebiT, braziT, agresiiTa da

damangreveli qmedebebiT;

• asakobrivi Tavisebureba _ mozardebSi maniis niSnebi vlindeba

fsiqoaqtiuri nivTierebebis Warbi moxmarebis da asocialuri qmedebebis

saxiT.

maniis klinikuri suraTi simZimis xarisxis mixedviT

maniakaluri aSlilobis simZimes tipiuri maniakaluri sindromis

gamovlinebis xarisxis garda, ganapirobebs klinikur suraTSi

heteronomuri siptomebis gamoCena da fsiqosocialuri funqcionirebis

done.

a. hipomania _ maniakaluri sindromis msubuqi formaa, xasiaTdeba fsiqo-

fizikuri tonusis momatebiT, sifxizlis, fizikuri da fsiqikuri

keTildReobis grZnobiT, aweuli guneba-ganwyobiT da optimizmiT. aweulia

TviTSefaseba. fsiqikuri funqcionireba _ aRqma, damaxsovreba, azrovneba _

gaiolebulia, aweulia saqmianobisadmi ltolva. avadmyofs sZinavs

xanmokle, magram Rrma ZiliT, dgeba fxizlad, swrafad energiulad,

damajereblad akeTebs misTvis Cveul saqmes, warmatebulia sawavlaSi,

samsaxurSi. miuxedavad didi raodenobiT energiis xarjvisa ver grZnobs

daRlas. gaZlierebulia mada, pulsi aCqarebulia, gamococxlebulia mimika

da metyveleba, gamoiyureba axalgazrdulad, energiuli moZraobebiT.

xSirad Znelia Seicno am mdgomareobis avadmyofuroba, axloblebis mier

igi aRiqmeba, rogorc saqmiani, yuradRebiani, mxiaruli, kontaqturi,

mixvedrili, xumara, iniciativiani da TviTdajerebuli adamiani. Cveuli

eiforia zogjer SeiZleba Seicvalos gaRizianebiT da uxeSobiT, magram es

ar iwvevs socialuri da SromiTi funqcionirebis darRvevas.

hipomania xSirad SeimCneva maniis dawyebis an maniidan gamosvli dros, misi

avadmyofurobis Secnoba mxolod gamoxatul maniakalur an depresiul

mdgomareobaSi gadasvlis Semdeg xdeba SesaZlebeli.

b. gamoxatuli maniakaluri sindromi _ avdmyofs damaxasiaTebeli

garegnuli ieri aqvs: Tvalebi gabrwyinebulia, saxe hiperemiuli, mimika

cocxali, mxiarul ganwyobazea, ganmsWvalulia optimizmiT, uzrnveli da

uproblemoa, araferi ar adrdebs da ar aRelvebs. dro da dro mxiaruli

da laRi ganwyoba, garegani faqtorebis zemoqmedebiT, icvleba eWviT,

gamRizianeblobiT da braziT, magram es afeTqebis xasiaTs atarebs da

swrafad qreba.

asociaciebi, azrovnebis tempi aCqarebulia, yuradReba gafantuli.

gamoTqvams zeoptimistur da eqspansiur zeRirebulovan azrebs. aweulia

sakuTari Rirsebis gancda, adgens grandiozul gegmebs da ver xedavs

veraviTar dabrkolebas. axdens sakuTari SesaZleblobebis gadafasebas.

avdmyofi laparakobs bevrs, swrafad, uwyvetad, afrqvevs nerwyvis Sxefebs,

xma exliCeba, gamoTqmebi araTanmimdevrulia, swrafad xteba erTi Temidan

meoreze, uxvevs ZiriTad Temas, yoveli wvrilmani ubiZgebs saubari axali

mimarTulabiT waiyvenos, ise rom veRar ubrundeba ZiriTads, azrovneba

21

wyvetili xdeba, viTardeba ,,ideaTa rbola” (fuga). xSirad iyenebs

kalamburebs, xumrobebs, citatebs, zogjer bilwsityvaobs, uadgilod

icinis, stvens, ukravs, mReris Txzavs leqsebs, yvelas siyvaruls eficeba,

saubarSi iniciativas iRebs da ugulebelhyofs SekiTxvebs. qmnis

erTdroulad mxiarul da daZabul atmosferos.

avadmyofi grZnobs energiis mozRvavebas, misTvis yvelaferi SesaZlebeli

da dasaSvebia, moZraobs swrafad, erT adgilze ver isvenebs, xSirad

icvlis pozas, wrialebs, dadis an darbis oTaxSi, yvalaferSi cxvirs yofs.

gaZlierebulia seqsualuri moTxovnileba da mada, Wams fexze mdgari,

swrafad, dauReWavad ylapavs. aRfrTovanebiT esalmeba yvelas. maniakaluri

agzneba saRamos kidev ufro Zlierdeba, Rame ver iZinebs, an Zinavs cota da

zedapiruli ZiliT. agznebis momatebisas xdeba cinikuri, gaSiSvlebuli,

seqsualuri uxeSobiT. hiperaqtiuroba da mizidulobebis gaZliereba

problemebs uqmnis mikro da makro socialur garemosTan urTierTobaSi.

mosalodnelia saxifaTo an kriminaluri qmedeba.

miuxedavad momatebuli aqtiurobisa da saqmianobisadmi ltolvisa,

daqveiTebulia produqtiuloba da darRveulia Cveuli fsiqosocialuri

funqcionireba.

g. fsiqozuri mania _ maniakaluri epizodis damZimeba xdeba fsiqozuri

simptomebis _ bodvis, halucinaciebis da cnobierebis abnevis damatebis

xarjze.

aweuli TviTSefasebisa da gandidebis zeRirebulovani ideebi gardaiqmneba

afeqtis kongruentul gandidebis, gansakuTrebuli warmoSobis eqspansiur

bodviT azrebad, xolo maniakaluri sindromis struqturaSi

gamRizianeblobis da eWvianobis dominirebis dros, viTardeba devnis bodva.

bodva Cveulebriv gamoirCeva mcire masStabiT, faqtis konstataciis xasiaTs

atarebs da ar xdeba misi inteleqtualuri gadamuSaveba. avadmyofis

cnobiereba ara aris koncentrirebuli bodviT produqciaze, TiTqos

mxolod keTilganwyobis, optimizmis, energiulobis gamoxatvas emsaxureba

da avadmyofi mas fizikuri da sulieri yovlisSemZleobis

damadastureblad ,,igonebs”, ris gamoc ,,gaTamaSebis” STabeWdilebas

tovebs. gansxvavebiT depresiuli mdgomareobisa, avadmyofi maniakaluri

parafreniis drosac ki, ar aris mocululi bodviTi gancdebiT. avadmyofis

gamoTqmebSi bevri fantaziaa, meryeobs, gadarwmunebis mcdelobisas am

ideebze iolad ambobs uars. fsiqikuri statusis damZimebisas ideaTa

rbola midis abnevamde. metyveleba gaugebari xdeba. piradi higienis,

sakvebis da siTxis miRebisadmi daudevarma damokidebulebam SeiZleba

gamoiwvios sicocxlisTvis saxifaTo mdgomareoba.

maniis struqturaSi ,,arakongruentuli” gulisxmobs afeqturad neitralur

bodviT da halucinaciur aSlilobas, mag. damokidebulebis bodva

damnaSaveobisa da braldebis gareSe, an xmebi, romlebic esaubrebian

avadmyofs misTvis emociurad neitralur Temaze.

C. Sereuli afeqturi aSliloba (1, 6, 8, 18)

afeqturi aSlilobis dros zogjer depresiuli da maniakaluri simptomebi

erTdroulad arsebobs, hiperaqtiur, sityvauxv pacients SeiZleba Rrma

22

depresiuli azrebi qondes, an aweul guneba-ganwyobasa da gandidebis

ideebs Tan axldes SfoTva, aJitireba, aqtivobis da libidos daqveiTeba, an

ideaTa rbola da hiperTimiuri afeqti iyos motoruli Sekavebis fonze,

rac SeZlebelia gadaizardos maniakalur stuporSi. sxva SemTxvevaSi

SesaZlebelia depresiuli, hipomaniakaluri an maniakaluri simptomebis

swrafi alternireba; mag. maniakaluri avadmyofi ramdenime saaTiT SeiZleba

mZime depresiam moicvas, Semdeg ki isev swrafad dabrundes maniakalur

mdgomareobaSi. (Griesinger 1867; Kotin, Guodwin 1972).

5. guneba-ganwyobis (afeqturi) aSlilobis diagnostireba (1, 7, 18, 19)

guneba-ganwyobis aSlilobis diagnostikuri kriteriumebi DSM-IV_is

mixedviT (1, 19)

a. didi depresiuli epizodis kriteriumebi (DSM-IV):

• daTrgunuli gunaba-ganwyoba, dRis umetes dros da TiTqmis

yoveldRiurad, subieqturi SefasebiT (mag. dardis da sicarielis

grZnoba) an obieqturi dakvirvebiT (mag pacienti tiris);

SeniSvna: bavSvebSi da mozardebSi SesaZlebelia iyos gamRizianebloba.

• gamoxatulia interesebis daqveiTeba an nebismieri tipis saqmianobidan

siamovnebis miRebis unaris dakargva dRis umetes dros da TiTqmis

yoveldRiurad (subieqturi SefasebiT an obieqturi dakvirvebiT);

• wonis mniSvnelovani dakleba, romelic ar ukavSirdeba dietas an

wonaSi momateba (mag. TveSi 5%-iT);

• uZiloba an Zilianoba, TiTqmis yoveldRiurad;

• fsiqomotoriuli agzneba an Sekaveba, TiTqmis yoveldRiurad,

obieqturi dakvirvebiT;

• daRliloba, Zalis dakargva TiTqmis yoveldRiurad;

• sakuTari uvargisobis da damnaSaveobis gazviadebuli grZnoba

(romelic SeiZleba bodviTi xasiaTis iyos), TiTqmis yoveldRiurad;

• azrovnebis da yuradRebis koncentrirebis unaris daqveiTeba,

daurwmunebloba TiTqmis yoveldRiurad (sibieqturi SefasebiT an

irgvlimyofebis azriT);

• perioduli fiqrebi sikvdilze da TviTmkvlelobaze, an

TviTmkvlelobis spontanuri mcdeloba an suicidi dagegmvis Sedegad.

diagnostikuri Sefaseba:

• xuTi an meti zemoT CamoTvlli simptomebi arsebobs 2 kviris manZilze

da iwvevs normaluri funqcionirebis daqveiTebas, aqedan erT-erTi

simptomi mainc unda iyos daqveiTebuli gunaba-ganwyoba an garemosadmi

interesis da siamovnebis miRebis unaris dakargva.

23

SeniSvna: am simptomebSi ar igulisxmeba somaturi daavadebiT

ganpirobebuli simptomebi, aseve afeqtis Seusabamo bodvebi da

halucinaciebi;

• simptomebi ar Seesabameba Sereuli epizodis kriteriumebs;

• simptomebi iwveven klinikurad gamoxatul distress an funqcionirebis

darRvevas socialur, SromiT da sxva sferoSi; • simptomebs ar aqvs pirdapiri paTofiziologiuri kavSiri fsiqoaqtiuri

nivTierebebis gamoyenebasTan da ar aris ganpirobebuli somaturi an

nevrologiuri daavadebiT; • simptomebi ar aris gamowveuli mZime danaklisiT.

b. melanqoliis diagnostikuri kriteriumebi (DSM-IV):

a. nebismieri qvemoT CamoTvlili simptomi arsebobs mimdinare epizodis

ufro mZime periodis ganmavlobaSi:

• raime saxis saqmianobidan siamovnebis miRebis unaris dakargva;

• reaqciis uqonloba im stimulze, romelic Cveulebriv siamovnebas

aniWebda (sasixarulo movlenazec ki gunaba-ganwyoba ar umjobesdeba). b. sami an meti qvemoT CamoTvlili simptomebidan:

• mkafiod gamoxatuli depresiuli guneb-ganwyoba;

• depresiis gamovlineba ufro gamoxatulia diliT; • diliT adre gamoRviZeba (Cveulebrivze >2 sT); • gamoxatuli fsiqomotoruli agzneba an Sekaveba; • gamoxatuli umadoba an wonaSi dakleba; • danaSaulis gadaWarbebuli an usafuZvlo gancda.

g. maniakaluri epizodis diagnostikuri kriteriumebi (DSM-IV):

• guneba-ganwyobis mdgradi aweva, eqspansiurobiT da gamRizianeblobiT,

romelic grZeldeba aranaklebi erTi kviris manZilze (an nebismieri

xangrZlivobiT, hospitalizaciis aucileblobis SemTxvevaSi);

• qvemoT CamoTvlili sami an meti simptomi am periodis ganmavlobaSi

mdgradia da gamoxatulia mniSvnelovnad (4 simptomi, Tu guneba-

ganwyoba gamRizianeblobiT xasiaTdeba):

- sakuTari pirovnebis gadafaseba da midrekileba grandiozuli

ideebisaken midrekilebiT;

- Zilis moTxovnilebis daqveiTeba (mag. dRe-RameSi 3 saaTi); - Cveulebrivze ufro meti laparaki an laparakis moTxovnileba; - azrovnebis tempis aCqareba an ideaTa rbolis subieqturi SegrZneba; - paologiurad gamoxatuli yuradRebis gafantva (garegan nebismier

umniSvnelo stimulze yuradRebis gadanacvleba); - momatebuli aqtiuroba, mimarTuli raime miznis (socialuri,

profesiuli, saganmaTleblo, seqsualuri) misaRwevad an

fsoqomotoruli agzneba; - ukiduresi gataceba siamovnebis momtani saqmianobiT, romelmac

SeiZleba damRupveli Sedegi gamoiRos (mag. ukontrolo ltolva

garTobis mizniT sayidlebis keTebisadmi, SemTxveviTi seqsualuri

kavSirebi da kapitalis uazrod dabandeba). • simptomebi ar Seesabameba Sereuli epizodis kriteriumebs;

24

• gamoxatuli emociuri aSliloba iwvevs socialuri da SromiTi

funqcionirebis da interpersonaluri urTierTobebis mniSvnelovan

darRvevas; zogjer aucilebelia hospitalizeba, raTa SesaZlo

safrTxe aarido piradad mas da irgvlivmyofebs.

SeiZleba ganviTardes fsiqozuri mdgomareoba;

• simptomebs ar aqvs pirdapiri paTofiziologiuri kavSiri

fsiqoaqtiuri nivTierebebis gamoyenebasTan da ar aris ganpirobebuli

somaturi an nevrologiuri daavadebiT;

SeniSvna: maniakaluri epizodis msgavsi simptomebi, romelic depresiis

mkurnalobis dros ganviTarda, ar unda iyos gaTvaliswinebuli I

tipis bipolaruli aSlilobis diagnostirebis dros.

d. DSM-IV (1994)_Si guneba_ganwyobis aSlilobis sistematizebisTvis

gamoyofilia Semdegi diagnostikuri kategoriebi:

291. 8X guneba-ganwyobis aSliloba gamowveuli alkoholiT da

fsiqoaqtiuri nivTierebebis gamoyenebiT

293. 83 guneba-ganwyobis aSliloba gamowveuli somaturi daavadebiT

didi depresiuli epizodi:

296. 2X didi depresiuli aSliloba erTaderTi epizodi;

296. 3X didi depresiuli aSliloba, rekurentuli mimdinareoba;

bipolaruli aSliloba

296. XX bipolaruli I aSliloba

. 0X erTdaerTi maniakaluri epizodi

. * Sereuli xasiaTis

. 40 mimdinare hipomaniakaluri epizodi

. 4X mimdinare maniakaluri epizodi

. 5X mimdinare epizodi Sereuli xasiaTis

. 6X mimdinare depresiuli epizodi

. 7X mimdinare epizodi dauzustebeli

296. 89 bipolaruli II aSliloba

* mimdinare an bolo epizodi hipomaniakaluri/depresiuli

296. 80 bipolaruli aSliloba dauzustebeli

296. 90 guneba-ganwyobis aSliloba dauzustebeli

300. 4 disTimiuri aSliloba

301. 13 cikloTimiuri aSliloba

guneba_ganwyobis sxva aSlilobebi

311 depresiuli aSliloba dauzustebeli

Ab. guneba-ganwyobis (afeqturi) aSlilobis diagnostikuri kriteriumebi _

ICD_10; F30_F39; (7,18)

F30 _ maniakaluri epizodi

gamoyofilia simZimis sami xarisxi, romlisTvisac saerTo ZiriTadi

kriteriumia:

25

• guneba-ganwyobis aweva;

• fsiqo-fizikuri aqtivobis tempis da moculobis gazrda.

am kategoriis qverubrikebi, SeiZleba gamoyenebuli iyos mxolod

erTaderTi maniakaluri epizodis dros.

F 30. 0 hipomania

kriterimebi:

• guneba-ganwyobis msubuqad aweva;

• momatebuli energiuloba da aqtivoba;

• fsiqo-fizikuri keTildReobis da produqtulobis gancda.

aseve:

• momatebuli socialuri aqtivoba;

• Warbsityvaoba;

• zedmeti familaroba;

• aweuli seqsualuri aqtivoba;

• Zilis moTxovnilebis daqveiTeba;

• yuradRebis koncentrirebis gaZneleba.

eiforiulobisa da momatebuli socialuri aqtivobis nacvlad SeiZleba

iyos:

• gamRizianebloba;

• momatebuli TviTSefaseba;

• uxeSi qceva.

diagnostirebisTvis aucilebeli pirobaa:

• aweuli an Secvlili guneba-ganwyobis zemoT moyvanili simptomidan

zogierTi mainc unda arsebobdes uwyvetad, aranaklebi ramdenime

dRisa, ramdenadme meti siZlieriT da meti mudmivobiT, vidre

cikloTimiis dros (F34.0); • fsiqosocialuri funqcionireba SenarCunebulia, miuxedavad

nawilobrivi gaZnelebisa.

F30.1 mania fsiqozuri simptomebis gareSe

ZiriTadi kriteriumebia:

• aweuli guneba-ganwyoba, romelic Seusabamoa realobasTan (SeiZleba

varirebdes uzrunveli mxiarulebidan ukontrolo agznebamde);

• energiis siWarbe:

• hiperaqtivoba;

• metyvelebis aCqareba;

• Zilis moTxovnilebis daqveiTeba.

damatebiTi kriteriumebia:

• socialuri normebis ignorireba da aqedan gamomdinare ukontrolo

qcevebi;

• gaZnelebulia yuradRebis koncentrireba, iolad xdeba gadanacvleba;

• momatebulia TviTSefaseba;

• gamoTqvams ze-optimistur da gandidebis ideebs.

26

SesaZlebelia iyos:

• aRqmis darRveva, subieqturi hiperakuzia;

• moufiqrebeli, mouridebeli da eqstravaganturi gadawyvetilebebi;

• gamRizianebloba da agresia;

dignostikuri miTiTeba:

• pirveli Seteva ufro xSirad 15-30 wlis askSi iwyeba (SesaZleblia

nebismier asakSi dawyeba);

• epizodi unda gagrZeldes aranaklebi erTi kvira;

• simptomebis simZimem unda gamoiwvios fsiqosocialuri funqconirebis

darRveva;

• gamoxatuli unda iyos aweuli guneba-ganwyoba

da

• momatebuli energiuloba;

• metyvelebis aCqareba;

• Zilis moTxovnis daqveiTeba;

• gandidebis azrebi;

• gadaWarbebuli optimizmi.

F30.2 mania fsiqozuri siptomebiT

diagnostikuri miTiTeba:

• F 30.1 –is klinikuri suraTi damZimebulia;

• gamoxatuli ideaTa rbola SesaZlebelia mivides abnevamde;

• metyveleba gaugebaria;

• maniakalur afeqts Tan erTvis fsiqozuri simptomebi _ bodva,

halucinacia, cnobierebis abneva, romelic SeiZleba iyos:

FXX.20 _ afeqtis kongruentuli. mag. gandidebis zeRirebulovani

ideebis da aweuli TviTSefasebis fonze viTardeba gansakuTrebuli

warmoSobis da gandidebis eqspansiuri bodva, xolo gamRizianeblobis

da eWvianobis dominirebis dros, viTardeba devnis bodva;

FXX.21 _ afeqtis arakongruentuli _ afeqturad neitraluri

halucinaciuri da bodviTi aSliloba. mag. damokidebulebis bodva

danaSaulis grZnobisa da braldebis gareSe an xmebi, romlebic

esaubrebian avadmyofs misTvis emociurad neitralur Temebze.

damatebiTi kriteriumebi:

• mosalodnelia agresia da Zaladoba aRgznebis gamo;

• SesaZlebelia dehidratacia da xelmiSvebuloba sakvebis, siTxis

miRebisa da piradi higienisadmi daudevari damokidebulebis gamo.

F31 bipolaruli afeqturi aSliloba

ZiriTadi dignostikuri kriteriumebi:

• ganmerebadi afeqturi epizodebi, romlis drosac guneba-ganwyoba da

fsiqo-fizikuri aqtivoba mniSvnelovnadaa darRveuli (depresia, mania,

hipomania an Sereuli afeqti);

27

• epizodebs Soris Cveulebriv aris sruli gamojanmrTeleba;

• avadoba Tanabaria qalebsa da mamakacebs Soris.

damatebiTi diagostikuri kriteriumebia:

• manakaluri epizodi Cveulebriv iwyeba mwvaved da grZeldeba

saSualod 4 Tves (SesaZlebelia _ 2 kviridan 5 Tvemde);

• depresiuli epizodi grZeldeba saSualod 6 Tves, iSviaTad erT

wlamde (moxucebSi iRebs gaxangrZlivebul da qronikul

mimdinareobas);

• pirveli epizodi SeiZleba ganviTardes nebismier asakSi.

F31.0; F31.1; F31.2_bipolaruli afeqturi aSliloba mimdinare epizodi

<hipomaniakaluri epizodi>, M<maniakaluri epizodi fsiqozuri simptomebis

gareSe>, <maniakaluri epizodi fsiqozuri simptomebiT>

diagnostikuri miTiTeba:

• mimdinare epizodi pasuxobs saTanadod …<hipomaniakaluri epizodi (F 30.0) >, M<maniakaluri epizodi fsiqozuri simptomebis gareSe (F30.1) >, <maniakaluri epizodi fsiqozuri simptomebiT (F30.2) > kriteriumebs;

• anamnezSi unda iyos sul mcire erTi afeqturi aSlilobis epizodi

mainc (hipomaniakaluri, maniakaluri, depresiuli an Sereuli

epizodi).

F31.3; F31.4; F31.5 _ bipolaruli afeqturi aSliloba mimdinare epizodi

<msubuqi an zomieri depresiis>, <mZime depresiis fsiqozuri simptomebis

gareSe>, <mZime depresiis fsiqozuri simptomebiT>

diagnostikuri miTiTeba:

• mimdinare epizodi pasuxobs saTanadod: <msubuqi an zomieri depresia

(F32. 0; F32. 1)>, <mZime depresiis fsiqozuri simptomebis gareSe (F32. 2)>, <mZime depresiis fsiqozuri simptomebiT (F32. 3)> kriteriumebs;

• anamnezSi unda iyos sul mcire erTi afeqturi aSlilobis epizodi

mainc (hipomaniakaluri, maniakaluri an Sereuli epizodi).

F31. 3 _ am rubrikaSi diagnostirebis dros SeiZleba gamoyenebuli iyos:

F31. 30 somaturi simptomebis gareSe;

F31. 31 somaturi simptomebiT.

• Tu gamoxatulia 4 an meti somaturi simptomi;

• an 2 an 3 sakmaod mkveTrad gamoxatuli somaturi simptomi.

F31. 2 da F31. 5 rubrikaSi diagnostirebis dros SesaZlebelia gamoyenebuli

iyos me-5 maCvenebeli fsiqozuri simptomebis kongruentulobis

aRsaniSnavad:

• FX. X0 _ wamyvani afeqtisadmi kongruantuli;

• FX. X1 _ wamyvani afeqtisadmi arakongruentuli.

28

F31. 6 bipolaruli afeturi aSliloba, mimdinare Sereuli epizodi

ZiriTadi diagnostikuri kriteriumia:

• anamnezSi unda iyos sul mcire erTi afeqturi aSlilobis epizodi

mainc (hipomaniakaluri, maniakaluri, depresiuli an Sereuli

epizodi);

• mimdinare epizodSi vlindeba hipomaniakaluri, maniakaluri an

depresiuli simptomebi Sereuli an alternirebadi saxiT (afeqtis

cvlileba SesaZlebelia dRegamoSvebiT an saaTobriv xdebodes);

• aucilebelia ori afeqtis Sereuli simptomebis arseboba Tanabari

siZlieriT, aranaklebi ori kviris manZilze.

F31. 7 bipolaruli afeqturi aSliloba, remisiis mdgomareoba

dignostikuri kriteriumebi:

• avadmyofs warsulSi unda hqondes erTi dadasturebuli

hipomaniakaluri maniakaluri an Sereuli tipis afeqturi epizodi

mainc;

• damatebiT, kidev erTi, hipomaniis, maniis, depresiis an Sereuli

afeqturi epizodi;

• mocemul periodSi ar unda iyos afeqturi aSliloba;

• dasaSvebia avadmyofi agrZelebdes profilaqtikur mkurnalobas

recidivis Tavidan acilebis mizniT.

F31. 8 sxva bipolaruli afeqturi aSlilobebi

• bipolaruli aSliloba II tipi;

• rekurentuli maniakaluri epizodebi.

F 32 depresiuli epizodi

F 32.0; F 32.1; F32.2; F32.3 rubrikaSi depresiuli epizodis dignostirebisas

aucilebeli pirobaa:

• depresiuli mdgomareobis xangrZlivoba unda iyos ara naklebi 2

kvirisa;

• anamnezSi ar undaiyos maniakaluri an hipomaniakaluri epizodebi;

• epizodi ar unda ukavSirdbodes fsiqoaqtiuri nivTierebis miRebas,

sxva fsiqikur an somatur aSlilobas.

ZiriTadi kriteriumebia:

• guneba-ganwyobis daqveiTeba;

• interesebis da siamovnebis miRebis unaris dakargva; • energiis daqveiTeba aqtivobis daqveiTebiT da daRlilobis grZnoba.

29

damatebiTi kriteriumebia:

• yuradRebis koncentrirebis unaris daqveiTeba;

• sakuTar TavSi rwmenis da TviTSefasebis daqveiTeba;

• TviTbraldebis da TviTdamcirebis dausabuTebeli ideebi;

• momavlis bundovani da pesimisturi xedva;

• xSiri, ganmeorebadi azri an qmedeba TviTdazianebisa da

TviTmkvlelobis mizniT;

• Zilis darRveva;

• madis daqveiTeba.

depresiis tipiuri simptomebi:

• daqveiebuli guneba-ganwyoba naklebad icvleba garegani faqtorebis

zegavleniT da ikavebs dRis umetes nawils;

• xasiaTdeba cirkadulobiT;

• SesaZlebelia SfoTva uimedoba da aJitacia ufro metad iyos

gamoxatuli, vidre depresia.

guneba-ganwyobis daqveiTeba SesaZlebelia SeniRbuli iyos damatebiTi

simptomebiT:

• gamRizianeblobiT;

• alkoholis Warbi moxmarebiT;

• isTeriulobiT;

• obsesiur-kompulsiuri simptomebiT;

* somato-vegetatiuri simptomebiT.

gansakuTrebuli klinikuri mniSvneloba aqvs depresiis somato-

vegetatiur anu “melanqoliis” niSnebs:

• Cveulebriv misTvis sasiamovno saqmianobisadmi interesis da

siamovnebis miRebis unaris dakargva _ anhedonia;

• emociuri reaqtiulobis dakargva garemosa da movlenebze;

• diliT Cveul droze adre gamoRviZeba ( >2 saaTiT);

• depresia ufro mZimea dilaobiT;

• madis mkveTri daqveiTeba;

• wonaSi dakleba_bolo erTi Tvis manZilze 5%-iT;

• fsiqomotoruli Sekaveba an aJitacia _ obieqturi monacemebi

mkveTrad gamoxatul Sekavebasa an aJitaciis Sesaxeb;

• libidos daqveiTeba;

F 32.0 msubuqi depresiuli epizodi

dignostikuri miTiTeba:

klinikur suraTSi warmodgenili unda iyos:

• depresiis minimum ori ZiriTadi kriteriumi

• da ori damatebiTi kriteriumi mainc

• arc erTi simptomi ar unda iyos gamoxatuli Rrma xarisxSi;

• depresiuli epizodis xangrZlivoba unda iyos aranaklebi 2 kvira.

30

tipiuri simptomebia:

• guneba-ganwyobis daqveiTeba;

• interesebis dakargva da anhedonia;

• ioli daRla.

me-5 niSanis gamoyeneba SesaZlebelia somaturi sindromis

aRsaniSnavad:

FXX. X0 _ somaturi simptomebis gareSe;

FXX. X1 _ somaturi simptomebiT

• akmayofilebs msubuqi depresiuli epizodis kriteriumebs;

• da Tan axlavs 4 an meti somaturi simtomi an

• Tan axlavs 2 an sami mZime somaturi simptomi.

msubuqi depresiuli epizodis dros, miuxedavad siZneleebisa

fsiqosocialuri funqcionireba SenarCunebulia.

F32. 1 _ zomierad gamoxatuli depresiuli epizodi

diagnostikuri miTieba:

• ZiriTadi kriteriumebidan minimum oris arseboba;

• ZiriTad kriteriumebTan erTad 4-5 damatebiTi kriteriumis arseboba

me-5 niSanis gamoyeneba SesaZlebelia somaturi sindromis aRsaniSnavad:

FXX. X0 _ somaturi simptomebis gareSe;

FXX. X1 _ somaturi simptomebiT

• akmayofilebs zomieri depresiuli epizodis kriteriumebs;

• da Tan axlavs 4 an meti somaturi simtomi an

• Tan axlavs 2 an 3 mZime somaturi simptomi.

fsiqo-socialuri funqcionireba zomieri depresiuli epizodis dros

mniSvnelovnad gaZnelebulia.

F32. 2 mZime depresiuli epizodi fsiqozuri simptomebis gareSe

mniSvnelovnadaa gamoxatuli:

• mousvenroba da aJitacia an SesaZlebelia Sekaveba;

• sakuTari arasrulfasovnebis, TviTdanaSaulis da TviTbraldebis

azrebi;

• maRalia suiciduri riski;

• mudmivia somato-vegetatiuri simptomebi.

dignostikuri miTiTeba:

• saerTo sami ZiriTadi kriteriumidan samive arsebobs;

31

• ZiriTad kriteriumebTan erTdroulad arsebobs aranaklebi 4

damatebiTi kriteriumi, romelTagan nawili mZime xarisxiT unda iyos

warmodgenili;

• depresiuli epizodi unda grZeldebodes aranaklebi 2 kvira;

• mwvave dasawyisis da simptomebis gansakuTrebuli simZimisas,

dasaSvebia mZime depresiuli epizodis diagnostireba 2 kviraze adre.

mZime depresiuli epizodis dros avadmyofis fsiqosocialuri

funqcionireba mkveTrad SezRudulia.

F32. 3 mZime depresiuli epizodi fsiqozuri simptomebiT

diagnostikuri miTiTeba:

• Seesabameba mZime depresiuli epizodis (F32. 2), kriteriumebs,

romelsac Tan erTvis:

• bodviTi ideebi, ufro xSirad TviTbraldebis, TviTdanaSaulis

codvianobis, danaklisis Sinaarsis;

• smeniTi an ynosviTi halucinaciebi _ xmebi, romlebic adanaSauleben

da Seuracxyofas ayeneben an gaxrwnili xorcis da sibinZuris suni;

• depresiuli stupori _ mZime motoruli Sekaveba SeiZleba stuporSi

gadaizardos.

Tu arsebobs amis saWiroeba, bodva da halucianacia SeiZleba

ganisazRvros, rogorc F

F32. 30 _ wamyvani afeqtis kongruentuli an

F32. 31 wamyvani afeqtis arakongruentuli

F33. rekurentuli depresiuli aSliloba

ZiriTadi diagnostikuri kriteriumebia:

• depresiis ganmeorebadi epizodebi (msubuqi _ F32.0; zomieri _ F32.1; an mZime _ F32.2);

• maniakaluri epizodebis (F30.1 ; F30.2), ararseboba anamnezSi; • dasSvebia anamnezSi hipomaniakaluri epizodis F30.0-is arseboba, Tu

is moyveba uSualod depresiul epizods da SesaZlebelia

Timoanaleptiuri mkurnalobis Sedegi iyos.

damatebiTi kriteriumebia:

• pirveli depresiuli epizodi viTardeba ufro gvian, vidre

bipolaruli depresiis dros, Sua xnis asakSi;

• epizodis xangrZlivoba aris 3 _12 Tve (saSualod 6 Tve);

• depresiuli epizodi umetesad gamojanmrTelebiT mTavrdeba;

• iSviaTad, gansakuTrebiT moxucebSi, iRebs qronikul xasiaTs;

• nebismieri siZlieris calkeuli epizodi, xSirad stresuli

situaciiT aris provocirebuli;

• 2-jer ufro xSiria qalebSi.

diagnostikuri miTiTeba:

32

• unda akmayofilebdes rekurentuli depresiuli aSlilobis

kriteriumebs;

• mimdinare epizodi akmayofilebs depresiuli epizodis kriteriumebs

Sesabamisad: F33.0 _ F32.0; F33.1 _ F32.1; F33.2_ F32.2; F33.3 _ F32.3; • warsulSi unda iyos, aranaklebi ori kviris xangrZlivobis, sul

mcire ori epizodi da maT Soris ramdenime Tve intervali, raime

mniSvnelovani darRvevis gareSe.

F34 guneba-ganwyobis qronikuli (afeqturi) aSliloba

am kategoriaSi Semavali afeqturi aSlilobebi:

• xasiaTdeba qronikuli an fluqtuirebadi mimdinareobiT;

• calkeuli epizodi Tavisi siRrmiT ver akmayofilebs hipomaniis an

msubuqi depresiis kriteriumebs;

• xangrZlivi mimdinareobis gamo daqveiTebulia fsiqosocialuri

funqcionireba;

• zogjer SeiZleba maniis an depresiis rekurentuli an erTeuli

epizodi zed daedos qronikul afeqtur aSlilobas;

• qronikuli afeqturi aSlilobis dros adgili aqvs afeqturi

paTologiiT memkvidrul datvirTvas;

• zogjer aseTi avadmyofebi dadebiTad reagireben igive

Timoanaleptiur mkurnalobaze, romelzec saerTod afeqturi

aSlilobis mqone avadmyofebi;

• SesaZlebelia iyo adreuli an mogvianebiTi dasawyisiT.

F34. 0 cikloTimia

ZiriTadi dignostikuri kriteriumebia:

• guneba-ganwyobis mudmivi, qronikuli meryeoba, msubuqi depresiis an

ganwyobis msubuqad awevis mravalricxvovani periodebi;

• afeqturi epizodebi xanmoklea da arasakmarisad gamoxatuli;

• arcerTi periodi ar akmayofilebs bipolaruli, rekurentuli,

maniakaluri an depresiuli epizodis kriteriumebs.

F34. 1 disTimia

ZiriTadi dignostikuri kriteriumebia:

• qronikuli depresiuli guneba-ganwyoba;

• mocemul momentSi depresia siZlieriT ver akmayofilebs

rekurentuli depresiuli aSlilobis kriteriumebs.

F34. 8 sxva qronikuli afeqturi aSlilobebi

am rezidualur kategorias miekuTvneba qronikuli afeqturi aSliloba,

romelic klinikurad mniSvnelovania, magram arasakmarisi simZimisa da

xangrZlivobis gamo ver akmayofilebs cikloTimiis (F34. 0) an disTimiis

33

(F34. 1); aseve, msubuqi (F32. 0) an zomieri (F32. 1) depresiuli epizodis

kriteriumebs.

F34. 9 guneba-ganwyobis (afeqturi) dauzustebeli qronikuli aSlilobebi;

F38 guneba-ganwyobis (afeqturi) sxva aSlilobebi

F38. 0 guneba-ganwyobis (afeqturi) erTeuli aSliloba

F38. 00 Sereuli afeqturi epizodi

afeqturi epizodi, romelic grZeldeba ara naklebi 2 kviris

ganmavlobaSi da xasiaTdeba hipomaniakaluri, maniakaluri da

depresiuli simptomebis swrafi monacvleobiT (Cveulebriv ramdenime

saaTis ganmavlobaSi) an Sereuli simptomebiT.

F38. 1 guneba-ganwyobis (afeqturi) sxva rekurentuli aSliloba

F38. 10 xanmokle rekurentuli depresiuli aSliloba

xanmokle depresiuli epizodebi, aRmocenebuli, bolo wlis

ganmavlobaSi, daaxloebiT TveSi erTxel. TiToeuli epizodis

xangrZlivoba aris 2 kviraze naklebi (tipiuria 2-3 dRe, sruli

gamojanmrTelebiT), magram pasuxobs msubuqi, zomieri an mZime

depresiuli epizodis kriteriumebs (F32.0; F32.1; F32.2)

F38. 8 guneba-ganwyobis (afeqturi) sxva dazustebuli aSliloba

es aris rezidualuri kategoria afeqturi aSlilobebisaTvis,

romelic ar pasuxobs F30. 0 _ F38. 1 kategoriis kriteriumebs.

F39 guneba-ganwyobis (afeqturi) dauzustebeli aSliloba

am kategoriis gamoyeneba xdeba roca sxva gansazRvreba ar arsebobs.

34

B. guneba-ganwyobis aSlilobis diferencialur-diagnostikuri algoriTmi ICD_10-is mixedviT (5)

cxrili #2

daqveiTebuli guneba-ganwyoba

organuli dazianebis Sedegad diax organuli afeqturi darRveva

(F 06.3) ara

fsiqoaqtiuri preparatebis fsiqoaqtiuri nivTierebiT gamowveuli

zemoqmedebi Sedegad diax fsiqikuri aSliloba (F1) ara

depresiis ramdenime gamoxatuli bolo 12 Tvis manZilze

Sizofreniis saerTo

simptomis arseboba (2 kvira) diax kriteriumebis arseboba, ara

ara romelTagan zogierTi isev

aris warmodgenili(F20) diax

postSizofreniuli depresia

(F20.4) ara

Sizofreniis erTi an ori

kriteriumis arseboba (F20) diax ara

depresiuli tipis

Sizoafeqturi aSliloba

(F25. 1) diax

depresiuli epizodi

( de - F32) anamnezSi maniakaluri,

hipomaniakaluri an Sereuli diax bipolaruli afeqturi

epizodis arseboba aSliloba (F31) ara

anamnezSi de –s arseboba diax rekurentuli depresiuli

ara aSliloba (F33)

guneba-ganwyobis xangrZlivi daqveiTaba, diax

romelic ar pasuxobs de –s ( F32) disTimia (F34.1) kriteriumebs

ara

guneba-ganwyobis xangrZlivi arastabiluroba

ganwyobis msubuqi awevis periodebiT diax cikloTimia (F34.0) ara

stresiT gamowveuli tranzitoruli(<1 Tve) diax xanmokle depresiuli

msubuqi depresiuli mdgomareoba reaqcia (F43.20) ara

stresuli situaciis xangrZlivi zemoqmedebiT diax prolongirebuli depresiuli

gamowveuli msubuqi depresiuli mdg-ba(< 2w.) reaqcia (F43.21) ara

depresiuli simptomebi, romlebis ar pasuxoben diax guneba-ganwyobis (afeqturi)

guneba-ganwyobis romelime specifiur aSlilobas sxva aSliloba(F38.8)

35

C. afeqturi aSlilobis mimdinareoba da prognozi (1, 2, 5, 8)

afeqturi aSlilobis mimdinareoba da gamosavali iseve mravalferovania,

rogorc fsiqopaTologiuri suraTi.

afeqtur aSlilobas SeiZleba cxovrebaSi erTaderTi depresiuli (iSviaTad

maniakaluri) epizodis, unipolaruli (rekurentuli) an bipolaruli

(hipomaniakaluri, maniakaluri da depresiuli epizodebis monacvleoba)

mimdinareobis saxe hqondes. zog SemTxvevaSi epizodebs Soris

mravalwliani remisiebia, zojer aSliloba mimdinareobs xanmokle

depresiuli epizodebis seriebis saxiT. asakis matebasTan erTad iklebs

remisiis xangrZlivoba. epizodi SesaZlebelia Sereuli afeqtis saxiT iyos

warmodgenili.

Denner D.L. (1976) da Angst J. ( 1978) _ is Sromebidan moyolebuli, miRebulia

bipolaruli aSlilobis dayofa bipolarul _ I da bipilarul _ II tipad.

I gulisxmobs maniakalur depresiuli fsiqozis tipur mimdinareobas,

gaSlili maniakaluri da depresiuli fazebis an upiratesad maniakaluri

epizodebis monacvleobiT, II _ mimdinareobs gaSlili, upiratesad

depresiuli da calkeuli hipomaniakaluri epizodebis monacvleobiT

romelmac, SeiZleba miiRos kontinualuri saxe. am sistematikis mixedviT,

cikloTimia pirovnuli aSlilobis diagnostikuri kategoriidan kvlav

gamocalkevebulia da Setanilia mcire intensivobis afeqturi speqtris

bipolarul aSlilobebSi.

bipolaruli aSlilobis depresiuli epizodis kupirebisas SesaZlebelia

fazis Terapiuli inversia, maniakaluri simtomebis ganviTareba, rac

Terapiis ZiriTad problemas warmoadgens.

afeqturi aSlilobis mimdinareobis da prognozis statistikuri

parametrebi Semdegnairad gamoiyureba:

• unipolaruli aSliloba 25-45 wlis, xolo bipolaruli 15-25 wlis

asakSi manifestirdeba;

• populaciaSi rekurentuli depresiuli aSlilobis gavrceleba 4-5-jer

ufro metia, vidre bipolarulis;

• depresiuli epizodis spontanuri xangrZlioba: unipolarulis dros

saSualod 6-10 Tve, xolo bipolarulis dros 4 Tvea, SeiZleba

gaxangrZlivdes 6-12 Tve;

• depresiuli epizodebis raodenoba sicocxlis manZilze saSualod 5-s

udris;

• pirveli depresiuli epizodidan pirveli 6 Tvis ganmavlobaSi

avadmyofebis sul mcire 70-80%-s uviTardebaT;

• depresiuli aSlilobis unipolaruli mimdinareobisas prognozi

ZiriTadad keTilsaimedoa:

- gamojanmrTeldeba da ubrundeba socialuri funqcionirebis

premorbidul dones avadmyofebis 50%;

- reducirebuli rezidualuri simptomatika aReniSneba avadmyoebis

30%-s;

- daavadeba iRebs qronikul xasiaTs SemTxvevaTa 20%-Si, rasac xels

uwyobs komorbiduli faqtorebis arseboba.

• pirveli depresiuli epizodis Semdeg praqtikulad SeuZlebelia

iwinaswarmetyvelo aSlilobis Semdgomi mimdinareoba;

36

• maniakaluri mdgomareobis ganviTarebis albaToba ufro maRalia

depresiis epizodis:

- adreul asakSi mwvaved manifestirebisas;

- simptomebis damZimebisas, gansakuTrebiT fsiqomotoruli SekavebiT da

fsiqozuri simptomebiT;

- pubertatul periodSi fsiqopaTologiuri darRvevebis ar

arsebobisas.

• disTimiuri aSlilobis mqone pacientebis 20-30%-Si viTardeba

depresiuli epizodi _ e. w. ormagi depresia;

• cikloTimiuri aSlilobis mqone pacientebis 1/3-Si viTardeba

ZiriTadad II tipis bipolaruli afeqturi aSliloba

• SemTxvevaTa 45%-Si maniakaluri epizodi meordeba;

• maniakaluri epizodis xangrZlivoba 4-6 Tvea, recidivis maRali

albaTobiT;

• maniakaluri epizodebiT mimdinare afeqturi aSlilobis dros, droTa

ganmavlobaSi, avadmyofebis 80-90%-Si depresiuli epizodic viTardeba.

• afeqturi aSlilobis prognozi sakmaod keTilsaimedoa:

- gamojanmrTeleba avadmyofTa 15% -Si;

- arasruli gamojanmrTeleba da mravlobiTi recidivebis ganviTareba

epizodebs Soris adaptaciis kargi maCveneblebiT 50-60%-Si;

- qronificirebis da socialuri dezadaptaciis albaTobaa SemTxvevaTa

1/3-Si.

• daavadebis simZimesa da qronikul xasiaTze, cxovrebis xarisxis

mniSvnelovan daqveiTebaze miuTiTebs Semdegi faqtebi:

- unipolaruli mimdinareobisas avadmyofebi Tavisi cxovrebis drois

30%-s depresiul mdgomareobaSi atareben, aqedan cxovrebis 10%-s

saavadmyofoSi;

- bipolaruli aSlilobis dros es cifrebi Sesabamisad 60% da 40% -

aRwevs (Levin S., 1986). • SemTxvevaTa 5-10%-Si bipolaruli aSliloba prognozulad

arakeTilsaimedo swrafcikluri mimdinareobis xasiaTs iRebs, romlis

drosac weliwadSi 4 da meti afeqturi epizodi viTardeba, rac

socialur _ SromiTi adaptaciis donis seriozul daqveiTebas da

invalidizacias iwvevs;

• bipolaruli afeqturi aSlilobis dros ar aris genderuli sxvaoba.

6. gamokvlevis sqema _ laboratoriuli da fsiqologiuri gamokvleva (1,8-12)

A. deqsametazonuri testi

hipoTalamo_hipofizur-adrenalinuri sistemis hiperaqtivobiT gamowveuli

kortizolis hipersekreciis daTrgunva ar xdeba deqsametazonis Seyvanis

Sedegad _ testze dadebiTi pasuxi. SezRudulia misi klinikuri gamoyeneba

testis sirTulisa da maRali cdomilebis gamo.

37

B. fsiqologiuri testebi

depresiis sakvlevi unificirebuli skalebi:

• bekis depresiis kiTxvari;

• hamiltonis depresiis Sefasebis Skala.

bekis depresiis kiTxvari (11,12)

(Beck Depression Inventory _ BDI)

A. 0. me ar var sevdiani

1. me sevdiani var

2. me mudam sevdiani var da unari ar Semwevs moviSoro es gancda

3. me imdenad sevdiani da ubeduri var, rom amis atana aRar SemiZlia

B. 0. me Cveulebriv uimedod ar vuyureb Cems momavals

1. me uimedoba meufleba Cemi momavlis gamo

2. me vgrZnob, rom momavalSi araferi ar maqvs saimedo

3. me vgrZnob, rom Cemi momavali sruliad uimedoa da amas araferi ar

eSveleba

C. 0. me ar vTvli Tavs warumatebel adamianad

1. me vgrZnob, rom sxva adamianebTan SedarebiT naklebad warmatebuli

var

2. me cxovrebaSi uamravi warumatebloba mqonda

3. me vgrZnob, rom sruliad warumatebeli adamiani var

D. 0. me iseTive siamovnebas viReb cxovrebidan, rogorc adre

1. me cxovrebidan iseT siamovnebas veRar viReb, rogorc adre

2. me Zalian miWirs raime siamovnebis miReba cxovrebidan

3. me saerTod veranair siamovnebas veRar viReb cxovrebidan

E. 0. me ara maqvs danaSaulis gancda

1. me zogjer maqvs danaSaulis gancda

2. me TiTqmis yovelTvis mawuxebs danaSaulis gancda

3. me mudmivad maqvs danaSaulis gancda

F. 0. me ar mawuxebs gancda, rom davisjebi

1. me vfiqrob, rom SeiZleba davisajo

2. me velodebi dasjas

3. me aucileblad davisjebi

38

G. 0. me ar var ukmayofilo sakuTari TaviT

1. me guli gamityda sakuTar Tavze

2. me mgonia, rom autaneli var

3. me mezizReba sakuTari Tavi

H. 0. me skuTari Tavi sxvebze nakleb adamianad ar mimaCnia 1. me Secdomebis gamo sakuTar Tavs xSirad vakritikeb

2. me mudmivad vsayvedurob sakuTar Tavs mravali naklis gamo

3. me yvelaferSi sakuTar Tavs vadanaSauleb

I. 0. me ara maqvs TviTmkvlelobis azrebi

1. me zogjer miCndeba TviTmkvlelobis azri, magram me maT ar vyvebi

2. me Tavis mokvla minda

3. me Tavs moviklav, rogorc ki amis SesaZlebloba meqneba

J. 0. me ar vtiri Cveulebrivze ufro mets 1. amJamad gacilebiT mets vtiri, vidre saerTod mCvevia

2. me axla sul vtiri

3. adre SemeZlo metira, axla ki tirilis unaric davkarge

K. 0. me ar vRiziandebi Cveulebrivze ufro metad.

1. me gacilebiT advilad vRiziandebi, Cveulebrivze ufro advilad

vgrZnob Tavs Suracxhyofilad.

2. mudmivad gaRizianebuli var

3. sul aRar maRizianebs is ambebi, rac adre maRizianebda

L. 0. sxva adamianebis mimarT interesi ar maqvs dakarguli

1. adrindelTan SedarebiT sxva adamianebi axla naklebad

mainteresebs

2. sxva adamianebis mimarT interesi umetesad dakarguli maqvs

3. absoluturad davkarge yovelgvari interesi adamianebis mimarT

M. 0. me Cveulebisamebr advilad viReb gadawyvetilebebs

1. me xSirad varideb Tavs raime gadawyvetilebis miRebas

2. me Zalian miWirs gadawyvetilebis miReba

3. me saerTod ver viReb veranair gadawyvetilebas

N. 0. me ara maqvs imis gancda, rom adrindelze uaresad gamoviyurebi

1. me ganvicdi rom moberebulad da dauZlurebulad gamoviyurebi

2. me vgrZnob, rom garegnoba Semecvala, Seuxedavi gavxdi

3. me vTvli, rom saSinlad gamoviyurebi

39

O. 0. me iseTive Sromisunariani var, rogorc adre

1. me zogjer Tavs Zalas vatan, rom Sevasrulo samuSao

2. me mudmivad mWirdeba Zaldataneba sakuTar Tavze, rom samuSao

Sevasrulo

3. me saerTod verafers veRar vakeTeb

P. 0. me Cveulebisamebr kargad mZinavs

1. me ise kargad aRar mZinavs, rogorc adre

2. me Cveulebrivze 1-2 saaTiT adre meRviZeba, Semdeg miWirs daZineba

3. me Cveulebrivze ramdenime saaTiT adre meRviZeba da veRar viZineb

Q. 0. me ar viRlebi adrindelze metad

1. me adrindelTan SedarebiT ufro advilad viRlebi

2. me yvelaferi mRlis

3. me iseTi daqanculi var, rom arafris gakeTeba ar SemiZlia

R. 0. me Cveulebriv cudi mada ar maqvs

1. me iseTi kargi mada aRar maqvs, rogorc adre

2. axla gacilebiT uaresi mada maqvs, vidre adre

3. saerTod ar maqvs Wamis mada

S. 0. wonaSi ar damiklia mniSvnelovnad

1. wonaSi davikeli 2,5 kiloramze meti

2. wonaSi davikeli 5 kg-ze meti

3. wonaSi davikeli 7,5 kg-ze meti

(daazusteT icavs Tu ara dietas: diax /ara)

T. 0. Cemi janmrTeloba ar mawuxebs Cveulebrivze metad

1. zogjer me mawuxebs sakuTari janmrTelobis mdgomareoba

2. mawuxebs sakuTari janmrTeloba da miWirs sxva rameze fiqri

3. imdenad var Sewuxebuli sakuTari janmrTelobiT, rom ar SemiZlia

sxva rameze fiqri

U. 0. bolo xanebSi ar SeminiSnavs raime cvlileba Cems seqsualur

SesaZleblobebSi

1. adrindelTan SedarebiT seqsiT naklebad var dainteresebuli

2. gacilebiT naklebad var dainteresebuli seqsiT

3. seqsis mimarT interesi sruliad davkarge

40

bekis kiTxvaris interpretacia

A. sevda B. uimedoba C. warumatebloba

D. daukmayofileba

E. danaSaulis gancda

F. sasjelis molodini

G. sakuTari pirovnebis miuRebloba H. TviTdanaSauli

I. suiciduri azrebi J. tirilis epizodebi

K. gamRizianebloba

L. socialuri gariyva

M. sakuTar TavSi daurwmunebloba

N. sxeulis xatis Secvla O. Seneleba, Sekaveba

P. uZiloba Q. daRliloba R. madis daqveiTeba S. wonis dakleba

T. wuxili somaturi Civilebis gamo

U. dabali energetikuli done

BDI Sedegebis Sesafaseba A _ 0 1 2 3 H _ 0 1 2 3 O _ 0 1 2 3 B _ 0 1 2 3 I _ 0 1 2 3 P _ 0 1 2 3 C _ 0 1 2 3 J _ 0 1 2 3 Q _ 0 1 2 3 D _ 0 1 2 3 K _ 0 1 2 3 R _ 0 1 2 3 E _ 0 1 2 3 L _ 0 1 2 3 S _ 0 1 2 3 F _ 0 1 2 3 M _ 0 1 2 3 T _ 0 1 2 3 G _ 0 1 2 3 N _ 0 1 2 3 U _ 0 1 2 3 eqsperimentis Sedegi BDI = depresiis simZimis xarisxi _

• BDI mowodebulia Aaron T. Beck_is mier 1961 wels;

• warmoadgens depresiis TviTSefasebis Skalas 17-80 wlis asakis

pirebSi;

• BDI gamoiyeneba depresiis simptomebis gamovlenis, simZimis xarisxis

gansazRvrisa da monitoringisaTvis klinikuri da eqsperimentuli

mizniT;

• eqsperimentatori SeiZleba iyos fsiqikuri janmrTelobis

specialisti, romelic trenirebulia am Skalis gamoyenebasa da

SefasebaSi;

• BDI testSi mocemulia 21 punqti, TiToeulSi 4 debuleba, romelic

dalagebulia simptomis simZimis xarisxis mixedviT _ 0, 1, 2, 3 _

neitraluridan maqsimalurad mZimemde;

• gamosakvlevi piri yovel punqtSi moniSnavs mxolod erT debulebas,

romelsac yvelaze metad eTanxmeba ,,amJamad“ da/an ,,bolo 7 dRis“

ganmavlobaSi;

41

• kiTxvaris Sesafaseblad eZleva 5-10 wuTi (ar aris mkacri SezRudva);

• testis 1 _13 punqtiT fasdeba fsiqologiuri bunebis, xolo 14 _ 21

punqtiT upiratesad fizikuri simptomebi _ fasdeba sakuTriv

depresiuli simptomebi da depresiis specifiuri bihevioruli

gamovlinebebi;

• testis saboloo jamuri maCvenebeli gansazRvravs depresiis simZimis

xarisxs;

• testis totaluri maCvenebeli fasdeba:

BDI = 0 _ 9 _ ar aqvs depresia (depresiis simptomebi minimaluria)

10 _ 16 _ msubuqi depresia

17 _ 29 _ zomieri depresia

30 _ 63 _ mZime depresia

• zogad populaciaSi depresiis maCvenebelia >21 jamuri maCvenebeli.B

42

hamiltonis depresiis Sefasebis skala (9,10)

(Hamilton Depression Raiting Scale _ HDRS)

1 depresiuli guneba-ganwyoba

daTrgunvis, uimedobis, uZlurebis

uunarobis grZnoba

0 = ar aris

1 = aRniSnuli grZnoba vlindeba mxolod

pirdapiri SekiTxvisas

2 = Civilebs spontanurad gamoTqvams

3 = aRniSnuli grZnoba ganisazRvreba

araverbalurad: mimika, poza, xma, cremlebi

4 = pacienti gamoxatavs mxolod am grZnobebs,

rogorc spontanur gamoTqmebSi,

aseve araverbalurad

11 SfoTvis somaturi niSnebi

SfoTvis fiziologiuri gamovlineba:

gastrointestinaluri-piris simSrale, boyini,

spazmebi, meteorizmi, diarea, dispepsia;

gul-sisxlZarRvTa_taqikardia, Tavis tkivili;

sasunTqi-qoSini, hiperventilacia;

gaxSirebuli Sardva; oflianoba;

0 = ar aris

1 = susti

2 = saSualo

3 = Zlieri

4 = ukiduresad Zlieri

2 danaSaulis grZnoba

0 = ar aris

1 = TviTbraldeba; Tvlis, rom damnaSavea

sxvebis mimarT

2 = danaSaulis ideebi an gansja

warsul Secdomebsa da codvebze

3 = arsebuli daavadeba fasdeba rogorc

sasjeli; danaSaulis bodvTi ideebi

4 = verbaluri halucinaciebi braldebisa da

gansjis SinaarsiT da/an mxedvelobiTi

halucinaciebi muqaris SinaarsiT

12 kuW-nawlavis somaturi

simptomebi

0 = ar aris

1 = umadoba, magram sakvebs iRebs zedmeti

Zaldatanebis gareSe, mucelSi simZimis

SegrZneba

2 = sakvebs iRebs mxolod Zlieri

Zaldatanebis Semdeg; saWiroebs

gastroenterologiur problemebis

kupirebas

3 suiciduri ganzraxva

0 = ar aris

1 = gancda, rom sicocxle ar Rirs

2 = sikvdilis survili an fiqri sakuTari

sikvdilis SesaZleblobis Sesaxeb

3 = suiciduri gamoTqmebi an Jestebi

4 = suiciduri mcdeloba (nebismieri

seriozuli mcdeloba fasdeba ,,4” quliT)

13 zogadi somaturi simptomebi

0 = ar aris

1 = simZime kidurebSi, zurgSi an

TavSi, tkivilebi kunTebSi;

energiis dakargvis an uZlurebis

SegrZneba

2 = nebismieri mkveTrad gamoxatuli

simptomi fasdeba ,,2” quliT

4 adreuli uZiloba

0 = CaZineba ar uWirs

1 = epizoduri Civilebi CaZinebis

gaZnelebaze (30wT-ze meti)

3 = yoveldRiuri Civilebi CaZinebis

gaZnelebaze

14 genitaluri simptomebi

libidos dakargva, menstrualuri darRvevebi

0 = simptomebi ar arsebobs

1 = sustad gamoxatuli

2 = mkveTrad gamoxatuli

5 Sualeduri uZiloba

0 = ar aris 1 = Civilebi mTeli Rame mousvenar Zilze

2 = mTeli Ramis ganmavlobaSi xSiri

gamoRviZeba. sawolidan nebismieri

wamodgoma Sefasdeba rogorc ,,2”

(fiziologiur moTxovnebis garda)

15 ipoqondria

0. ar aris

1. moculia sakuTari TaviT (fizikurad)

2. gadaWarbebuli zrunva sakuTar

janmrTelobaze

3. xSiri Civilebi, daxmarebis moTxovna da

sxva

4. ipoqondriuli bodva

6 gviani uZiloba

0 = ar aris

1 = dilaadrian gamoRviZeba Semdgomi CaZinebiT

2 = dilaadrian sruli gamoRviZeba

16. wonaSi dakleba

am punqtis Sefaseba xdeba:

16A anamnezis mixedviT: 0 = ar aris wonaSi dakleba

43

7 Sromis unari da aqtivoba

0 = ar aris sirTuleebi

1 = ususurobis azri da SegrZneba, sisustis da

daRlilobis gancda saqmianobasTan

(samsaxuri an hobi) dakavSirebiT

2 = saqmisadmi (samuSao an hobi) interesis

dakargva, gamxatuli uSualod CivilebiT an

apaTiurobiTa da meryeobiT (samuSaos

dasawyebad an aqtiurobisaTvis

damatebiTi Zaldatanebis aucileblobiT)

3 = aqtiurobis gamovlenis realuri periodis

Semcireba an produqtiulobis daqveiTeba;

_ stacionaris pirobebSi ,,3” Sefaseba

gamoaqvT, Tu pacientis aqtiuroba grZeldeba

aranaklebi 3saaTi; (samuSao an hobi).

4 = arsebuli daavadebis gamo samuSaoze uaris

Tqma; stacionarSi Sefaseba ,,4” gamoaqvT, Tu

pacienti saerTod ar aqtiurobs, an martiv

saqmianobasac ki ver axerxebs damoukideblad

1 = savaraudoa wonaSi dakleba am

daavadebis gamo

2 = aSkara dakleba wonaSi (avadmyofis

sityvebiT)

3 = Sefaseba SeuZlebelia

16B wonis yovelkvireuli SefasebiT

0 = wonaSi dakleba kviraSi < 0,5kg-ze

1 = kviraSi > 0,5kg-ze

2 = kviraSi > 1 kg-ze

3 = Sefaseba ar xerxdeba

17 kritika daavadebis mimarT

0 = acnobierebs, rom depresiul

mdgomareobaSia da avadaa

1 = gacnobierebulia mdgomareobis

avadmyofuroba, magram amis mizezad

miiCnevs cud sakvebs, gadaRlas, virusul

infeqcias da sxva

2 = daavadebis gacnobierebis sruli

ararseboba

8 Sekaveba

azrovnebis da metyvelebis Seneleba, yuradRebis

koncentrirebis unaris da motoruli aqtiurobis

daqveiTeba

0 = normaluri azrovneba da metyveleba

1 = msubuqi Sekaveba intervius dros

2 = gamoxatuli Sekaveba intervius dros

3 = mniSvnelovani gaZneleba intervius dros

4 = sruli stupori

18. sadReRamiso meryeoba

18A - daazusteT, aris Tu ara simptomebis

sadReRamiso meryeoba

0 = ar aris meryeoba

1 = uaresdeba diliT

2 = uaresdeba saRamos

18B -Tu arsebobs sadReRamiso meryeoba

SeafaseT maTi gamoxatvis xarisxi;

0 = ar aris 1 = susti 2 = Zlieri

9 aJitacia (SfoTviTi aRgzneba)

0 = ar aris

1 = mousvenroba

2 = xelebis fSvneta, Tmebis wvaleba da sxva

3 = moZraoba, wriali

4 = mudmivi xelebis fSvneta, frCxilebis da

tuCebis kvneta, Tmebis wiwkna

19 depersonalizacia da derealizacia

mag. garemos ararealurobis SegrZneba

0 = ar aris

1 = susti

2 = zomieri

3 = Zlieri

4 = autaneli

10 fsiqikuri SfoTva

0 = ar aris

1 = subieqturi daZabuloba da gamRizianebloba

2 = mousvenroba umniSvnelo sababiT

3 = gangaSi, romelic vlindeba metyvelebasa da

saxis gamometyvelebaSi

4 = SiSi, gamoxatuli gamokiTxvis gareSec

20 paranoiduli simptomebi

0 = ar aris

1 = eWvianoba

2 = damokidebulebis ideebi

3 = damokidebulebis da devnis bodva

21. obsesiur-kompulsuri simptomebi

0 = ar aris

1 = msubuqi

2 = mZime

HDRS Sedegebis Sesafaseba 1 __ 0 1 2 3 4 9 __ 0 1 2 3 4 16B __ 0 1 2 3 4 2 __ 0 1 2 3 4 10 __ 0 1 2 3 4 17 __ 0 1 2 3 4

3 __ 0 1 2 3 4 11 __ 0 1 2 3 4 18A __ 0 1 2 3 4

4 __ 0 1 2 3 4 12 __ 0 1 2 3 4 18B ---- 0 1 2 3 4 5 __ 0 1 2 3 4 13 __ 0 1 2 3 4 19 __ 0 1 2 3 4

6 __ 0 1 2 3 4 14 __ 0 1 2 3 4 20 __ 0 1 2 3 4

7 __ 0 1 2 3 4 15 __ 0 1 2 3 4 21 __ 0 1 2 3 4

8 __ 0 1 2 3 4 16A__ 0 1 2 3 4

eqsperimentis Sedegi HDRS = depresiis simZime _

44

HDRS = 0 – depresia ar aris! HDRS = 52-depresiuli sindromi ukiduresad mZimea!

• HDRS _mowodebulia M. Hamilton _is mier 1960 wels depresiis simZimis

xarisxis Sesafaseblad klinikuri da eqsperimentuli kvlevis mizniT;

• gasazomi maCveneblebia depresiis simptomebi;

• eqsperimentis dro=20-30wT;

• populacia _ depresiuli aSlilobis mqone mozrdili pirebi;

• eqsperimentatori SeiZleba iyos kvalificirebuli fsiqiatri an

klinikuri fsiqologi, romelsac gavlili aqvs specialuri trenireba;

• Sesafasebeli periodi ganisazRvreba, rogorc: ,,amJamad” an ,,bolo erTi

kviris ganmavlobaSi”;

• originaluri versia Sedgeba 21 punqtisagan, aqedan 2 punqti dayofiali 2

nawilad;

• HDRS Seicavs sam faqtors: ,,zogadi depresiuli faqtori”, ,,SfoTviTi

depresia” da arastabilurobis indeqsi. testis bolo 4 punqti ar

gansazRvravs sakuTriv depesias, aramed azustebs depresiis tips;

• qulebis mniSvneloba:

_ 9 punqti fasdeba raodenobrivad _ 0-dan 4-mde;

_ 6 punqtis maCvenebeli fasdeba Tvisobrivad, 0-dan 2 qulamde;

• ,,7” punqtis Sesafaseblad mkvlevarma SeiZleba informacia miiRos

axloblebis an samedicino personalisagan;

• ,,16” punqtze, pasuxi unda gaeces erT-erTs; 16A–punqtiT Sefaseba

mkurnalobis dasawyisSi xdeba, xolo mkurnalobis procesSi sasurvelia

obieqturi Sefaseba 16B–punqtiT;

• ,,18B” punqti mxolod im SemTxvevaSi fasdeba, Tu 18A punqtSi aRniSnulia

guneba-ganwyobis sadReRamiso meryeoba;

• eqsperimentis dros ar SeiZleba zewola pacientze;

• paciants sakmarisi dro unda daeTmos amomwuravi pasuxis gasacemad,

magram ar unda gadauxvios Temas, pirdapiri SekiTxvebi minimumamde unda

iyos dayvanili, varireba unda xdebodes dadebiTi da uaryofiTi

pasuxebis kombinaciiT; Sesafaseblad amorCeuli unda iyos is pasuxi,

romelic ufro zustad axasiaTebs pacientis mdgomareobas;

• ganmeorebiTi gamokvleva xdeba damoukideblad, cariel blankze,

mkvlevarma ar unda naxos wina eqsperimenti.

45

roSaxis testi

10 feradi cxrilisagan (,,laqebi”) Semdgari standartuli krebuli,

romelsac Tavazoben pacients interpretaciisaTvis. rezultatis Sefasebas

axdens eqsperimentatori. depresiis dros vlindeba Raribi

asociaciur_inteleqtualuri funqcionireba da Senelebuli reagireba.

Tematuri apercefciis testi

30 suraTisagan Semdgari suraTebis seria, situaciebis gamosaxulebiT,

romelic uSvebs orazrovan axsnas. pacienti axdens calkeuli situaciis

Sefasebas. depresiuli pacientis monaTxrobi naRvliania, maniis dros ki,

amaRlebuli da dramatuli.

C. Tavis tvinis funqcionirebis vizualuri gamokvlevebi (1)

cvlilebebi Tavis tvinSi umniSvneloa. kompiuteruli tomografiis

meTodiT skanireba uCvenebs, rom maniis da fsiqozuri depresiis dros

gafarToebulia Tavis tvinis parkuWebi. zogierT avadmyofs didi

depresiuli epizodis simptomebiT aReniSnebaT bazalur birTvebSi sisxlis

nakadis Semcireba. MRI tomografiis Sedegad gamovlinda, rom pacientebs

didi depresiuli epizodis simptomebiT, kudiani birTvi da Sublis wilebi

ufro patara aqvT, vidre janmrTelebs. MRI speqtroskopiis meSveobiT I

tipis bipolaruli aSlilobis mqone pacientebiSi Catarebuli

gamokvlevebis Sedegebi Seesabameba hipoTezas imis Sesaxeb, rom aSlilobis

paTofiziologiuri Tavisebureba SeiZleba Seicavdes membranebSi

fosfolipiduri cvlis regulirebis darRvevas.

46

7. mkurnalobis sqema

I. depresiuli epizodi (1, 3-5, 8, 13-15, 18, 152)

A. fsiqiatriuli menejmenti (13, 14, 152)

1. SeafaseT diagnostikurad (18)

gansazRvreT, aris Tu ara depresia (13, 14, 152, 153)

gansazRvreT fsiqikuri da zogadi samedicino komorbiduli

faqtorebis arseboba (13, 14, 152, 153)

• Tanmimdevruli diagnostikuri Sefasebisas gaiTvaliswineT

fsiqikuri aSlilobis, maT Soris, gadatanili maniakaluri

an depresiuli epizodis da warsulSi Catarebuli

mkurnalobis subieqturi da obieqturi istoria, aseve

mimdinare simptomebi da mkurnalobis efeqturoba (73, 148, 178.

A);

• zogadi samedicino istoria (148, 178. A);

• fsiqoaqtiuri nivTierebebis miRebiT gamowveuli

aSlilobebis istoria (101. D);

• personaluri istoria _ mag. genetikuri faqtori, adreuli

fsiqo-fizikuri ganviTareba, mniSvnelovan cxovrebiseul

clilebebze reagireba (94 D; 44 A);

• socialuri, profesiuli da ojaxuri istoria(173 C, 44 A ); • pacientis mkurnalobis gadasinjva (153);

• fsiqiatriuli daxmarebis Sesabamisi donis SerCeva(16);

• fsiqikuri statusis gamokvleva (1, 3, 5, 8) (24, 34, 36, 37 _ A);

• fizikuri statusis gamokvleva (1-4) (178 A):

_ sisxlis saerTo analizi;

_ Tirkmlis funqciuri sinjebi (Sardovanas da kreatininis

gansazRvra);

_ eleqtrolitebis koncentracia sisxlSi;

_ RviZlis funqciuri sinjebi;

_ farisebri jirkvlis funqciuri sinjebi;

_ ekg da eeg (38, 158 _ B ); • gamoiyene specialistebis konsultacia klinikuri da

paraklinikuri gamokvlevebis Sedegebis Sesabamisad

(178 A);

• gamoiyene depresiis sakvlevi unificirebuli skala

diagnozis dazustebis da mkurnalobis efeqturobis

Sefasebis mizniT:

_ bekis depresiis kiTxvari _ BDI (11, 12) _ hamiltonis depresiis reitinguli skala _ HDRS (9, 10)

47

2. SeafaseT pacientis da sxva pirebis usafrTxoeba (1, 3, 13, 152, 153)

• gansakuTrebuli mniSvneloba aqvs suiciduri riskis

Sefasebas (ix. dafa 1.)

(29, 89 _ A);

• Tu pacienti avlens suicidur an homicidur ideebs,

intenciebs an gegmebs, saWiroa uSualo meTvalyureoba;

• Tu riski mniSvnelovania, SeiZleba mizanSewonili iyos

hospitalizeba(16).

• yuradReba!

suiciduri mcdelobis winaswari ganWvretis SesaZlebloba

Zalze mwiria!

dafa 1. suiciduri riskis Sefasebisas sayuradReboa (13, 152, 153):

• suiciduri an homociduri azrebis, intenciebis an gegmebis arseboba;

• suiciduri saSualebebis da am saSualebebis letalurobis

xarisxis Seafaseba;

• fsiqozuri simtomebis, imperatiuli halucinaciebis an Zlieri

SfoTvis da aJitaciis arseboba;

• komorbiduli faqtorebis, fsiqoaqtiuri nivTierebebis moxmarebis

arseboba;

• wina suciduri mcdelobis istoria da misi seriozuloba;

• ojaxis wevrTa Soris bolodroindeli gamJRavnebuli suicidis

istoria.

yuradReba!

aRniSnuli faqtorebis arsebobisas mdgomareoba fasdeba, rogorc

maRali suiciduri riskis mqone.

3. SeafaseT fsiqosocialuri funqcionirebis gauaresebis done

(13, 14, 152, 153)

• interpersonaluri urTierTobebis, samuSao da

sacxovrebeli pirobebis gauareseba, aseve

janmrTelobasTan dakavSirebul problemebis arseboba;

• gauaresebis miznobrivi Sefaseba (mag. samsaxuris gacdena,

samuSao gegmis uqonloba, mkurnalobis reJimis ararseboba

da sxva).

(164, 173, 174-C);

48

4. gansazRvreT fsiqiatriuli daxmarebis done (13, 14, 152, 153)

ganmeorebiT SeafaseT fsiqiatriuli daxmarebis

optimaluroba fsiqo-fizikuri mdgomareobis dinamikis

gaTvaliswinebiT.

gaiTvaliswineT hospitalizaciis saWiroeba, Tu pacienti (16):

• seriozul saSiSroebas uqmnis Tavis Tavs an irgvlimyofebs

_ Tu pacienti uars acxadebs mkurnalobaze, SeiZleba misi

aranebayoflobiTi mkurnaloba (29, 89 _ A);

• agznebulia, ar aqvs Sesabamisi socialuri mxardaWera da

alternatiuli intensiuri mkurnalobis SesaZlebloba (mag.

dRis stacionari, stacionari binaze da sxva) (164, 173_C, 166- A);

• gamoxatulia fsiqikuri an zogadi samedicino komorbiduli

faqtorebi (94, 101- D, 44-A);

• ar an ver miiRebs adekvatur ambulatoriul mkurnalobas,

fsiqiatriuli daxmarebis dayovneba ki safrTxes Seuqmnis

pacientis an sxva piris sicocxles da/an janmrTelobas.

5. Terapiuli aliansis Camoyalibeba da xelSewyoba(13, 14, 152, 153)

mniSvnelovani yuradReba unda miaqcioT pacientis da misi

ojaxis wevrebis problemebs

• gacnobierebuli unda gqondeT mosalodneli transferis

da ukutransferis SesaZlebloba. (92-eqspertTa mosazreba,

73, 166-A);

amorCevisas gaiTvaliswineT Semdegi:

• klinikuri mdgomareoba _ simptomebis simwvave,

komorbiduli faqtorebi, suiciduroba, homociduroba da

fsiqosocialuri funqcionirebis done;

• mxardamWeri sistemebis xelmisawvdomoba;

• pacientis unari, miiRos gacnobierebuli gadawyvetileba

SeTavazebuli fsiqiatriuli daxmarebis Sesabamisobis,

fsiqiatrTan saimedo ukukavSirisa da mkurnalobis dros

TanamSromlobis Sesaxeb.

(164-C; 29, 73, 89, 166, 178 - A);

49

6. fsiqikuri statusis da usafrTxoebis monitoringi(13, 14, 152, 153)

monitoringi pacientebis, sakuTari Tavis an sxvebisadmi

destruqciuli impulsebis mosalodneli gamovlinebis gamo

(73-A);

monitoringi fsiqikuri statusis cvalebadobisas. iyavi

yuradRebiT rogorc depresiis, aseve SesaZlo komorbiduli

simptomebis mimarT (58-C, 73-A);

gaiTvaliswineT ganmeorebiTi diagnostikuri Sefaseba, Tu

siptomebi mniSvnelovnad Seicvala an aRmocenda axali

simptomebi (172-D, 57,73-A);

urgentul situaciaSi, romelic xSiria mZime depresiis dros,

eqimi moklebulia srulyofili gamokvlevis Catarebis

SesaZleblobas da gadaudebeli Terapiis aucileblobis dros

unda daeyrdnos mdgomareobis situaciur analizs da

ixelmZRvanelos sakuTari gamocdilebiT (5).

7. pacientis da, Tu SesaZlebelia, misi ojaxis wevrebis

fsiqoganaTleba (13, 14, 152, 153)

• gansakuTrebuli xazgasmiT auxseniT is, rom depresiuli

aSliloba realuri daavadebaa;

• miawodeT informacia SeTavazebuli fsiqiatriuli daxmarebis

da mkurnalobis Sesaxeb, rac daexmareba pacients

informirebuli gadawyvetilebis miRebaSi, mkurnalobis

efeqturobis, SesaZlo gverdiTi efeqtebis da sxva Tanmxlebi

movlenebis gacnobierebaSi.

(181, 182-A);

50

8. uzrunvelyaviT mkurnalobis reJimis mkacrad dacva(13, 14, 152, 153)

depresiis diagnozis dadgenisTanave aucilebelia mkurnalobis

Tanmimdevruli gegmis Sedgena, romelic sam periods mocavs: • mwvave fazis mkurnaloba anu kupireba _ mwvave depresiuli

simptomebis swrafi alageba, avadmyofis tanjvis Semcirebisa

da suicidis Tavidan acilebis mizniT;

• SemanarCunebeli anu mastabilizebeli Terapia _ depresiuli

simptomebis sruli alageba da Terapiuli remisiis miRweva;

• damWeri anu profilaqtikuri Terapia _ gamwvavebis da axali

epizodis ganviTarebis riskis Semcireba da Tavidan acileba,

fsiqosocialuri reabilitacia, SromiTi adaptacia.

(4) (164-C, 73, 148, 178-A)

mkurnalobis reJimis mkacri dacvis mizniT, garkveviT auxseniT:

• rodis da ra sixSiriT miiRos medikamenti;

• rom dadebiTi Sedegi Cveulebriv 2-4 kviris Semdeg

gamovlindeba;

• rom aucilebelia mkurnalobis gagrZeleba, imis Semdegac,

roca pacienti Tavs kargad igrZnobs;

• rom mkurnaloba SeiZleba Sewyvitos mxolod mkurnal

eqimTan konsultaciis Semdeg;

• rogor unda moiqces, Tu problemebi warmoiqmneba.

(73, 76, 166, 181, 182-A);

mkurnalobis reJimis mkacri dacva moxuc pacientebSi

uzrunvelyaviT mkurnalobis reJimis gamartivebiT da

mkurnalobis Rirebulebis minimumamde dayvaniT

(71-B);

gaiTvaliswine fsiqoTerapiuli Careva Terapiuli aliansis

gaumjobesebis da mkurnalobis reJimis darRvevis Tavidan

acilebis mizniT (166, 181-A);

9. recidivis adreuli niSnebis marTva(13, 14, 152, 153)

moaxdineT pacientis (da ojaxis) informireba recidivis riskis

arsebobis Sesaxeb. (169-B, 76, 166, 181-A);

aswavleT pacients (da ojaxs) axali epizodis adreuli

niSnebis da simptomebis Secnoba.

(169-B, 76, 166, 181-A)

xazgasmiT auxseniT pacients, Tu vis mimarTos fsiqiatriuli

daxmarebis misaRebad recidivis pirvelive niSnebis da

simptomebis gamovlinebisas, raTa Tavidan aicilos daavadebis

sruli egzacerbacia. (169-B, 76, 166, 181-A);

51

B. mwvave fazis mkurnaloba anu kupirebak(3, 4, 5, 13, 14, 152)upireba.

1. inicialuri mkurnalobis modelis arCeva (13) (ix. sur. 1; 2);

suraTi 1.

ara diax

ara diax

ara diax

gadadiT mkurnalobis sxva variantebis ganxilvaze

1. saWiroa specifiuri fsiqoTerapia (sf)?

• msubuqi depresia: upiratesoba eniWeba

monoTerapias an kombinacias medikamentebTan.

• zomieri da mZime depresia: kombinaciaSi

medikamentebTan an ekT-sTan, Tu mniSvnelovnadaa

gauaresebuli fsiqosocialuri funqcionireba

da/an roca pacianti aniWebs upiratesobas

ar CarToT

sf

mkurnalobi

s gegmaSi da

gadadiT me-2

skiTxze

CarTeT sf

mkurnalobi

s gegmaSi da

gadadiT

meore

sakiTxze

ar CarToT

medikament

uri da sf

mkurnalobis

gegmaSi da

gadadiT me-4

kiTxvaze

CarTeT ekT

mkurnalobi

s gegmaSi da

gaagrZeleT

mkurnalo-

bis sxva variantebis

ganxilva

CarTeT

medikamenti

mkurnalobis

gegmaSi da

gaagrZeleT

sxva saxis mkurnalobis

ganxilva

2. saWiroa medikamenturi mkurnaloba?

• msubuqi depresia: Tu arCeulia medikamenturi

monoTerapia

• zomieri da mZime depresia: medikamentis

kombinacia sf-sTan, an mis gareSe, Tu ar aris

dagegmili ekT

• fsiqozuri depresia: antifsiqozuri da

antidepresiuli medikamenturi mkurnalobis

kombinacia an ekT

ar CarToT

ekT

mkurnalobis

gegmaSi da

gaagrZeleT

mkurnalobis

saxva

variantebis ganxilva

4. saWiroa Tu ara ekT-s gamoyeneba?

• qronikuli, zomieri da mZime depresiis dros

kombinaciaSi sf_Tan an mis gareSe, rogorc

pacienti airCevs.

• mZime depresis dros da yvela Semdeg

SemTxvevaSi:

_ fsiqozuri simptomebiT

_ roca pacienti irCevs

_ warsulSi efeqturobis istoria.

_ swrafi antidepresiuli pasuxis saWiroeba

_ medikamentebisadmi intolerantoba

ar CarToT

medikamenturi

mk-ba

mkurnalobis

gegmaSi da

gadadiT

mesame kiTxvaze

CarTeT

medikamenti

da sf

mkurnalobis

gegmaSi da

gaagrZeleT

mkurnalobis sxva

variantebis

ganxilva

3. saWiroa medikamenturi mk-ba da sf kombinaciaSi?

• msubuqi depresia:

_ Tu arCeulia, rogorc kombinirebuli mkurnaloba

_ Tu aris monoTerapiis nawilobrivi efeqturoba

_ cudi komplaenturoba

• zomieri da mZime depresia

_ darRveuli fsiqosocialuri funqcionireba

_ interpersonaluri problemebi

_ personologiuri aSlilobebi

_ cudi komplaenturoba

52

suraTi 2. depresiuli aSlilobis mwvave fazis mkurnaloba (13)

araefeqturia nawilobrivi efeqti sruli efeqti

damatebiTi 4-8 kviris Semdeg ganmeorebiT SeafaseT

mkurnalobis efeqturoba

“airCieT meore antidepresanti igive klasidan, an wina ori mcdelobis dros am klasis

antidepresantis araefeqturobis SemTxvevaSi, airCieT sxva klasis antidepresanti.

mkurnalobis dawyeba

medikamenturi da/an fsiqoTerapia

Tu mk-ba araefeqturia da

klinikurad mZimea, gaiTvaliswineT:

• medikamentis dozis momateba

• fsiqoTerapiis intensivobis

momateba

• ekT

4-8 kviris Semdeg SeafaseT

mkurnalobis efeqturoba

gadadiT

SemanarCunebeli

mkurnalobis

fazaSi

1. medikamenturi

mkurnalobisas:

• SecvaleT doza

• daumateT meore

antidepresanti’’

• SecvaleT

antidepresanti • daumateT

fsiqoTerapia • ekT 2. fsiqoTerapiiT

mkurnalobisas

• gazardeT

fiqoTerapiis

intensivoba

• SecvaleT

fsiqoTerapiis

tipi

• daumateT an

SecvaleT

medikamentozur

iT

1. medikamenturi

mkurnalo bisas:

• SecvaleT

antidepresanti

• daumateT

fsiqoTerapia

@2. fsiqoTera-

piiT mkurnalo

bisas:

* daumateT an

SecvaleT

medikamenturiT

monitoringi:

• pacientis da sxva

pirebis

usafrTxoebis

xarisxi

(dafa 1)

• fsiqikuri

statusi

• fsiqosocialuri

statusi

• mkurnalobis

efeqti

• gverdiTi efeqti

(ix. sur 6; 7; .8;

9.)

• maniis niSnebis

gamoCena

• komorbiduli

fsiqikuri

aSlilobebi

fsiqoaqtiuri

nivTierebebis

gamoyenebis

CaTvliT

• zogadi

samedicini

komorbiduli

faqtorebi

53

2. inicialuri medikamenturi mkurnaloba (3-5, 13-15, 150,152)

(ix. sur. 1; sur. 2 dafa 2)

• inicialuri medikamenturi mkurnalobis upiratesobas

gansazRvravs warsulSi medikamentur mkurnalobaze

dadebiTi efeqtis istoria;

• fsiqikuri mdgomareobis simZime Zilis da madis

mniSvnelovani darRveva an aJitacia;

• savaraudoa damWeri Terapiis aucilebloba

• pacientis arCevani medikamentur mkurnalobaze

• alternatiuli adekvaturi mkurnalobis modelis deficiti.

(20, 22, 28, 67- eqspertTa mosazreba; 25, 33, 58-C, 24, 29, 32, 36 56, 57, 73, 80, 84, 178-A)

dafa 2. depresiuli epizodis

simZimis xarisxi:

farmakoTerapia

msubuqi antidepresanti, Tu pacienti mas aniWebs

upiratesobas

zomieri da mZime antidepresanti aris mkurnalobis arCevani, Tu

ar aris dagegmili eleqtrokonvulsiuri

Terapia (ekT)

mZime, fsiqozuri

simptomebiT

antidepresanti + antifsiqozuri preparati

an ekT

a. inicialuri antidepresantis amorCevis pricipi (3-5, 13-15, 150,152)

Timoanalefsiuri mkurnalobis dros gasaTvaliswinebelia (4):

• antideprasantebis klasifikacia xdeba qimiuri struqturis an

moqmedebis meqanizmis Sesabamisad (ix. sur. 3; sur. 10);

• antidepresantebi xanmokle Terapiisas sinafsur da xangrZlivi

Terapiis dros receptorul cvlilebebs iwvevs da yvela

antidepresanti ama Tu im doziT zemoqmedebas axdens

serotoninur da HT sistemaze (ix. sur. 6.). (46-49, 75, 87_ A)A

• Cveulebriv, sxvadasxva klasis antidepresantebs aqvT Tanabari

Timoanalefsiuri efeqti, Tumca, antidepresantebis klasebs

Soris da klasebs SigniT, arsebobs SedarebiTi efeqturoba

calkeul depresiuli simptomis mimarT (ix. sur. 4. da 5). (33-C, 32, 33, 36, 45, 56, 73, 178_ A)A

• antidepresantebi gansxvavdebian usafrTxoebis diapazoniT da

gverdiTi efeqtebis gamovlinebis xarisxiT (ix. sur. 6; 7; 8; 9;

10). (31, 32, 46, 56_ A)A

• antidepresantebis swori gamoyenebisas klinikuri efeqturoba

60_70%-ia (8). (57_ A)A

• mkurnalobis dawyebidan antidepresiuli efeqtis

gamovlinebamde SeiZleba 4-6 kvira gavides (3, 5, 14, 15)

54

antidepresantis inicialuri seleqciisas yuradReba unda mieqces

Semdeg faqtorebs:

• mosalodneli gverdiTi efeqtebi (sur. 6 7; 8; 9; 10)

(74-eqspertTa mosazreba);

• pacientis individualuri amtanoba

(20, 22, 28-eqspertTa mosazreba);

• Terapiuli usafrTxoebis diapazoni

(154,155-eqspertTa mosazreba; 46, 56, 31, 32_ A);

• pacientis arCevani (22, 92-eqspertTa mosazreba; 25_C. 77-79_ A);

• klinikuri gamokvlevis Sedegebi (49-55, 84_ A);

• Rirebuleba (20, 92-eqsperTTa mosazreba);

am faqtorebis gaTvaliswinebiT, pacientebis umravlesobis

mkurnalobisas efeqturi iqneba: serotoninis ukumitacebis

seleqtiuri inhibitori _ sumsi (48, 53, 54_ A), an dezipramini,

nefazadoni, nortriftilini, trazadoni, bupropioni (37, 39, 49 50,

51, 87_ A), venlafaqsini (53, 54_ A) da mirtazapini.®

• tricikluri antidepresantis (tca) pirveli rigis da

xangrZlivi moxmarebis preparatad arCeva SezRudulia Zlieri

qolinolizuri da kardiotoqsikuri gverdiTi efeqtis gamo

(62-qspertTa mosazreba; 40, 41, 45_B, 75_ A).

gasaTvaliswinebelia sxva faqtorebic:

• depresiuli sindromis Tavisebureba, misi calkeuli simptomis

gamoxatvis xarisxi

(35_C, 45_B, 31, 36, 37, 53-56_ A);

• warsulSi garkveuli antidepresantis maRali efeqturobis

istoria (45, 47_B, 24, 32, 36, 50, 57 77_ A);

• fsiqikuri an zogadi samedicino komorbiduli faqtorebi

(161-D, 24, 34, 36, 37_ A).

monoaminooqsidazas inhibitorebi (maoi) gamoiyeneT mxolod sxva

klasis antidepresantebis araefeqturobis SemTxvevaSi, radgan

maTi gamoyenebisas mosalodnelia seriozuli gverdiTi efeqtebi

da saWiroa Tiraminis Semcvel produqtebze mkacri dieturi

SezRudva.

• maoi SeiZleba gansakuTrebiT efeqturi iyos atipiuri

depresiuli epizodis dros (30, 31, 32, 34, 55, 56_ A), Tumca

klinikur praqtikaSi atipiuri depresiis mkurnalobisas

farTod gamoiyeneba sumsi, kargi Terapiuli indeqsis da

naklebi gverdiTi efeqtebis gamo (77_B; 39, 46_ A; 40, 41, 45_B, 75_ A).

55

b. damatebiTi informacia antidepresantebis Sesaxeb

antidepresantebis inicialuri seleqciisas gaiTvaliswineT

mowodebuli informacia _ antidepresantebis klasifikacia,

dozireba, moqmedebis meqanizmi, medikamentebTan urTierTqmedeba

gverdiTi efeqtebi.

suraTi #3

antidepresantebis klasifikacia, dozireba da naxevardaSlis periodi

(4, 13, 14, 15, 17)

generiuli

(saerTaSoriso)

saxelwodeba

dozireba

mg/dReSi

naxevardaSlis

periodi (sT-Si)

inicialuri Terapiuli maqsimaluri

1. tricikluri antidepresantebi (tca)

amitriftilini* 25 75 - 150 300 27 _ 32 (18 _ 96)

klomipramini 25 100 _ 200 250 17 _ 28 (57 _ 77)

doqsepini 25 75 _ 150 300 8 _24 (28 _52)

imipramini* 25 50 _ 150 300 5_25

trimipramini 25 50 _ 150 200 _300 7 _ 23

dezipramini 25 100 _ 200 300 24

nortriftilini 10 _ 25 75 _ 150 300 36 (18 _96)

Tianeptini* 25 37, 5 50 3 _ 5

protriftilini 15 15 _ 40 60 74 (50 _200)

2. tetracikluri antidepresantebi _ tetca

amoqsapini 50 _ 75 200 _ 300 400 (600) 8 _ 24

maprotilini 25 75 _ 150 225 51

mianserini* 30 30 _ 90 120 10 _ 20

3. serotoninis ukumitacebis seleqtiuri inhibitorebi _ sumsi

citaloprami 20 20 _ 40 60 23 _ 45

fluoqsetini* 20 20 _ 40 80 48 _ 360

fluvoqsamini* 50 50 _ 200 300 9 _ 28

paroqsetini* 20 20 _ 40 50 24

sertralini* 50 50 _ 150 200 22 _ 36 (10 _109)

4. sxva qimiuri struqturis antidepresantebi

bupropioni 150 150 _ 300 450 10 _ 27

venlafaqsini 37,5 75 _ 225 375 3 _ 7 (9_13)

5. serotoninis modulatorebi

nefazadoni 200 300 _ 500 600 2 _ 4 (12)

trazodoni 150 300 _ 400 400 _ 600 3 _ 9

6. mao-s Seuqcevadi inhibitorebi

nialamidi 300 300 - 400 500 ?

fenelzini 45 45 _ 75 90 1,5 _ 3 (21 dRemde)

tranilcipromini 30 30_40 60 1,5_3 (21 dRemde)

7. mao-s Seqcevadi inhibitorebi

moklobemidi 150 300 _ 600 600 1 _ 4 (24)

pirazidoli 100 150 _ 400 500 ?

* saqarTveloSi registrirebuli preparatebi

56

suraTi 4

antidepresantebis klnikuri klasifikacia (4)

antidepresantebi sedaciuri efeqtiT: sedaciuri efeqti

ftoracizini

trimipramini

doqsepini

amitriftilini

mianserini

mirtazapini

fluvoqsamini

femoqsetini

trazodoni

medifoqsamini

nefazadoni

antidepresantebi mabalansirebadi efeqtiT:

venlafaqsini

triftofani

maprotilini

dosuleptini

Tianeptini

midalciprami

sertranili

paroqsiteni

pirazidoli

klomipramini

citaloprami

antidepresantebi mastimulirebeli efeqtiT:

viloqsazini

iprindoli

fluoqsetini

imipramini

nortriftilini

protriftilini dezipramini amineptini

bupropioni

moklobemidi

mastimulirebeli nialamidi efeqti

57

suraTi 5.

antidepresantebis efeqturoba depresiuli sindromis calkeuli

simptomis reducirebis tempis mixedviT (4)

moqmedebis Zala preparatebSi iklebs Semdegi TanmimdevrobiT

1. sakuTriv Timoanaleptiuri

klomipramini imipramini amitriftilini maprotilini

pirazidoli doqsepini nialamidi fluoqsetini fluvoqsamini

sertralini mianserini

2. antifobiuri

klomipramini fluvoqsamini sertralini fluoqsetini

imipramini nialamidi pirazidoli maprotilini

amitriftilini doqsepini mianserini

3. anqsiolituri

klomipramini fluvoqsamini amitriftilini sertranili

mianserini doqsepini maprotilini pirazidoli fluoqsetini

imipramini nialamidi

4. mastimulirebeli

nialamidi imipramini klomipramini pirazidoli

fluoqsetini fluvoqsamini sertranili maprotilini

mianserini doqsepini amitriftilini

5. sedaciuri da hipnoturi

doqsepini amitriftilini mianserini maprotilini

klomipramini sertralini pirazidoli fluvoqsamini

imipramini fluoqsetini nialamidi

58

suraTi 6.

Tanamedrove antidepresantebis SedarebiTi farmakologiuri

aqtivoba, maoi-s garda (5)

preparatebi

zemoqmedebis xasiaTi

ukumitacebis

blokada

receptorebis blokada

NA SER DA H1 M. alfa1 alfa2 DA2 SER2 SER3amitriftilini

amoqsapini

bupropioni

dezipramini

doqsepini

imipramini

klomipramini

maprotilini

mianserini

nortriftilini

paroqsetini

sertralini

trimipramini

trazodoni

fluvoqsamini

fluoqsetini

citaloprami

3

2

5

1

3

3

3

2

4

2

4

5

4

5

5

4

6

3

4

6

4

4

3

2

6

5

4

1

2

5

4

2

2

2

4

4

3

5

5

4

4

4

5

4

4

3

4

6

4

4

6

2

3

5

4

1

3

3

2

2

3

6

6

1

4

6

5

4

1

4

6

3

2

2

2

4

4

2

3

5

2

5

6

5

5

1

2

5

3

1

2

2

2

2

2

5

4

1

1

5

5

4

2

4

6

5

3

4

5

5

1

4

5

4

3

1

5

5

6

4

1

6

4

4

4

2

4

4

4

4

5

3

4

6

6

6

3

1

6

5

3

4

4

4

2

3

6

6

3

2

6

5

6

3

?

?

5

?

4

1

?

3

4

2

1

?

?

?

2

?

suraTi 6 -is axsna: preparatis gavlenis SedarebiTi Zala (erTi antidepresantis

meoresTan SedarebiT) gamosaxulia 6 baliani skaliT:

1- maqsimaluri efeqti 4 _ susti efeqti

2- gamoxatuli efeqti 5 _ ukiduresad susti an efeqti saeWvoa

3- zomieri efeqti 6 _ efeqti ar arsebobs

NA– noradrenalini; SER- serotonini; DA _Adofamini;

59

suraTi 7.

antidepresantebis gverdiTi efeqtebi (4)

tca maoi sumsi

qolinerguli:

piris simSrale, yabzoba, Sardis Sekaveba,

peristaltikis da eakulaciis daTrgunva,

akomodaciis darRveva, deliriumi_xSirad

moxucebSi

kupireba:_dozebis Semcireba an moxsna,

detoqsikacia.

simptomuri Terapia _ prozerini an galantamini

1_4mg kanqveS; fizostigmini 0,5_2mg yovel saaTSi,

I/M an kanqveS; pilokarpini 1_2% (Tvalis

wveTebi);

igive, rc tca-s dros _

kardio-vaskuluri:

• taqikardia, orTostatikuri hipotenzia;

saWiroa: _dozis Semcireba; kordiamini 2%

_1,0mlI/M

• ekg-s darRveva: T kbilis daTrgunva an

inversia, QRS segmentis gaxangrZliveba,

ariTmia, gamtareblobis darRveva.

(xangrZlivi miRebisas _ miokardiumis

infarqti da kardiomiopaTia);

saWiroa: mk-is Sewyveta; simptomuri Terapia;

• taqikardia,

orTostatiuri

hipotenzia;

kupireba:

dozebis Semcireba

• taqikardia,

TA-s momateba

saWiroa:

dozebis Semcireba

gastro-enterologiuri:

• gulisreva, Rebineba, pirSi mware gemo,

nawlavebis peristaltikis darRveva;

saWiroa: _ dozebis Semcireba;

_medikamentis ufro danawevrebuli miReba;

• siyviTle, hepatiti;

kupireba:

mkurnalobis Sewyveta

gulisreva, kuWis

gadavsebis grZnoba,

Rebineba, buybuyi,

muclis kolika,

diarea, meteorizmi;

hematologiuri:

leikocitozi, leikopenia, eozinofilia,

Trombocitopenia; saWiroa: mkurnalobis Sewyveta

centraluri: sedacia, Zilianoba, sisuste,

Tavbrusxveva, nistagmi, ataqsia, dizarTria,

paroqsizmuli movlenebi, eqstrapiramiduli

simptomebi, wvrilamplitudiani tremori,

romelic ar reagirebs qolinolizur

preparatebze);

saWiroa: _ dozis Semcireba an mkurnalobis

Sewyveta; dozis Semcireba+beta blokerebi;

fenobarbitali; maniakaluri mdg-is

ganviTarebisas

saWiroa_mk-is Sewyveta+liTiumi+neiroleptikebi

hipertonuli krizi;

koma, sxva

preparatebTan .

interaqtivobis gamo.

smenis da optikuri

nervis dazianeba

saWiroa mk-is moxsna

alergiuli:

* qolestatikuri siyviTle, agranulocitozi,

(mk-is dawyebidan 1-2 TveSi), dermatovaskuliti,

WinWris cieba; saWiroa: mkurnalobis moxsna

dermatovaskuliti

arTropaTia, arTriti,

limfadenopaTia

saWiroa: mk-is moxsna

sxvadasxva:

• ,,moxsnis sindromi” _ saWiroa medikamentis

moxsna 4-6kviris ganmavlobaSi (ix. dafa 6.)

• wonis momateba, libidos daqveiTeba,

prolaqtinemia, hipoglikemia

priapizmi, libidos

daqveiTeba, anorgazmia,

,,moxsnis sindromi”

prolaqtinemia

,,serotoninuli

sindromi”.

(ix. suraTi 8.)

60

suraTi 8.

serotoninuli sindromi (4, 14);

• kuWnawlavis mxriv _ muclis kolika da buybuyi, meteorizmi, gulisreva,

iSviaTad - Rebineba, diarea;

• cns-is mxriv: tremori, dizarTria, akatizia, hiperrefleqsia, kunTovani

hipertonusi, mioklonuri SekrTomebi (iwyeba terfSi da vrceldeba mTel

sxeulSi), SesaZloa ataqsia da kordinaciis darRveva;

• gul-sisxlZarRvTa sistema: TA-s arteriuli wnevis momateba, taqikardia

(serotononerguli antidepresantebi Cveulebriv, bradikardias iwveven);

• mdg-is damZimebisas: fsevdomaniakaluri sindromi, metyvelebis gaZneleba,

ideaTa rbola, Zilis darRveva, hiperaqtiuroba, abneva da dezorientacia;.

• terminaluri stadia Zalian waagavs avTvisebian neirolefsiur sindroms

_ maRali temperatura, profuzuli ofli, niRbiseburi, gapoxili saxe;

• simptomebi qreba sumsi-s dozis Semcirebis an moxsnis Semdeg.

mkurnaloba mZime SemTxvevebSi _ciproheptadini

16-32 mg dReSi; beta-blokerebi; detoqsikacia, simptomuri Terapia;

• sikvdili viTardeba mwvave kardio_vaskuluri ukmarisobiT.

61

suraTi 9.

calkeuli antidepresantis gverdiTi efeqtis SedarebiTi daxasiaTeba

(4,14); preparati gverdiTi efeqti

generiuli

(saerTaSoriso)

saxelwodeba

qoli-

noli-

zuri

Zilia-

noba,

sedacia

uZiloba

aJitacia

orTosta-

tiuri

hipo-

tenzia

gulis

riTmis

darRvev

a

gastro-

-entero-

logiuri

wonis

momat

eba

sqeso

brivi

sfer

o

tricikluri antidepresantebi

amitriftilini ++++ ++++ _ ++++ +++ + ++++ ++

dezipramini ++ + +++ +++ ++ + ++ _

doqsepini +++ ++++ _ +++ +++ + ++ +

imipramini ++++ ++ ++ ++++ +++ ++ +++ ++

klomipramini ++++ ++ + ++++ +++ ++ +++ ++

nortriftilini ++ ++ + +++ +++ + ++ +

protriftilini +++ ++ ++ +++ +++ + + _

Tianeptini + + ++ _ + ++ _ _

trimipramini +++ ++++ _ +++ ++ _ +++ ++

tetracikluri antidepresantebi

amoqsapini ++ +++ _ +++ ++ ++ +++ ++

maprotilini ++ +++ + + ++ _ +++ +

mianserini + +++ _ + _ + ++ +

antidepresantebi sxva qimiuri struqturiT

bupropioni _ _ +++ _ ++ ++ _ _

venlafaqsini ++ ++ ++ _ _ +++ + ++

trazodoni

serotoninis ukumitacebis seleqtiuri inhibitorebi

paroqsetini ++ + ++ _ _ +++ _ +++

sertralini _ ++ ++ _ _ +++ _ +++

fluvoqsamini _ ++ ++ _ _ +++ _ +++

fluoqsetini _ _ +++ _ _ +++ _ +++

citaloprami _ + ++ _ _ +++ _ +++

mao-s Seuqcevadi inhibitorebi

nialamidi ++ ++ ++++ +++ _ ++ ++ +

mao-s Seqcevadi inhibitorebi

moklobemidi + _ ++ _ _ ++ + _

pirazidoli + + ++ _ _ ++ + _

SeniSvna _ gverdiTi efeqti: _ _ ar aris

+ _ Zalian iSviaTia

++ _ iSviaTia

+++ _ xSiria

++++ _ Zalian xSiria

62

suraTi 10.

farmakokineturi interaqtivoba (14)

citoqromi P450IA2

citoqromi P4502C citoqromi P4502D6 citoqromi P4503A

genetikuri

polimorfizmi

TeTri rasis 5-10%-s

aqvs misi ukmarisoba

TeTri rasis 3-5%-s

aqvs misi ukarisoba

P450 Semcvelobis

60%

inducireba:

sigaretis moweva

SeSis naxSiris

boli

karbamazepini

omeprazoli

fenobarbitali

fenitoini

inducireba:

fenitoini

rifampicini

inducireba:

karbamazepini

fenitoini

inducireba:

karbamazepini

fenitoini

prednizoloni

rifampicini

inhibireba:

cimetidini

ciprofloqsacini

eriTromicini

fluvoqsamini

paroqsetini

inhibireba:

cimetidini

fluoqsetini

fluvoqsamini

sertralini

inhibireba:

qlorpromazini

citaloprami

duloqsetini

flufenazini

haloperidoli

paroqsetini

sertralini

triciklurebi

inhibireba:

eriTromicini

fluoqsetini

fluvoqsamini

ketokonazoli

paroqsetini

sertralini

triciklurebi

metabolizmi:

klozapini

haloperidoli

mirtazapini

olanzapini

Teofilini

triciklurebi

varfarini

metabolizmi:

diazepami

omeprazoli

fenitoini

tolbutamidi

triciklurebi

varfarini

metabolizmi:

klozapini

kodeini

donepezili

haloperidoli

fenoTiazini

risperidoni

tca meoradi

aminebi

tramadoli

trazodoni

venlafaqsini

metabolizmi:

benzodiazepinebi

Ca++ blokatorebi

karbamazepini

cimetidini

klozapini

kodeini

donepezili

eriTromicini

galantamini

metadoni

mirtazapini

risperidoni

steroidebi

terfenadini

triciklurebi

valproati

venlafaqsini

Z _ hipnoturebi

63

c. inicialuri mkurnaloba antidepresantebiT (3-5, 13-15, 150, 152)

antidepresantebis inicialuri dozebi mocemulia sur. 3.

Terapiuli dozis misaRwevad antidepresantis titraciis dros

gaiTvaliswineT:

• gverdiTi efeqtebi (ix. sur. 7; 8; 9; 10);

• pacientis asaki

mag. inicialuri da Terapiuli doza unda ganaxevrdes

moxucebsa da fizikurad dauZlurebul pacientebSi

• komorbiduli faqtorebi.

(20, 22, 28, 74, 150, 155-eqspertTa mosazreba; 67_B, A57, 58 73, 81 148, 178-A)

• monitorings da Sefasebas saWiroebs gverdii efeqtebi;

• klinikuri mdgomareoba;

• usafrTxoeba (mag. suicuduroba).

• Terapiis efeqturoba;

(73, 148-A)

monitoringis sixSire damokidebulia daavadebis simZimeze;

• suicidur riskze;

• mniSvnelovan gverdiT efeqtebze an wamlebis interaqtivobaze

(ix. sur. 6; sur. 10);

• pacientis mkurnalobisadmi damokidebulebaze;

• socialur mxardaWeraze da

• komorbiduli zogadi samedicino problemebis arsebobaze.

(73, 148-A):

monitoringis meTodebi gansazRvreT klinikuri konteqstis

Sesabamisad _ pirispir, telefoniT, eleqtronuli fostiT,

kontaqti pirveladi jandacvis eqimTan

(74, 155 – eqspertTa mosazreba)

mkurnalobis efeqturobis Sesafaseblad gamoiyeneT depresiis

Sesafasebeli unificirebuli skalebi _ hamiltonis, bekis da sxva

moaxdineT medikamenturi mkurnalobis gverdiTi efeqtebis marTva

(ix. sur.11)

64

suraTi 11.

medikamenturi mkurnalobis gverdiTi efeqtebis

menejmenti (13-15, 150, 152) (74, 155-eqspertTa mosazreba)

miawodeT pacients informacia potenciuri gverdiTi

efeqtebis Sesaxeb, moTxoveT, gansakuTrebuli

yuradRebiT iyos maT mimarT.

moaxdineT gamovlenili gverdiTi efeqtebis

monitoringi

mniSvnelovani gverdiTi efeqtebis gamovlenisas:

• daakvirdiT da daicadeT _ Tu ar aris Terapiuli

riski;

• SecvaleT wamlebis doza, miRebis sixSire da dro;

• SecvaleT sxva, diferencirebuli klasis

medikamentiT;

• uzrunvelyaviT gverdiTi efeqtebis specialuri

mkurnaloba.

gaagrZeleT gverdiTi efeqtebis monitoringi,

gansakuTrebuli yuradReba miaqcieT:

• Terapiuli riskis arsebobas;

• pacientis mier mkurnalobis reJimis mkacrad dacvas;

• pacientis TviTgrZnobas.

65

d. inicialuri mkurnalobis warumatebloba (3-5, 13-15, 150,152)

Tu 4-8 kviris Semdeg pacientis mdgomareoba zomierad mainc ar

gaumjobesda, SecvaleT mkurnalobis reJimi (sur. 2.) (73, 166-A);

• gaarkvieT, Tanmimdevrulad icavs Tu ara pacienti

mkurnalobis reJims (25-C, 72, 78-B, 23, 26, 77, 79-A)

gaiTvaliswineT farmakodinamikuri da farmakokineturi

faqtorebi (SeiZleba saWiro iyos sisxlis plazmaSi

antidepresantis koncentraciis gansazRvra) (58- B, 57-A);

gadasinjeT mkurnalobis gegma

maqsimumamde gazardeT inicialuri Terapiuli doza

(46, 81-A):

_ nawilobri efeqtis miRebisas gaaxangrZliveT mkurnaloba

gazrdili doziT, mag. 2-4 kviriT

(58-C; 57-A):

_ saSualo dozebis araefeqturobis an sisxlis plazmaSi

dabali koncentraciisas gazardeT doza da daakvirdiT

gverdiT efeqtebs

(74, 155 - eqspertTa mosazreba; 58-C; 44, 45, 67-B; 46, 75, 81-A):

• daumateT, SecvaleT, an gazardeT fsiqoTerapiis

intensivoba (20, 69, 92- eqspertTa mosazreba; 25-C, 72, 78-B, 23, 26, 77, 79-A);

• gadadiT sxva, igive an gansxvavebuli klasis, ara maoi–s

jgufis antidepresantze (ix. sur. 3; dafa 3. da 4.)

(27-C; 24, 31, 48, 64-A);

• Tu nawilobrivi efeqti mainc gaqvT, daumateT:

_ ara maoi-s jgufis, sxva diferencirebuli klasis

antidepresanti (iyaviT fxizlad wamlebs Soris

interaqtiobis gamo)

(27-C; 24, 55, 56, 87-A); an

_ sxva damxmare medikamenti _ mag. liTiumi (59, 60-C; 106-B donis mtkicebuleba); Tiroiduli hormoni, (61-eqspertTa

mosazreba 62-D), antikonvulsanti, (60, 63-C),

fsiqostimulatori (62-eqspertTa mosazreba);

• gadadiT maoi-s jgufis antidepresantze (62-eqspertTa

moszreba; 30, 32, 34, 56-A);

• daniSneT ekT (156, 43-eqspertTa moszreba; 25-C, 67-B, 66-A)

dafa 3.

aucilebeli intervali antidepresantebis Secvlis dros

(1, 13, 152) antidepresantebis Secvla minimaluri intervali

66

1. xangrZlivi naxevardaSlis

periodis mqone preparatebis (mag.

fluoqsetini) Secvla maoi-s

preparatebiT

2. maoi-s preparatebis Secvla

xangrZlivi naxevardaSlis

periodis mqone preparatebiT (mag.

tca, paroqsetini, fluvoqsamini,

venlafaqsini) an maoi-s sxva

preparatiT;

3. maoi-s preparatebis Secvla

ara-maoi-s preparatebiT

5 kvira

2 kvira

2 kvira

rodesac erTi antidepresanti meore antidepresantiT

icvleba, mizanSewonilia araefeqturi an dabali

tolerantobis mqone antidepresantis dozebis Semcireba

garkveuli drois ganmavlobaSi da axali preparatiT

TandaTanobiTi Canacvleba (14). garda zemoT, dafa 3 –ze gaTvaliswinebuli SezRudvebisa

dafa 4

magaliTi pirveli

kvira

meore

kvira

mesame

kvira

meoTxe

kvira

doTiapinis

moxsna

150mg 100 mg /dReSi 50mg/dReSi 25mg/dReSi araferi

citalopramis

daniSvna

araferi 10mg/dReSi 10mg/dReSi 20mg/dReSi 20mg/dReSi

• fsiqozuri simptomebiT mimdinare depresiuli epizodis dros

simptomebis marTvisaTvis gamoiyeneT antifsiqozuri

medikamentebi(3):

• mizanSewonilia 2-generaciis (atipiuri) antifsiqozuri

preparatebiT mkurnaloba, maTi zogadad ufro asatani

gverdiTi efeqtebis profilis gamo:

mag.

_ risperidoni 0,5 _ 8 mg/dReSi;

_ olanzapini 5 -20 mg/dReSi;

_ queTiapini 200_400 mg/dReSi;

(28- eqspertTa mosazreba; 96,161-D, 28, 29-A)

67

e.antidepresantis SerCeva gaxangrZlivebuli araefeqturobisas

(3-5, 13-15, 150,152)

• gadaamowmeT diagnozis siwore da pacientis mier

mkurnalobis reJimis Tanmimdevruli dacva eqspertTa

moszreba; 25-C, 72, 78-B, 23, 26, 77, 79-A):

• Tu 4-8 kviris Semdeg pacientis mdgomareoba zomierad mainc

ar gaumjobesda, gamoikvlieT mkurnalobisaTvis xelis

SemSleli faqtorebi:

• zogadi samedicino komorbiduli faqtorebi;

• komorbiduli fsiqikuri faqtorebi, fsiqoaqtiuri

nivTierebebis moxmarebis CaTvliT;

• mniSvnelovani fsiqosocialuri problemebi.

(164-C, 40-B, 55, 35-37, 73-A)

Tu zemoT aRniSnuli RonisZiebebis gatarebisas araefeqturobis

mizezi ar gamoavlindeba gaiTvaliswineT konsultacia an ekT

(156-eqspertTa mosazreba; 67, 157-B, 42, 43, 65-A);

3. inicialuri fsiqoTerapiuli mkurnaloba (13, 14, 152, 153)

msubuqi an zomieri depresiis dros fsiqoTerapiis monoTerapiis

saxiT gamoyeneba xdeba pacientis arCevanis gaTvaliswinebiT

(20, 22, 155- eqspertTa mosazreba; 160-D, 21, 78, 154-B, 23, 26, 76,180, 181, 182-A)

fsiqoTerapiuli intervencia damokidebulia Semdeg

Taviseburebebze:

• mniSvnelovani fsiqosocialuri stresorebis arseboba;

• intrafsiqikuri konfliqti;

• interpersonaluri siZneleebi;

• komorbiduli personologiuri aSliloba;

• orsulobis da laqtaciis periodi an daorsulebis survili;

• pacientis arCevani.

68

a. fsiqoTerapiis SerCevis principi.

mkurnalobis modelis arCeva:

• kognitur-bihevioruli Terapis da interpersonaluri

Terapiis maRali efeqturoba dadasturebulia(70, 71, 72, 78, 85-B, 77, 79.-A)

• fsiqodinamiuri fsiqoTerapia, romelzec miRweulia farTo

klinikuri konsensusi, orientirebulia rogorc depresiis,

aseve personologiuri aSlilobis simptomebze (20- eqspertTa

mosazreba; (159- eqspertTa mosazreba)

gaiTvaliswineT:

• pacientis arCevani;

• specifiur problemebze saTanadod trenirebuli

klinicistebis xelmisawvdomoba.

b. fsiqoTerapiuli mkurnalobis ganxorcieleba

gansazRvreT fsiqoTerapiis sixSire

fsiqoTerapiis intensivoba mwvave fazaSi (Cveulebriv, kviraSi

erTxel an ramdenimejer) damokidebulia:

• fsiqoTerapiis specifikaze da miznebze;

• Terapiuli aliansis Seqmnisa da xelSewyobis saWiroebaze;

• komplaenturobis miRwevis aucileblobaze;

• suicidurobis monitoringis da marTvis saWiroebaze.

(159, 167-eqspertTa mosazreba; 70, 71, 72, 78, 85-B, 77, 79, 180, 181, 182-A)

roca mkurnalobis procesSi erTze meti klinicisti

monawileobs, xeli SeuwyveT pacientis kontaqts sxva

klinicistebTan (13).

Tu 4-8 kviris Semdeg pacientis mdgomareoba, sul mcire,

zomierad mainc ar gaumjobesda, CaatareT srulyofili

ganmeorebiTi Sefaseba da gadadiT mkurnalobis sxva

variantebis ganxilvaze (ix. sur. 3.) (73 A)

69

4. farmakoTerapiis da fsiqoTerapiis kombinireba (13, 15, 152)

farmakoTerapiis da fsiqoTerapiis kombinirebas gansazRvravs

zomieri da mZime depresiuli epizodis simwvave,

fsiqosocialuri funqcionirebis mniSvnelovani gauareseba,

interpersonaluri problemebi an komorbiduli

personologiuri aSliloba (20, 22, 155, 159, 167- eqspertTa

mosazreba; 160-D, 21, 78, 154-B, 23, 26, 76, 179 -182-A)

kombinirebuli mkurnalobis ganmsazRvreli damatebiTi

faqtorebia:

• warsulSi monoTerapiis araefeqturobis istoria

• mkurnalobis Tanmimdevruli reJimis darRveva

(fsiqoTerapiuli intervencia orientirebulia

komplaenturobis miRwevaze)

5. eleqtrokonvulsiuri Terapia

eleqtrokonvulsiuri Terapiis ganxilva xdeba Semdegi

faqtorebis arsebobisas:

• depresiuli epizodis simZimis maRali xarisxi,

fsiqosocialuri funqcionirebis darRveviT;

• fsiqozuri simptomebi da katatonia;

• antidepresiuli efeqtis urgentuli saWiroeba (mag.

suiciduroba an uari sakvebis miRebaze).

(156, 74, 43-eqspertTa moszreba; 25-C, 157, 67-B, 66-A)

ekT SesaZlebelia upiratesi mkurnaloba iyos:

• antidepresantebiT mkurnalobis gamomricxavi zogadi

samedicino komorbiduli faqtorebis arsebobis dros;

• warsulSi ekT-s kargi efeqturobis dros;

• roca pacienti irCevs ekT-s.

(43-eqspertTa moszreba; 42-A)

6. mkurnalobis efeqtis adekvaturi Sefaseba (13, 152, 153)

ar Sewyvito mwvave fazis mkurnaloba arasruli efeqturobisas,

nawilobrivi efeqti cud fsiqosocialur gamosavalTan

asocirdeba (164, 174_C, 73, 178-A).

70

C. SemanarCunebeli anu mastabilizebeli mkurnalobis faza

(13, 14, 152, 153)

SemanarCunebeli anu mastabilizebeli mkurnalobis faza

ganisazRvreba mwvave fazis amowurvis da remisiis

Camoyalibebidan 16_20 kviris xangrZlivobis periodiT.

(82_B, 73-A) recidivis prevenciis mizniT, gaagrZeleT antidepresantebiT

mkurnaloba igive doziT, rogorc mwvave fazis periodSi

(73, 80, 82, 84-A).

recidivis prevenciis mizniT, gaiTvaliswineT fsiqoTerapiis

gamoyeneba. (85_B, 166, 179, 180, 181-A)

recidivis prevenciis mizniT, gaiTvaliswineT ekT-s SeTavazeba,

Tu araefeqturi iyo medikamenturi an fsiqoTerapiuli

mkurnaloba. (86_B)

klinikuri mdgomarebasa da gamoyenebuli mkurnalobis

specifiurobis Sesabamisad gansazRvreT vizitebis sixSire.

sixSire SeiZleba meryeobdes kviraSi ramdenime vizitidan, 2-3

TveSi erTxel vizitamde.

71

D. damWeri anu profilaqtikuri Terapiis faza (3, 13, 14, 152, 153)

damWeri anu profilaqtikuri Terapiis mizania depresiuli

epizodis rekurentobis prevencia

(174_C, 73, 148, 178 -A)

damWeri anu profilaqtikuri Terapiis Sesaxeb gadawyvetilebis

miRebisas gaiTvaliswineT Semdegi faqtorebi:

faqtori komponenti

• ganmeorebis riski

• epizodebis simZime

• SemanarCunebeli

mkurnalobis periodSi

gverdiTi efeqtebi

• pacientis arCevani

• wina epizodebis raodenoba,

epizodebis polaruloba,

komorbiduli problemebi,

epizodebs Soris

rezidualuri simptomebi;

• suiciduroba, fsiqozuri

simptomebi, fsiqosocialuri

funqcionirebis daqveiTebis

done;

gaagrZeleT mkurnaloba, romelic efeqturi iyo mwvave da

SemanarCunebeli mkurnalobis fazaSi (82, 85, 87,_B, 80-A).

gamoiyeneT antidepresantebis igive dozebi, romlebic efeqturi

iyo mkurnalobis wina fazaSi. (80, 81, 82, 84 _ A).

gansazRvreT vizitebis sixSire klinikuri mdgomarebis da

gamoyenebuli mkurnalobis specifikurobis Sesabamisad.

stabiluri pacientebisaTvis viziti SeiZleba daigegmos 2-3

TveSi erTxel, xolo Tu pacienti mkurnalobs fsiqodinamiuri

fsiqoTerapiiT _ kviraSi ramdenjerme (180, 181, 182- A)

gansazRvreT ekT-s gamoyenebis saWiroeba pacientebTan,

romlebic uars acxadeben ganmeorebadi zomieri an mZime

epizodis dros Sesabamis farmakologiur mkurnalobaze. (86-B).

72

E. aqtiuri mkurnalobis Sewyveta (3, 13, 14, 152, 153)

gaiTvaliswineT, rom mkurnalobis Sewyveta igive faqtorebzea

damokidebili, romlis mixedviTac gamogvaqvs daskvna damWeri

mkurnalobis dawyebaze

(44, 73, 80, 81, 82, 84 _ A donis mtkicebuleba). • magaliTad, gaiTvaliswineT gameorebis SesaZlebloba,

sixSire da bolo epizodis simZime (ix. cxrili 4)

SeafaseT depresiuli epizodis rekurentulobis riski

(dafa 5. )

dafa 5.

depresiuli epizodis rekurentulobis risk_faqtorebi

(13, 14, 152):

• anamnezSi xSiri depresiuli epizodebi;

• bolo depresiuli epizodis simZime;

• ojaxuri uTanxmoeba, cudi emociuri da socialuri

maxardaWera;

• stres-faqtorebisadmi aweuli mgrZnobeloba;

• disTimiuri an sxva fsiqikuri aSlilobis komorbidoba;

• Tanmxlebi qronikuli somaturi daavadebis arseboba.

mkurnalobis Sewyvetisas fsiqoTerapiis meTodis arCeva

damokidebulia pacientis problemebze, fsiqoTerapiis tipze,

mkurnalobis xangrZlivobasa da intensivobaze.

eqvs kviriani an ufro xangrZlivi Timoanaleptiuri

mkurnalobis mkveTrad Sewyveta ar aris mizanSewonili,

SesaZlebelia ,,moxsnis sindromis” ganviTareba (ix. dafa 6.)

antidepresantebis moxsna xdeba TandaTanobiT, dozis

SemcirebiT, zogjer saWiroa preparatis datoveba kviraSi 2-3-

jer. kleba unda gagrZeldes oTxi kviris manZilze an ufro met

xans, rac mniSvnelovanwilad damokidebulia preparatis

naxevardaSlis periodze (14)

magaliTi antidepresantebis Sewyveta (14).

dozebis kleba (mg/dReSi)

preparati Terapiuli

doza

I kviris

Semdeg

II kviris

Semdeg

III kviris

Semdeg

IV

kviris

Semdeg

amitriftilini 150 100 50 25 arafe

ri

paroqsetini 30 20 10 10mg

dRegamoSvebiT

arafe

ri

trazodoni 450 300 150 75 arafe

ri

73

gaiTvaliswineT, rom Timoanaleptiuri Terapiis mkveTri

Sewyvetisas, potenciurad nebismier andidepresants SeuZlia

gamoiwvios ,,moxsnis sindromi” (14).

dafa 6. antidepresantebis ,,moxsnis sindromi” (14)

maoi tca sumsi

simptomebi aJitacia, ataqsia

gamRizianebloba,

aSlilobis

gamwvaveba, insomnia,

somnolencia,

koSmaruli

sizmrebi,

kognituri

darRvevebi,

gaugebari

metyveleba,

* iSviaTad _

halucinacia, bodva

gripismagvari

simptomebi _

Semcivneba, mialgia,

hiperhidrozi, Tavis

tkivili, gulis

reva),DuZiloba an

mZafris sizmrebi.

* iSviaTad

viTardeba mania da

kardialuri

ariTmia

gripismagvari simptomebi,

,,eleqtro Sokismagvari”

SegrZnebebi, insomnia, an

uzomo Zilianoba

Tavbrusxveva,

gamRizianebloba,

wamoyvirebebi.

* iSviaTad _aSlilobis

gamwvaveba, yuradRebis

koncentraciis da

mexsierebis

problemebi.

xSirad iwvevs

xanmokle

naxevardaSllis

peridis mqone

antidepresanti

tranilcipromini amitriftilini

imipramini

paroqsetini

venlafaqsini

• Tu gamovlinda ,,moxsnis” sindromi, wamlis Sewyveta ki

aucilebelia, gaaxangrZliveT moxsnis vadebi da SeamcireT

wamlis daklebis doza (14);

• Tu moxsnis simptomebi 1-2 kviraze met xans mainc rCeba,

xelaxla SeafaseT da gadawyviteT, ra ufro rekomendebulia,

moxsna Tu mkurnalobis gagrZeleba (14).

• Tu pacients aqvs mkurnalobis Sewvetis SemTxvevaSi recidivis

gamocdileba, aRadgineT adrindeli, Terapiulad efeqturi

mkurnaloba (14);

• depresiis simptomebis recidivis SemTxvevaSi ufro swrafad

daubrundiT srul Terapiul dozas;

• SeimuSaveT mkurnalebis ganaxlebis gegma recidivis

SemTxvevisaTvis(14).

74

II. bipolaruli aSlilobis mkurnaloba A fsiqiatriuli menejmenti (13, 14, 151)

fsiqiatriuli menejmentis miznebi (13, 151):

• Terapiuli aliansis Camoyalibeba da xelSewyoba;

• pacientis fsiqikuri statusis monitoringi;

• bipolaruli aSlilobis Sesaxeb ganaTlebis gavrce

• leba;

• mkurnalobis Tanmimdevruli reJimis mkacri dacva;

• aqtiurobisa da Zilis bunebrivi riTmis xelSewyoba;

• winaswari sifrTxile stresorebis mimarT;

• axali epizodis adreuli identificireba;

• fsiqosocialuri funqcionirebis gauaresebis minimumamde

dayvana.

1. Seafase diagnostikurad (18)

SeafaseT fsiqoaqtiuri nivTierebebis moxmareba an sxva

komorbiduli faqtorebis arseboba, romelsac SeuZlia

gamoiwvios daavadeba, gavlena moaxdinos daavadebis

mimdinareobaze, an xeli SeuSalos mkurnalobis process

• gafantuli sklerozi da am daavadebaSi monawile, limbiur

sistemasTan mWidrod dakavSirebuli, marjvenamxrivi

subkortikaluri da kortikaluri zonebis organuli

dazianeba, Cveulebriv, meorad maniasTan asocirdeba;

• L–dofas preparatebiT da kortikosteroidebiT

mkurnalobisas Zalze xSirad viTardeba meoradi mania;

• fsiqoaqtiuri nivTierebebis gamoyeneba SesaZloa

gaxdesGguneb-ganwyobis aSlilobis epizodis maprovocire-

beli faqtori an, SesaZlebelia, pacienti aseTi epizodis

simptomebis Casaqrobad iRebdes am nivTierebebs.

(1, 2, 8) (103, 104, 171 C, da 101, 102, 172 D)

gamokiTxeT guneba-ganwyobis meryeobis da maniasTan

asocirebuli siptomebis labilurobis istoria, mag. Zilis

darRveva, gadaWarbebuli aqtiuroba da sxva.

(93, 94, 172 _D 178- A)

• bipolaruli aSliloba Cveulebriv warmodgenili unda

iyos depresiuli, hipomaniakaluri, maniakaluri an Sereuli

afeqturi epizodebis monacvleobiT (18) (178 - A)

• pacienti uCveulo xalisiT iZleva informacias maniakaluri

an hipomaniakaluri simptomebis Sesaxeb (18)

75

@2. uzrunvelyaviT pacientis da sxva pirebis usafrTxoeba.

gansazRvreT fsiqiatriuli daxmarebis done (13, 151)

usafrTxoebis Sefaseba

• gansakuTrebuli mniSvneloba aqvs suicidis riskis zust

Sefasebas (90-91 _ C);

• suicidur mcdelobaTa umravlesoba depresiul an Sereul

epizods ukavSirdeba (88-89-D); • SeekiTxeT yvela pacients suiciduri azrebis, tendenciebis,

suicidis dagegmvis Sesaxeb da gansazRvre maTi intensivoba;

• SeagroveT damatebiTi informacia ojaxis wevrebisa da sxva

pirebisagan;

• SeafaseT im saSualebebis xelmisawvdomoba, romliTac

Caidina suicidi (mag medikamentebi, cecxlsasroli iaraRi

da sxva) da am saSualebebis letalurobis xarisxi;

• SeafaseT suiciduri riskis momatebasTan dakavSirebuli

komorbuli faqtorebi, rogoricaa aJitacia, Zilis

darRveva, impulsuroba, fsiqoaqtiuri nivTierebebis Warbi

moxmareba (101-102_D; 103-C), fsiqozuri simptomebi

(gansakuTrebiT imperatiuli halucinaciebi) da

personologiuri aSliloba (104-C);

• SeafaseT ojaxuri istoria suicidze da axali

gamJRavnebuli suicidis istoria (94- D); • gansazRvreT nebismieri wina suiciduri mcdelobis arsi da

potenciuri letalurobis xarisxi;

• gansakuTrebuli zedamxedveloba gauwieT pacients,

romelic amJRavnebs suiciduri da Zaladobis Sinarsis

mqone azrebs an ganzraxvebs (100- D); • iyaviT frTxili daskvnis gamotanis procesSi.

gaiTvaliswineT hospitalizaciis saWiroeba, Tu pacienti (13,16):

• seriozul saSiSroebas uqmnis Tavis Tavs an irgvlimyofebs;

• agresiulia da saavadmyofos gareT ar aqvs Sesabamisi

socialuri mxardaWera an aSkaraa gauaresebis

SesaZlebloba;

• aqvs garTulebuli fsiqikuri an zogadi samedicino

mdgomareoba;

• ar an ver miiRebs adekvatur ambulatoriul mkurnalobas,

fsiqiatriuli daxmarebis dayovneba ki safrTxes Seuqmnis

pacientis an sxva piris sicocxles da/an janmrTelobas.(16)

ganmeorebiT SeafaseT SeTavazebuli fsiqiatriuli daxmarebis

donis optimaloba (13, 151, 153)

gaiTvaliswineT, Tu ramdenad xelmisawvdomia avadmyofisaTvis

manqana, sakredito baraTi, sabanko angariSebi, telefoni da

sxva, radgan maniakaluri mdgomareobis dros qonebisadmi

daudevari mopyrobis maRali riskia

(13, 153; 164-C);

76

3. Terapiuli aliansis Seqmna da xelSewyoba (13; 151)

Terapiuli aliansis Seqmna:

• gadamwyvetia TiToeuli pacientisagan fsiqiatriul

daxmarebaze Tanxmobis miRebis da SemTxvevis marTvis

procesSi (16);

• pacientisa da avadmyofobis Sesaxeb ufro meti informaciis

miRebis, prodromuli simptomebis adreuli identificirebis

da axali epizodis adreuli Secnobis saSualebas iZleva

(92-eqspertTa mosazreba, 95, 181-A);.

4. pacientis fsiqikuri statusis monitoringi (13; 151, 153)

• gansakuTrebulad mniSvnelovania monitoringi maniakaluri

epizodis mimdinareobisas, roca pacients SezRuduli an

dakarguli aqvs sakuTari daavadebis gacnobierebis unari

(166-A);

• gaxsovdeT, rom qcevis an guneba-ganwyobis mciredi

cvlilebac ki SeiZleba epizodis dasawyisis mauwyebeli

iyos (95, 178- A);A

5. pacientis da misi ojaxis fsiqoganaTleba (13; 151)

• TandaTanobiT pacienti ufro kompetenturi xdeba, igebs da

imaxsovrebs miwodebul informacias, iRebs da egueba

daavadebis xangrZlivi mkurnalobis saWiroebas

fsiqoganaTleba unda iyos uwyveti procesi, romlis drosac

fsiqiatri TandaTanobiT awvdis cnobebs avadmyofobisa da

misi mkurnalobis Sesaxeb;

• SeiZleba gamoyenebuli iyos beWdviTi da/an internetis

masalebi;

• igive saganmanaTleblo meTodebi gamoiyene ojaxis wevrebisa

da mkurnalobaSi CarTuli sxva pirebisaTvis

(92-eqspertTa mosazreba; 95, 181- A);

6. gaaumjobeseT mkurnalobis reJimis mkacri dacva (13; 151)

• mkurnalobisadmi ambivalenturi damokidebuleba xSirad

rogorc medikamenturi, aseve sxva saxis mkurnalobis reJimis

darRvevis mizezi xdeba

• ambivalenturi damokidebulebis mizezebia:

_ sakuTari daavadebis seriozulobis mimarT

gacnobierebuli damokidebulebis ukmarisoba;

_ hipomaniis an maniis Sesaxeb miRebuli piradi

gamocdilebis ignorireba.

• pacientTan diskusiisas ganxiluli unda iyos medikamentebis

gverdiTi efeqtebi, Rirebuleba da sxva problemebi, romelic

xangrZlivi mkurnalobisas SeiZleba tvirTad daawves

77

pacients;

• gverdiTi efeqtebis umetesobis koreqcia SeiZleba dozebis

frTxili SerCeviT, daniSnulebis reJimis da wamlis formis

SecvliT (mag. gaxangrZlivebuli moqmedebis, Txevadi

formis)(3).

(92-eqspertTa mosazreba; 166- A);

7. daexmareT, Seicnos stresogenuli faqtori. Seqmnas aqtiurobisa

da Zilis regularuli modeli (13; 151)

• stresogenuli faqtori ZiriTadad win uswrebs daavadebis

epizods

• socialuri riTmis darRveva, Zilis da aqtiurobis riTmis

darRvevasTan erTad, SeiZleba CaiTvalos maniakaluri

epizodisaTvis specifiur biZgis mimcem faqtorad; pacients

da misi ojaxis wevrebs unda hqondes informacia Zilis

darRvevis potenciur rolze maniakaluri epizodis

ganviTarebaSi

• xelSewyobili unda iyos dRis aqtiurobis regularuli

modeli (Zilis, kvebis, fizikuri aqtiurobis, socialuri da

emociuri stimulirebis CaTvliT).

(93, 94- D, 95, 181-A);

8. muSaoba pacientTan gamwvavebis adreuli niSnebis Secnobis da

marTvis mizniT(13; 151)

• fsiqiatri exmareba pacients, misi ojaxis wevrebs da

dainteresebul sxva pirebs maniakaluri an depresiuli

epizodis adreuli niSnebis da simptomebis winaswar

Secnobasa da marTvaSi

• epizodis Setevis adreuli markerebi xSirad TiToeuli

pacientisaTvis epizodis dawyebis mauwyebelia;

• fsiqiatris mWidro urTierToba, rogorc pacientTan, aseve

mis ojaxTan, aadvilebs prodromis adreul Secnobas.

(95, 181-A);

8. fsiqosocialuri funqcionirebis gauaresebis Sefaseba da

marTva (13; 151)

gansazRvre da warmarTe fsiqosocialuri funqcionirebis

gauareseba daexmareT pacients saqmianobis da sxva

movaleobebis ganrigis SedgenaSi;

• daexmareT pacients, Tavi aaridos mniSvnelovan

cxovrebiseul cvlilebebs maniakalur an depresiul

mdgomareobaSi;

• SeafaseT bipolaruli aSlilobis mqone pacientis

bavSvebis problemebi da daxmareba aRmouCineT maT.

(96-D; 97, 163, 164, 174-C)

78

B. mkurnalobis arCevani

1. mwvave maniakaluri an Sereuli epizodi (13, 14, 151)

mkurnalobis miznebi:

• simptomebis marTva, raTa pacientma SeZlos fsiqosocialuri

funqcionirebis Cveul doneze dabruneba

• aJitaciis, agresiis da impulsurobis swrafi marTva.

(163, 164-C, 178- A);

inicialuri mkurnalobis modelis arCeva

pirvelad pacientebSi:

mZime maniakaluri an Sereuli epizodis dros, rekomendebulia

mkurnalobis dawyeba (114-B da 162_C):

• liTiumiT, romelime antifsiqozur preparatTan

kombinaciaSi (111-112-A)

• an valproatiT* romelime antifsiqozur preparatTan

kombinaciaSi. (127-B da 129, 128, 140-A)

• naklebad mZime pacientebisaTvis rekomendebulia

monoTerapia liTiumiT (105-107, 109-B, 115, 147-A),

valproatiT* (124-B, 110 125-126-A), an romelime

antifsiqozuri preparatiT, mag. olanzapiniT* (111, 112, 136,

137, 138,-A);

• SeiZleba saWiro iyos, xanmokle periodis ganmavlobaSi

benzodiazepinebiT damatebiTi mkurnaloba (142-143-A);

• Sereuli epizodis dros SeiZleba, liTiumTan SedarebiT,

ufro efeqturi iyos valproati (110, 115-A);

• atipiur antifsiqozur preparatebs upiratesoba eniWeba

tipiurTan SedarebiT, ZiriTadad maTi ufro asatani

gverdiTi efeqtebi gamo (mag. olanzapini an risperidoni*)

(138-139-A);

• alternatiuli mkurnaloba gulisxmobs:

1) karbamazepini* an oqskarbamazepini, 132, 165_B da 108, 131,133, 138- A); liTiumis an valproatis nacvlad;

2) ziprazidoni an queTiapini sxva antifsiqozuri

preparatis nacvlad (13);

gaiTvaliswineT:

• mkurnalobis SerCeva damokidebulia daavadebis simZimis

xarisxze, rac swrafi ciklurobis an fsiqozis arsebobas

ukavSirdeba da, roca SesaZlebelia, pacientis arCevanze

(178-A);

• liTiumis aqtiuri moqmedebis dawyebamde latenturi

periodi 4-10 dRea, amitom, maniis simptomebis marTvis

mizniT, SeiZleba saWiro gaxdes antifsiqozuri

preparatebis damateba (3) (139, 140, 141-A);

• antidepresanti Semcirebuli an Sewyvetili unda iyos

79

saWiroebis mixedviT (98 B da 146-A);

• rekomendebulia fsiqosocialuri da

fsiqofarmakologiuri Terapiis kombinireba

(164_C, 179, 180, 181- A)

* saqarTveloSi registrirebuli preparatebi

pacientebTan, romlebsac damWeri Terapiis fonze ewyebaT

maniakaluri an Sereuli epizodis Seteva, saWiroa

medikamentebis dozebis optimizeba

• darwmundiT, rom sisxlis SratSi medikamentis

koncentracia Terapiulis farglebSia. zogjer

aucilebelia, miaRwioT Terapiuli koncentraciis zeda

zRvars (175-D, 68, 123- B, 122-A);

• xSirad, kvlav saWiro xdeba antifsiqozuri preparatis

damateba (139-141-A);

• daavadebis simZimis an gamoxatuli aJitaciis dros

SesaZlebelia, saWiro gaxdes, pacients daeniSnos

benzodiazepiniT damatebiTi moklevadiani mkurnaloba,

mag. lorazepami an klonazepami* 2- 4 mg/dReSi (4) (142-143-

A);

Tu maniis simptomebi 10-14 dRis ganmavlobaSi pirveli rigis

medikamenturi mkurnalobis optimizebuli dozebiT

arasakmarisad kontrolirdeba, daumateT sxva pirveli rigis

medikamenti. (113, 114-C, 110-112, 115-A);

mkurnalobis alternatiuli variantebia:

• pirveli rigis medikamentebis (liTiumi, valproati,

antifsiqozuri praparati) damatebis nacvlad, daumateT

karbamazepini an oqskarbamazepini

(113-C, 116, 165-B, 108-A);

• daumateT antifsiqozuri preparati, an erTi antifsiqozuri

preparati SecvaleT meore antifsiqozuri preparatiT

(139-141_A);

• daavadebebis rezistentulobis dros SeiZleba nawilobriv

efeqturi iyos klozapini (149-B); • eleqtrokonvulsiuri Terapia (ekT) mizanSewonilia:

_ pacientebSi mZime maniakaluri an medikamenturi

Terapiisadmi rezistentuli mdgomareobis dros;

_ pacientebSi, romlebic fsiqiatrTan konsultaciis

Semdeg airCeven ekT-s;

_ pacientebSi Sereuli epizodiT da

_ pacientebSi, romlebsac ganuviTardaT mZime mania

orsulobis periodSi

(43, 155, 156-eqspertTa mosazreba, 157- B)

80

siqozuri simptomebiT mimdinare maniakaluri an Sereuli

epizodis dros simptomebis marTvisaTvis gamoiyeneT

antifsiqozuri medikamentebi:

mizanSewonilia meore Taobis (atipuri) antifsiqozuri

preparatebiT mkurnaloba, maTi zogadad ufro asatani gverdiTi

efeqtebis profilis gamo (3):

_ risperidoni 2-6 mg;

_ olanzapini 10-20 mg;

_ queTiapini 200_400 mg;

_ ziprazidoni 40_80 mg.

(127-B, 128, 136-141-A)

• arakomplaenturi, mZime maniakalur pacientebSi, oraluri

antifsiqozuri preparatebis nacvlad, mizanSewonilia

deponirebuli fenoTiazinis gamoyeneba, mag. Sol. Fluphenazine* 12,5 _25 mg. kunTebSi 3-4 kviraSi erTxel (3)

• aseve SeiZleba ganxiluli iyos ekT (156, 43-eqspertTa

mosazreba, 157- B);

81

2. bipolaruli mwvave depresia(13, 151)

mkurnalobis mizani:

• depresiis simptomebis alageba da pacientis fsiqosocialuri

funqcionirebis Cveul doneze dabruneba;

• maniakaluri an hipomaniakaluri epizodis maprovocirebeli

faqtoris Tavidan acileba

(97, 164-C, 98, 106, 154-B, 134, 145, 147, 66_A).

airCieT inicialuri mkurnalobis modeli

pacientebTan, romlebsac pirvelad utardebaT mkurnaloba

bipolaruli aSlilobis gamo, mkurnaloba daiwyeT liTiumiT (105-

107_B); an lamotrijiniT* (145- B, 99, 134, 135, 144-A).

• rogorc alternativa, gansakuTrebiT ufro mZime depresiis

dros _ mizanSewonilia mkurnaloba daiwyoT liTiumis da

antidepresantis erTdroulad micemiT(13, 3)

• antidepsantTan kombinirebuli mkurnalobis xangrZlivoba

SezRudulia _ saSualod 4-12 kvira (3);

• antidepresantebiT monoTerapia ar aris rekomendebuli (146_A, 98- B);

• gaiTvaliswineT ekT:

_ fizikurad dauZlurebul, suicidur an fsiqozur

pacientebTan;

_ pacientebTan, romlebsac orsulobis fonze

ganuviTardaT mZime depresia (155, 43-eqspertTa mosazreba,

160-D, 67, 86, 157-B da 66_A)

• mkurnalobis seleqciisas unda ixelmZRvaneloT daavadebis

simZimiT, romelic swraf ciklurobaSi an fsiqozuri

simptomebis arsebobaSi vlindeba da aseve, SesaZleblobis

farglebSi, unda gaiTvaliswinoT pacientis arCevani (96, 172-

D, 178-A);

• interpersonaluri da kognitur-bihevioruli fsiqoTerapia

SesaZlebelia sasargeblo iyos farmakoTerapiasTan

kombinaciaSi (167) (180, 181 A);

• bipolaruli aSlilobis dros fsiqodinamiuri fsiqo-

Terapiis efeqturoba ar aris mecnierulad Seswavlili,

magram klinikur praqtikaSi farTod gamoiyeneba

fsiqofarmakoTerapiasTan kombinaciaSi (159) (179 A);

pacientebTan, romlebsac damWeri Terapiis periodSi daewyo

depresiuli epizodis Seteva, saWiroa medikamentebis dozebis

optimizeba.

darwmundiT, rom sisxlis SratSi medikamentis koncentracia

Terapiulis farglebSia: zogjer saWiroa, miaRwioT

Terapiulad dasaSvebi koncentraciis zeda zRvars. (63, 175_ D, 123-B, 122-A).

Tu damWeri Terapiis optimizebis Semdeg pacientis

82

mdgomareoba ar gaumjobesda, mizanSewonilia lamotrijinis

(134,135-A), bupropionis an paroqsitenis (98–B da 146-A) damateba.

• alternatiuli Semdegi nabijia sxva axali antidepresantis

damateba (mag. sumsi–is sxva preparati, an venlafaqsini an

monoaminoqsidazas inhibitori _maoi (13) • tricikluri antidepresantebis daniSvna sariskoa, is

SeiZleba fazis inversiis precipitirebadi faqtori gaxdes,

ris gamoc ar aris rekomendirebuli (13);

• maoi-is gamoyeneba rTuli da SezRudulia sxva medikamentebsa

da sakvebTan interaqtivobis riskis gamo (13);

• fsiqozuri simptomebiT mimdinare depresia Cveulebriv

saWiroebs damatebiT adekvatur mkurnalobas antifsiqozuri

preparatebiT (127_B, 136-141-A);

• mizanSewonilia ekT _ mZime an Terapiisadmi rezistentuli

depresiis dros;

_ fsiqozuri simptomebiT mimdinare depresiisas;

_ katatonuri simptomebiT mimdinare depresiisas;

(156, 43-eqspertTa mosazreba; 86, 157- B) • klinicistma SeiZleba airCios antidepresantis frTxili

gamoyeneba bipolarulis II depresiis SemTxvevaSi, am dros

ufro dabalia antidepresantebiT inducirebul maniaSi an

hipomaniaSi gadasvlis SesaZlebloba, vidre bipolarulis I

depresiisas. (1, 3, 14, 13)

3. swrafi cikluroba

gamoavlineT swrafi ciklurobis xelSemwyobi komorbiduli

faqtorebi, rogoricaa hipoTireodizmi (117_B, 118-C),

narkotikebis an alkoholis moxmareba (103_C, 102-D);

da CaatareT saTanado medikamenturi mkurnaloba.

• Tu SesaZlebelia, SezRudeT medikamentebi,

gansakuTrebiT, antidepresantebi, romlebsac SeuZliaT

xeli Seuwyon ciklurobas (98_B, 146-A);

guneba-ganwyobis mastabilizebeli pirveli rigis

preparatebiT, maT Soris liTiumiT an valproatiT

inicialuri mkurnalobis alternativaa:

• mkurnaloba lamotrijiniT (99-A);

• bevri pacientisaTvis mizanSewonilia medikamentebis

kombinacia, e.i kombinacia ori zemoT xsenebuli agentisa

(108, 110, 115 -A), an erT-erT maTgans damatebuli romelime

antifsiqozuri preparati (111, 112, 128, 129, 140, 141 -A);

• liTiumis antikonvulsantTan kombinaciisas

rekomendebulia orive preparatis Terapiuli doza

ganaxevrdes an Semcirdes 1/3-iT, sisxlis plazmaSi

Sesaferisi da usafrTxo koncentraciis dacvis mizniT. (3)

83

4. damWeri, anu profilaqtikuri Terapia (13, 14, 151)

mkurnalobis miznebi:

• recidivis da rekurentobis prevencia;

• rezidualuri simptomebis reducireba;

• suiciduri riskis reducireba;

• ciklurobis sixSiris an guneba-ganwyobis umniSvnelo

labilobis reducireba;

• zogadi funqcionirebis gaumjobeseba

(164, 174-C, 178- A);

gansazRvreT damWeri Terapiis Cveneba:

• damWeri Terapiis rekomendireba gamomdinareobs maniakaluri an

depresiuli epizodis mimdinareobidan;

• bipolaruli II aSlilobis dros, sul umniSvnelo daxmarebac

ki, gaazrebulad da mkacri meTvalyureobis garantiiT unda

gatardes.

(172-D, 178-A)

airCieT inicialuri mkurnalobis modeli

rekomendebuli arCevani:

• mkurnalobis arCevanSi didi upiratesoba eniWeba liTiums

(165-B, 147-A) an valproats (125-A); SesaZlo alternativaa

lamotrijinis (145_B da 144, 99-A), karbamazepinis an

oqskarbamazepinis (131, 133-A) CarTva;

• Tu erT-erTma zemoT aRniSnulma preparatma bolo

depresiuli an maniakaluri epizodis Semdgomi remisia

gamoiwvia, damWeri Terapiis dros igive preparati unda

gagrZeldes 6 Tve, Semdeg 1_3 Tvis ganmavlobaSi TandaTanobiT

Semcirdes da Sewydes (3)

• guneba-ganwyobis mastabilizebeli preparatis miReba unda

ganaxldes epizodis Semobrunebisas da SenarCundes, Tu

epizodi meordeba 3 welze nakleb droSi (3);

• profilaqtikuri mkurnaloba mizanSewonilia liTiumiT, Tu 2

tipiuri maniakaluri epizodis Seteva ganviTarda 3 welze

nakleb droSi (3);

• profilaqtikuri mkurnalobis mizniT antidepresantebis

gamoyenebam, Tundac normoTimul preparatebTan kombinaciaSi,

SesaZlebelia swrafi ciklurobis provocireba gamoiwvios (3)

(146_A, 98- B); • ekT gamoyeneba damWeri Terapiis mizniT SeiZleba

mizanSewonili iyos pacientebisaTvis, romlebsac kargi efeqti

hqondaT ekT-ze mwvave epizodis dros

(86_B); • damWeri Terapiis seleqciisas unda ixelmZRvaneloT

daavadebis simZimiT, rasac daavadebis swrafi cikluroba an

fsiqozuri simptomebis arseboba ganapirobebs da, roca

SesaZlebelia, unda gaiTvaliswinoT pacientis arCevani. (96, 172-D, 178-A);

84

antifsiqozuri preparatebis roli

• antifsiqozuri preparatebiT mkurnaloba unda

Sewydes, Tu ki is persistentuli fsiqozis marTvis an

guneba-ganwyobis epizodis rekurentulobis

prevenciisaTvis ar aris saWiro (3);

• damWeri Terapiis dros atipiuri antifsiqozuri

preparatebis gamoyenebisas, gaiTvalisawineT, rom

damWeri Terapiisas maTi efeqturoba SefardebiTia;

sakiTxi sadaoa da jer ar aris sabolood

dadasturebuli, zogierTi moqmedi faqtori

ganxilulia zemoT (13).

(149-B, 139_A)

fsiqosocialuri intervenciis roli

• Tanmxlebi fsiqosocialuri intervencia mimarTulia

daavadebis marTvaze _ mkurnalobis reJimis

Tanmimdevrulobis mkacri dacva, cxovrebis stilis

Secvla, prodromuli simptomebis adreuli Secnoba

da, aseve, interpersonaluri problemebis mowesrigeba;

• medikamentebTan kombinaciaSi farTod gamoiyeneba

mxardamWeri da fsiqodinamiuri fsiqoTerapia;

• jgufuri da ojaxuri fsiqoTerapia daexmareba

pacients iseTi problemebis gadaWraSi, rogoricaa

Terapiuli gegmis Tanmimdevrulobis mkacri dacva,

qronikul daavadebasTan adaptireba, pirovnuli

Cvevebis regulireba, col-qmruli da sxva

fsiqosocialuri sadao sakiTxebis marTva

• jgufebi daexmareba pacients bipolaruli

aSlilobebis da misi mkurnalobis Sesaxeb saWiro

informaciis miRebaSi.

(159, 167-eqspertTa mosazreba; 164, 173-C 44, 166, 179, 180,

181 -A);

Tu pacienti arasakmarisad reagirebs, gamoxatulia qvemwvave

simptomebi an grZeldeba guneba-ganwyobis epizodis Seteva,

daumateT sxva medikamenti, romelime atipiuri neiroleptiki

an antidepresanti (146_A, 98- B); • monacemebi arasakmarisia, preparatebis romelime erT-

erTi kombinaciis mxardasaWerad (13);

• ekT gamoyeneba damWeri Terapiis mizniT SeiZleba

mizanSewonili iyos pacientebisaTvis, romlebsac

kargi efeqti hqondaT ekT-ze mwvave epizodis dros.

(86_B);

85

C. damatebiTi informacia farmakoTerapiuli agentebis Sesaxeb.

1. liTiumi (1, 3, 4, 13, 14, 15)

liTiumis Terapiuli efeqturoba (3, 13, 14)

dadebiTi Terapiuli efeqtis prediqtorebia:

• maniakaluri sindromis tipiuroba;

• weliwadSi 2 _ze naklebi afeqturi epizodi;

• liTiumis dadebiTi Terapiuli efeqturobis

personaluri an ojaxuri istoria.

(105, 122, 123-B da 109, 147-A)

liTiumi araefeqturia:

• Sereuli epizodis dros

• bipolaruli aSlilobis swrafi ciklurobis dros

• SfoTvis komorbidobisas;

• fsiqoaqtiuri nivTierebebis Warbi moxmarebisas;

• nevrologiuri daavadebebis komorbidobisas.

(113-C, 172- D da 114, 116-B, 178-A);

gverdiTi efeqtebi (1, 3, 4, 13, 14, 15)

• gverdiTi efeqtebis umravlesoba aris umniSvnelo da

SesaZloa, reducirdes dozebis daklebiT an

daniSnulebis reJimis SecvliT;

• gverdiTi efeqtebi, romelic dakavSirebulia sisxlis

plazmaSi liTiumis koncentraciis pikTan (mag., tremori

dozis miRebidan 1-2 saaTis Semdeg), SesaZlebelia

reducirdes micemuli preparatis dozebis SemcirebiT

an daniSnulebis reJimis SecvliT _ dRis dozis

Semcirebis xarjze saRamos dozis gazrda;

• gverdiT efeqtebia: poliuria, polidifsia, wonis mateba,

kognituri problemebi, tremori, sedacia an leTargia,

kordinaciis darRveva, gastrointestinaluri distresi,

Tmebis cvena, keTilTvisebiani leikocitozi, akne da

SeSupeba;

• liTiumis miRebisas Zlierdeba organizmidan siTxis da

natriumis gamoyofa (3);

• xangrZlivi drois ganmavlobaSi liTiumiT

mkurnalobisas (>10 weli), pacientebis 10_20%-s

uviTardeba morfologiuri cvlilebebi TirkmelSi.

savaraudoa liTiumiT inducirebuli renaluri

ukmarisobis ganviTareba (119-D da 68, 120, 121-C);

• sisxlis plazmaSi 1,5 mEq/L -ze ufro maRali

koncentracia pacientebisaTvis ufro xSirad

toqsiuria, xolo 2,0 mEq/L –ze ufro maRali

koncentracia, Cveulebriv, sicocxlisaTvis saSiS

gverdiT movlenebTan asocirdeba. maRali

koncentraciisas toqsikurobis minimummde dayvanisTvis

SeiZleba saWiro gaxdes hemodializi (91-C);

• sisxlis plazmaSi liTiumis koncentraciis gansazRvra

unda moxdes liTiumis bolo dozis miRebidan 12 saaTis

86

Semdeg, umjobesia diliT, uzmoze, preparatis pirveli

dozis miRebamde (14)

(105, 106, 123- B, 122- A);

mkurnalobis Tanmimdevroba (13)

inicialuri samuSao

zogadi rekomendaciebi liTiumiT mkurnalobis

dawyebamde:

• zogadi samedicino istoriis Seswavla da fizikuri

statusis gamokvleva (178-A);

• sisxlSi Sardovanas da kreatininis koncentraciis

gansazRvra (68, 120, 121-C);

• farisebri jirkvlis funqciuri sinjebis Catareba

(118-C da 117-B); • eleqtrokardiografia;

• orsulobis testi (Svilosnobis asakis mqone qalebSi).

dozireba (1, 3, 4, 13, 14, 15)

• gverdiTi movlenebis minimumade dayvanis mizniT

liTiumis karbonatiT mkurnaloba daiwyeT dabali,

danawevrebuli dozebiT

mag. 300mg. 2-3-jer dReSi pacientis wonisa da asakis

gaTvaliswinebiT;

• dozebis mateba xdeba 7-10 dRis ganmavlobaSi, vidre

sisxlis plazmaSi liTiumis koncentracia ar miaRwevs

0,8 _ 1,0 mEq/L, rac Cveulebriv 450-900 mg. liTiumis

regularuli miiRebis Sedegad yalibdeba (4);

• dozebis titraciis mateba (sisxlis SratSi liTiumis

koncentracia Cveulebriv 0,5_1,2 mEq/L farglebSi unda

iyos SenarCunebuli) damokidebulia Terapiul

efeqtsa da gverdiT movlenebze;

• liTiumis efeqturi samkurnalo doza da Terapiuli

koncentracia sisxlis plazmaSi individualuria

TiToeuli pacientisaTvis;

• dozis yoveli matebis Semdeg gansazRvreT sisxlis

plazmaSi liTiumis koncentracia (koncetraciis

gawonasworeba dozis koregirebidan daaxloebiT 5

dRis vadaSi xdeba);

• mozardebSi renaluri funqciebis gaZlierebis gamo,

saWiroa liTiumis maRali Terapiuli dozebiT

mkurnaloba (3);

• moxucebSi saWiroa liTiumis dabali dozebiT

mkurnaloba (3);

• liTiumis doza da sisxlis plazmaSi koncentracia

mwvave fazis mkurnalobisas ufro maRali unda iyos,

vidre damWeri Terapiis dros (3).

(91-C,105, 123- B, 122- A);

87

laboratoriuli maCveneblebis grZelvadiani monitoringi

• sisxlis plazmaSi liTiumis koncentracia (119_ C, 109, 123_ B da 122 -A);

_ rogorc minimumi, kontroli xorcieldeba yovel 3-6

TveSi erTxel stabiluri pacientebisaTvis da yovelTvis

klinikuri statusis Secvlisas;

_ monitoringis sixSiris optimaloba damokidebulia

droTa gamavlobaSi liTiumis sisxlis plazmaSi

koncentraciis stabilurobaze da pacientis

mdgomareobaze, romelic SeiZleba Seicvalos

sayuradRebo da angariSgasawevi simptomebiT;

• renuli funqciebi _ mkurnalobis pirveli 6 Tvis

ganmavlobaSi

analizi yovel 2-3 TveSi erTxel.

_Semdgomi kontroli yovel 6-12 TveSi erTxel

stabiluri pacientebisaTvis da yovelTvis klinikuri

statusis Secvlisas;

(68, 120 da 121-C ); • farisebri jirkvlis funqciebi _ mkurnalobis pirveli

6 Tvis ganmavlobaSi erTi an ori testi.

_ Semdgomi kontroli 6-12 TveSi erTjer stabiluri

pacientebisaTvis da yovelTvis klinikuri statusis

Seicvlisas.

(118-C da 117-B);

88

liTiumis gverdiTi efeqtebis menejmenti (183) gverdiTi efeqti kupireba

postabsorfciuli sindromi G/I diskomforti, gulisreva, sisuste,

Tavbrusxveva

• gamowveulia sisxlSi liTiumis

koncentraaciis swrafi momatebiT

• gaivlis droTa ganmavlobaSi

• dozebis Semcireba an daniSnulebis

reJimis Secvala _ dRis dozis

Semcirebis xarjze saRamos dozis

gazrda;

• alternatiuli preparatis micema

xelebis wvrilamplitudiani tremori,

romelic daRlilobisas vlindeba da

persistentulia

• gazome koncentracia sisxlSi

• damoiyene propranololi an msgavsi

preparati

wyurvili, polidifsia, poliuria, Sardis

dabali xvedriTi wona

• medikamentiT inducirebuli

renaluri disfunqcia,

antidiuretikul hormonze

Tirkmlis sapasuxo reaqciis

Semcirebis gamo

• zogierT pacients SeiZleba

daqveiTebuli qondes koncentraciis

unari

• SesaZloa nefrogenuli uSaqro

diabeti gamovlindes

• poliuria SeiZleba mowesrigdes

medikamentis Zilis win erTjeradi

micemiT

• dozebis reducireba SeiZleba iqnes

gamoyenebuli simptomebis kontrolisTvis

• saTanado xsnarebis da eleqtrolitebis

gadasxma SeiZleba iqnes gamoyenebuli

• mwvave simptomebis dros SeiZleba

gamoyenebuli iqnes Tiaziduri

struqturis preparatebi, magram

eleqtolitebis monitoringia saWiro,

kaliumis micema SeiZleba iyos saWiro da

liTiumis doza unda Semcirdes.

• kaliumis damzogavi diuretiki SeiZleba

efeqturi iyos, romelic Cveulebriv ar

gaaZlierebs potasiumis eqskrecias da

liTiumis reabsorbcias

interstinaluri fibrozi, glomeruluri

sklerozi, auaresebs wylis reabsorbcias,

iwvevs sisxlSi kreatininis momatebas

• asocirebulia liTiumis

xangrZlivad gamoyenebasTan,

zogierT etapze

• Tirkmlis funqciis monitoringi

dasawyisSi da weliwadSi orjer

repolarizaciis darRveva ekg-ze _

gamtareblobis darRveva an zogjer

ariTmia

• ekg gamokvleva dasawyisSi da

individualurad 40 w < asakis zemoT

hipotireodizmi

• ufro xSiria qalebSi

• vlindeba pacientebis 1/3 -Si

liTiumiT mkurnalobisas

• SeiZleba gamovlindes pacientebSi

liTiumiT mkurnalobisas 6-18 Tvis

ganmavlobaSi

• arsebobs depresiis gamovlinebis

riski liTiumiT inducirebuli

hipoTireodizmis mqone pacientebSi

• levoTiroqsinis gamoyeneba pacientebSi,

romlebic moixmaren liTiums

• Tiroiduli hormonis CarTva

mkurnalobaSi da guneba-ganwyobis

stabilizebadi sxva preparatiT

Canacvleba SeiZleba iqnes gamyenebuli

roca swrafi cikluroba an depresiaa

gamoxatuli

• Tiroiduli hormonebis gamokvleva unda

moxdes inicialur etapze da

1-2-jer weliwadSi

dermatologiuri cvlilebebi _ Cirqovani

gamonayari, fsoriazis eqsacerbacia an

precipitacia, antipsoriazuli mkurnalbis

inhibireba.

• mkurnaloba empiriulad

• sisxlis plazmaSi 1,5 mEq/L -ze ufro maRali koncentracia pacientebisaTvis ufro

xSirad toqsiuria, xolo 2,0 mEq/L –ze ufro maRali koncentracia Cveulebriv

sicocxlisaTvis saSiS gverdiT movlenebTan asocirdeba. maRali koncentraciisas

toqsiurobis minimizebisaTvis SeiZleba saWiro gaxdes hemodializi.

89

2. valproati / valproatis mJava / divalproeqsi (1, 3, 4, 13, 14, 15)

• antikonvulsantebis Terapiuli upiratesoba

liTiumTan SedarebiT, maTi ufro farTo Terapiuli

indeqsiT da SedarebiT dabali renaluri

toqsikurobiT ganisazRvreba(3)

(63-D, 124, 127-B, 125, 126, 128, 176-A);

gverdiTi efeqtebi (1, 3, 4, 13, 14, 15, 74)

• valproatis sawyisi doziT gamovlenili gverdiTi

efeqtebia: gastointestinaluri distresi, RviZlis

transaminazas keTilTvisebiani momateba,

osteoporozi, tremori da sedacia;

• pacientebSi, RviZlis gadatanili an arsebuli

daavadebiT, mosalodnelia hepatotoqsikurobis

riskis momateba (130-B); • SedarebiT iSviaTia asimptomuri leikopenia da

Trombocitopenia, romelic Seqcevadia wamlebis

Sewyvetis Semdeg. (175-D);

• sxva gverdiTi efeqtebia: Tmis cvena, gaZlierebuli

mada da wonis mateba(63-D);

• qalebSi arsebobs sakvercxis polikistozuri

sindromis ganviTarebis riski, rac saWiroebs

monitorings (63-D);

• iSviaTad idiosinkrazia, magram SesaZlo fataluri

gamosavaliT: RviZlis Seuqcevadi ukmarisoba,

hemoragiuli pankreatiti da agranulocitozi.

• pacienti gafrTxilebuli unda iyos, rom RviZlis da

hematologiuri disfunqciis niSnebis da simptomebis

gamovlinebisas aucileblad mimarTos Terapevts

(63, 175, 177-D,130-B);

mkurnalobis Tanmimdevroba (1, 3, 4, 13, 14, 15, 74, 151)

inicialuri samuSao (13)

zogadi rekomendaciebi valproatiT mkurnalobis dawyebis

win:

• SeiswavleT zogadi samedicino istoria,

gansakuTrebuli yuradReba miaqcieT RviZls,

hematologiur paTologias da sisxldenis

SemTxvevebs (175-D, 130-B); • sasurvelia RviZlis funqciuri testebis da

homatologiuri maCveneblebis gansazRvra(63-D);

dozireba (1, 3, 4, 13, 14, 15)

• pacientebs mwvave maniiT, stacionaris pirobebSi

SeiZleba daeniSnos valproatis sawyisi doza 20-30

mg/kgGdReSi. valproatis Terapiulad efeqturi doza

90

Seesabameba sisxlis plazmaSi 50 _ 125 mg/mL valproatis koncentracias;

• dozis mateba xdeba TandaTanobiT, 250-500mg-iT, 2-3

dRis intervaliT, rac damokidebulia klinikur

efeqtsa da gverdiT movlenebze (4);

• Cveulebriv, mozrdilis maqsimaluri dRiuri doza 60 mg/kg–ze dReSi, iZleva sisxlis plazmaSi 50-125 mg/mL preparatis koncentracias;

• pacientebs ambulatoriul pirobebSi, moxucebs an

pacientebs hipomaniiT da euTimiiT, eniSnebaT

valproatis sawyisi doza 250 mg 3-jer dReSi. stabilur pacientebs SeiZleba daeniSnoT erTjeradi

an orjeradi dRiuri doza gamartivebulad, erTxel

dReSi;

• gaxangrZlivebuli moqmedebis preparatis, mag.

divalproeqsi ER_is biosargeblianoba, daaxloebiT

15%-iT ufro naklebia, vidre uSualo moqmedebis

preparatebis. amitom divalproeqs ER -is dozis mateba unda moxdes proporciulad

(63-D, 125, 126, 128, 176-A);.

wamlebis urTierTqmedeba (4, 13, 14, 15)

• valproati gamodevnis cilebTan SekavSirebis maRali

unaris mqone preparatebs maTi SekavSirebis

adgilidan da saWiro xdeba dozis koregireba

• radgan valproati axdens lamotrijinis

metabolizmis inhibirebas, lamotrijiniT

mkurnalobis dawyeba unda moxdes ganaxevrebuli

doziT.

laboratoriuli monacemebis xangrZlivi monitoringi

(1, 3, 4, 13, 14, 15)

• saWiroa, pacients hqondes informacia RviZlis da

hematologiuri disfunqciis niSnebisa da

simptomebis Sesaxeb da am simptomebis gamoCenis

SemTxvevaSi acnobos eqims;

• stabilur pacientebSi, romlebic iReben valproats,

fsiqiatris mier hepatologiuri da hematologiuri

testebis pasuxis klinikuri Sefaseba saWiroa minimum

eqvs TveSi erTxel;

• sisxlis plazmaSi valproatis mJavas koncentracia

unda ganisazRvros klinikuri Cvenebis arsebobisas

(mag., roca valproatis mJavas metabolizmi SeiZleba

Secvalos sxva medikamentma).

(63-D, 125, 125, 126, 128, 176-A);

91

valproatiT gamowveuli gverdiTi efeqtebis marTva (183)

gverdiTi efeqti kupireba

sedacia da GI distresi gamovlenili

mkurnalobis dawyebisas

• wamlebiT gamowveuli GI distresis marTva

xdeba dozebis SemcirebiT, valproatis

jgufis sxva preparatis daniSvniT da/an H2-

receptoris blokatoris daniSvniT

Tmebis cvena, wonaSi momateba, madis

gaZliereba • urCie dieta da varjiSi

• ganixile wonis damklebi agentebi

msubuqi leikopenia, Trombocitopenia,

Trompocitebis funqciis gauareseba • unda gakeTdes sixlis saerTo analizi

srulad;

• gansazRvre Trombocitebis analizi da

sisxlis Sededebis dro, Tu pacients

dagegmili aqvs operacia da roca pacients

aqvs Zlieri sisxlnaJRenTebi an hemoragia;

• Seqcevadia mkurnalobis Sewyvetis Semdeg.

SeiZleba gamovlindes tremori • mkurnaloba beta-blokerebiT

SeiZleba gazardos policistozuri

ovariuli sindromis gamovlinebis

SemTxvevebi

• mkurnaloba oraluri kontraceptivebiT

RviZlis funqciis darRveva,

hiperamonemiis mZime SemTxvevebis

gamovlineba zogierT pacientSi

• RviZlis funqciuri sinjebis monitori

yovelTviurad mkurnalobis dasawyisSi da

Semdeg weliwadSi orjer

hepatocelularuli nekrozi,

hemoragiuli pankreatiti da

agranulocitozi.

iSviaTad idiosinkraziuli reaqcia

• pacienti gafrTxilebuli unda iyos rom

dauyovnebliv mimarTos samedicino

daxmarebas abdominaluri tkivilis,

siyviTlis sicxiT mimdinare mwvave

faringitis, sisxldenis an purpuris

gamovlinebis SemTxvevaSi

3. karbamazepini

karbamazepinis Terapiuli efeqturoba (3, 4, 13, 14, 15)

• monoTerapia mwvave maniis kupirebisas (116-B, 131, 133-A donis mtkicebuleba);

• kombinirebuli mkurnaloba antifsiqozur preparatebTan

mwvave maniis dros (127-B); • monoTerapia bipolaruli depresiis dros;

• kombinirebuli mkurnaloba antidepresantebTan an sxva

guneba-ganwyobis mastabilizebel preparatTan

refraqteruli unipolaruli depresiis dros (108-A);

• bipolaruli aSlilobis profilaqtikuri mkurnaloba

liTiumisadmi rezistentuli SemTxvevebis dros

• swrafi ciklurobis dros (4 an meti Seteva weliwadSi).

(178-A);

gverdiTi efeqtebi (4, 13, 14, 15)

• karbamazepinis miRebisas gverdiTi efeqtebi gamovlindeba

SemTxvevaTa 50%-Si da meti;

• yvelaze xSiri gverdiTi efeqtebia: daRliloba,

gulisreva, nevrologiuri simptomebi _ diplopia, laqebi

92

mxedvelobis velSi da ataqsia;

• naklebi sixSiris gverdiTi efeqtebia: kanze gamonayari,

zomieri leikopenia, RviZlis enzimebis zomieri momateba,

zomieri Trombocitopenia, hiponatremia (132-C, 177-D);

• iSviaTi, idiosinkraziuli, magram seriozuli da

potenciurad fataluri gverdiTi efeqtebia:

agranulocitozi, aplastiuri anemia, Trombocitopenia,

RviZlis ukmarisoba, eqsfoliatiuri dermatiti (mag

steven_jonsonis sindromi) da pankreatiti;

• damatebiTi sifrTxilea saWiro klinikuri statusis

monitoringis dros _ aucilebelia pacients aswavloT

RviZlis, hematologiuri da dermatologiuri reaqciebis

niSnebi da simptomebi, instruqtirebuli unda iyos, rom

am simptomebis gamovlenis SemTxvevaSi dauyovnebliv

Seatyobinos eqims;

• sxva iSviaTi gverdiTi efeqtebia: sistemuri

hipersenzitiuri reaqciebi, gulis gamtareblobis

darRveva, fsiqozebis sporadiul SemTxvevebi da Zalian

iSviaTia renaluri efeqti _ Tirkmlis ukmarisoba,

oliguria, hematuria da proteinuria;

• karbamazepinTan SedarebiT, oqskarbamazepins zomieri

efeqturoba da naklebi gverdiTi efeqtebi aqvs (3). (133-B);

mkurnalobis Tanmimdevroba (1, 3, 4, 13, 14, 15, 74)

inicialuri samuSao (13, 14, 151)

zogadi rekomendaciebi karbamazepiniT mkurnalobis

dawyebis win:

• aucilebelia hematologiuri, hepatologiuri da

renaluri funqciebis testebis Catareba da

gaanalizeba.

• sasurvelia SratSi eleqtrolitebis koncentraciis

gansazRvra, gansakuTrebiT, moxucebSi, sadac

hiponatremiis maRali riskia.

• zogadi samedicino istoriis da fizikuri statusis

gamokvleva unda gakeTdes wesisamebr, gansakuTrebuli

yuradReba unda mieqces warsulSi Zvlis tvinis

kompresiis da RviZlis daavadebis arsebobis istorias.

dozireba (3, 13, 14, 15)

• karbamazepinis Cveulebrivi sawyisi dRiuri doza aris

200 _600 mg/dRe-RameSi (3-4 miRebaze); (14, 15)

• pacientebSi mwvave maniiT, stacionarul pirobebeSi,

doza SeiZleba gaizardos 200-dan 800-1000mg-mde dReSi,

momateba xdeba TandaTanobiT, yovel kviraSi 200 mg-iT,

ganawilebuli dRis ganmavlobaSi, Sesabamisi Cvenebis

da gverdiTi movlenebis gaTvaliswinebiT (15);

93

• daavadebis qvemwvave gamovlinebisas, ambulatoriul

pacientebSi doza TandaTan unda Semcirdes gverdiTi

efeqtebis minimumamde dayvanis mizniT(13);

• Terapiuli doza saSualod utoldeba 1000 mg-s dReSi,

magram SeiZleba meryeobdes klinikur praqtikaSi

dasaSvebis farglebSi 200_1600 mg. dReSi (13);

• aSlilobis kupirebisaTvis saWiroa bipolaruli

aSlilobis mqone pacientebis sisxlis plazmaSi

karbamazepinis Terapiuli koncentraciis miRweva.

(sisxlis plazmaSi preparatis Terapiuli

koncentracia 4-12 mg/mL farglebSi meryeobs); (13)

• sisxlis plazmaSi koncentraciis piki dgeba

preparatis miRebidan 4_10 saaTis Semdeg (3);

• sisxlis plazmaSi karbamazepinis koncentraciis

monitoringi unda gakeTdes diliT, dRis pirveli

dozis miRebamde (14);

• dedis rZeSi karbamazepinis koncentracia sisxlis

plazmaSi koncentraciis 25-60%-s Seadgens (3) (161_C);

• Sesabamisi Terapiuli koncentracia sisxlis

plazmaSi, dozis Secvlidan 5 dRis Semdeg yalibdeba

(13).

laboratoriuli maCveneblebis xangrZlivi monitoringi (13)

• karbamazepiniT mkurnalobis dawyebidan ori Tvis

ganmavlobaSi hematologiuri da hepatologiuri

funqciuri testebi unda Semowmdes or kviraSi

erTxel;

• amis Semdeg, Tu laboratoriuli testebi normis

farglebSi darCa, ar gamovlinda Zvlis tvinis

kompresiis da hepatitis simptomebi, sisxlis analizi

da RviZlis funqciuri testebi unda gakeTdes 3-6

TveSi erTxel. monitoringis intensivoba

hematologiuri an hepatologiuri darRvevebis

gamovlinebazea damokidebuli.

94

4. olanzapini (13)

gverdiTi efeqtebi (3, 13, 14, 15)

• SedarebiT xSiria: somnolencia, yabzoba, piris

simSrale, madis gaZliereba da wonaSi mateba;

• inicialuri dozis matebisas, olanzapinma SeiZleba

gamoiwvios hipotenzia, rac asocirdeba

TavbrusxvevasTan, taqikardiasTan da, zog pacientSi,

sinkopes ganviTarebasTan.

mkurnalobis Tanmimdevroba (1, 3, 4, 13, 14, 15)

• pacientisaTvis mwvave maniiT, stacionaris pirobebSi

inicialuri dozaa 15 mg/dReSi

• ambulatoriuli pacientisaTvis inicialuri doza ufro

dabalia, 5-10 mg/dReSi.

(136_139 A);

5. lamotrijini (1, 3, 13, 14, 15)

gverdiTi efeqtebi

• yvelaze xSiri gverdiTi efeqtia sedacia, Tavbrusxveva,

ataqsia, tremori, insomnia, Tavis tkivili, gulis reva,

infeqciebi da mxedvelobis dabindva an gaoreba,

daRliloba, gastro_intestinaluri disfunqcia,

gripismagvari simptomebi, cvlilebebi sisxlSi (15);

• lamotrijinis dozis swrafma titraciam SeiZleba

gamoiwvios gamonayari _ steven-jonsonis sindromi da

toqsiuri epidermaluri nekrolizi. mozrdilebSi riski

aris daaxloebiT 0,3%; bavSvebSi _ daaxloebiT 1%;

• pacienti informirebuli unda iyos gamonayaris

ganviTarebis riskis Sesaxeb, raTa saWiroebis

SemTxvevaSi droulad daukavSirdes fsiqiatrs an

pirveladi jandacvis Terapevts;

• gamonayari SeiZleba mkurnalobis nebismier periodSi

gamovlindes, magram ufro savaraudoa mkurnalobis

dasawyisSi;

• gamonayaris gamovlinebisas Zneli gasarCevia, ramdenad

seriozuli an keTilTvisebiania gamonayari;

• gansakuTrebiT SemaSfoTebelia, roca gamonayars Tan

erTvis cxeleba da yelis tkivili, gamonayaris

difuzuri gavrceleba da saxis da lorwovanis

SeSupeba. am SemTxvevaSi rogorc lamotrijini, aseve

valproati unda moixsnas;

• klinikuri dakvirvebiT, dabali dozebis titraciis

reJimis gamoyeneba (ix. qvemoT) amcirebs mniSvnelovani

gamonayaris risks mozrdilebSi 0,01%-iT (igivea sxva

antikonvulsantebis dozirebis dros);

95

• ufro naklebada mosalodneli gamonayaris garTuleba

Tu vmarTavT lamotrijinis da valproatis gverdiT

movlenebs.

(134, 135, 144 _ A da !45_B)

mkurnalobis Tanmimdevroba (1, 3, 4, 13, 14, 15)

• lamotrijini unda dainiSnos 25 mg/dReSi pirveli ori

kviris ganmavlobaSi; Semdeg _ 50mg/dReSi, mesame da

meoTxe kviraSi

• amis Semdeg 50 mg/kviraSi SeiZleba moematos klinikuri

CvenebiT;

• valproatis mimReb pacientebSi gamonayaris potenciuri

riskis minimumamde dayvanis mizniT, lamotrijinis doza

unda ganaxevrdes da titraciis periodi 2-jer ufro

gaxangrZlivdes (mag. 12,5 mg/dReSi an 25 mg

dRegamoSvebiT 2 kviris ganZilze, xolo 25 mg/dReSi

mesame da meoTxe kviris ganmavlobaSi).

(134, 135, 144 _ A da !45_B)

96

6. liTiumis karbonatis, valproatis da karbamazepinis

zogierTi SedarebiTi farmakokineturi parametri (4)

parametrebi

preparatebi liTiumi

valproati

karbamazepini

sadReRamiso dozis

Terapiuli

intervali gramebSi

0,6 _ 1, 2

0,6 _ 1, 4 ^

0,4 _1,0

sisxlis plazmaSi

optimaluri

Terapiuli

koncentracia

0,5_0,8

mmoli/l

50 _100

mkg/ml

6 _ 8

mkg/ml

sisxlSi preparatis

konc-is Terapiul

efeqtTan kavSiri

+ +

aSkara, pirdapiri

+

arapirdapiri,

?

(saeWvo)

toqsikuri konc.-ia 1,5 mmoli/l 200 mkg/ml 18 mkg/ml

Tirkmlis

fermentebis

autoinduqcia

_ _ +

per - os miRebisas SratSi konc-is piki

1 – 3 sT_s Semdeg 1 _ 4 sT-s Semdeg 4_10 sT-s Semdeg

sisxlis cilebTan

SekavSireba (%)

0 90 75

sisxlis plazmidan

naxevargamoyofis

periodi

8 _ 41 sT

(saSualod

24sT)

8 _ 17 sT

30 _ 40 sT

(8_17 sT xangrZlivad

miRebisas fermentuli

autoinduqciis gamo)

sisxlis plazmaSi

stabiluri konc-is

fazis miRwevis dro

2_6 dRis Semdeg (ar

icvleba xangrZlivi

miRebisas)

2 dRis Semdeg

(ar icvleba xangrZlivi

miRebisas)

7_10 dRe dawyebidan,

xangrZlivi miRebisas,

dozis Secvlidan 3-

5dRe

organizmidan

gamoyofis ZiriTadi

gzebi

80_90% SardiT

Seucvleli saxiT

3% SardiT da ganavliT

Seucvlelad, danarCenis

metabolizmi _ RviZlSi,

glukuronis mJavasTan

mierTebiT

2% SardiT da

ganavliT

Seucvlelad,

danarCenis

metabolizmi xdeba

RviZlSi glukuronis

mJavasTan mierTebis

da hidroqsilirebis

gziT

wamlebTan

urTierTmoqmedeba

zrdis liTiumis

neirotoqsiurobas:

_antifsiqozuri

preparatebi,

_Ca antagonistebi, _ACE inhibitorebi koncentracias zrdis:

alkoholi

diuretikebi; gamoyofas aZlierebs

_ NaCl; sifrTxilea saWiro:

aspirini, ibuprofeni

kompleqsuri

interaqtivoba: sxva

antikonvulsantebTan

_saWiroa nevrologis

konsultacia

potencirebas axdens

aspirinis da varfarinis

aqtivobis;

SeuZlia gazardos maoi-

s da tca-s koncentracia.

zrdis cns-is mxriv

gverdiT efeqts:

liTiumi,

antifsiqozuri

preparatebi,

Ca++ antagonistebi; maoi-sTan_

aucilebelia 2 kvira

intervali;

tca, neiroleptiki.

toqsiuria gripis

vaqcinaciisas, efeqti

sxvadasxvaa

fenitoinTan da

oralur

kontraceptivebTan.

97

7. normoTimuli Terapiis gverdiTi efeqtebis SedarebiTi speqtri (4)

gverdiTi efeqti liTiumis karbonati karbamazepini valproatis natriumi

adreuli

(adaptaciuri

periodis gverdiTi

efeqtebi)

viTardeba, ufro

xSirad,

mkurnalobis

pirveli Tvis

ganmavlobaSi da ar

saWiroebs

prepatatis moxsnas

_wyurvili

_xSiri Sardva

_tremori

_gulis reva

_sisuste, moduneba

_msubuqi Sekaveba

_libidos daqveiTeba

_pirSi liTonis gemo

_tkivilebi mucelSi

_kuWis wva

_diarea

_Zilianoba

_gugis akomodaciis

darRveva

_Sekaveba

_ataqsia

_Tavbrusxveva

_tremori

_madis daqveiTeba

_gulisreva

_piris simSrale

_menstrualuri

ciklis darRveva

_gulisreva

_kuWis wva, piris

simware, gemos Secvla

_tkivilebi mucelSi

_wonaSi momateba

_tremori

_alopecia

_menstrualuri

ciklis darRveva

mogvianebiT

gverdiTi efeqtebi

viTardeba iSviaTad,

preparatis

xangrZlivi

miRebisas da

saWiroebs

specialur

koreqcias an

preparatis moxsnas

_myari tremori

_dizarTria

_kunTovani sisuste,

moduneba

_wonis momateba

_hipoglikemia Sardis

gaZlierebuli

gamoyofiT da

Tirkmlis ukmarisobis

simptomebi

_ Civilebi mexsierebis

daqveiTebasa da

yuradRebis

koncentrirebis

gaZnelebaze

_libidos daqveiTeba

_ diarea an yabzoba

_ farisebri jirkvlis

funqciis daqveiTeba

_gulis riTmis

darRveva

_dermatiti, aknes da

fsoriazis gamwvaveba

_alopecia

_mravlobiTi kariesi

_neitrofilia

_eriTrocitozi

_gulisreva

_piris simSrale

_oflianoba

_kunTebis tkivili

_Tavis tkivili

_Civilebi RviZlze

(alergiuli

hepatiti)

_alergiuli

dermatiti

_aweuli

mgrZnobeloba

ultraiisfer

gamosxivebaze

_leikopenia

_Civilebi RviZlis

mxriv (RviZlis

fermentebis momateba,

idiosinkraziuli

hepatiti)

_madis dakargva

_alopecia

_mucelSi tkivilebi

_gulisreva

_diarea

_ wonis momateba

_tremori

_pankreatiti

_Trombocitopenia

(sisxlis Sededebis

periodis gazrda)

98

8. normoTimuli preparatebis gamoyenebis ukuCveneba (4)

liTiumis

karbinati

karbamazepini valproatis natriumi

sruli

ukuCveneba

1.Tirkmlis

daavadebebi funqciis

daqveiTebiT

(glomerulonefriti,

pielonefriti da

sxva)

1. gulis riTmis

darRveva

2. krb-s an tca–s

mimarT alegiuli

raqcia

3. maoi-s

preparatebTan

erTdrouli an maTi

moxsnidan 2 kviraze

adre daniSvna.

4. RviZlis

daavadebebi,

funqciis

daqveiTebiT

1. valproatis mJavas

preparatebisadmi

alergiuli reaqcia

2. RviZlis funqciis

daqveiTeba(mwv. da qr.

hepatiti da sxv)

3. hemoragiuli diaTezi

SedarebiTi

ukuCveneba 1. eu_ da

hiperTireoiduli

Ciyvi;

2. umarilo dieta

3. kataraqta

4. Zvlis daavadebebi

_ osteoporozi

5. heqtiuri T _ iT da Warbi

oflianobiT

mimdinare

daavadebebi

6. orsulobis

pirveli

trimestri da

laqtaciis

periodi (sisxlSi

preparatis

koncentraciis

50% gadadis

dedis rZeSi)

1. glaukoma

2. winamdebare

jirkvlis daavadeba

(Sardis Sekaveba)

3. gulis ukmarisoba

4. RviZlis da

Tirkmlis

ukmarisoba

5. moxucebuli asaki

6. sisxlis daavadeba,

TeTri sisxlis

warmoqmnis

daTrgunviT

7. orsulobis I

trimestri da

laqtaciis periodi

(sisxlSi

Semcvelobis 30-60%

gadadis rZeSi)

1. gulis ukmarisoba

2. RviZlis da Tirkmlis

ukmarisoba

3. sisxlis daavadebebi

(gansakuTrebiT

Trombocitopenia

4. orsulobis I trimestri

da laqtaciis periodi

(rZeSi gadadis sisxlis

Semcvelobis mxolod

1-10%, amitom valproatis

natriumis amorCeva

mizanSewonilia

gansakuTrebuli

yuradreba unda

mieqces anamnezSi

1. Tirkmlis

anTebadi

daavadebebi

2. farisebri

jirkvlis

funqciis

darRveva

1. kanis

alergiulireaqcia

2. hepatitis

3. Zvlis tvinis

sisxlmbadi

funqciis daTrgunva

4. gulis riTmis

darRveva

1. alergiuli hepatiti

2. sisxlis Sededebis

unaris darRveva

99

9. liTiumis marilebiT mkurnalobis gverdiTi movlenebis kupireba (4) adreuli gverdiTi

efeqti _ pirveli

ori kvira

_ ar saWirobs

Terapiis srul

moxsnas,

dasaSvebia:

• droebiT dozebis

Semcireba an

• retardirebul

preparatebze

gadasvla an

• mkurnalobis

reJimis Secvla

liTiumis marilebiT

intoqsikacia (liTiumis

koncentracia sisxlis

plazmaSi > 1,5 _ 2,0

mmol/l)

• liTiumis marilebis

miRebis

dauyovneblivi

Sewyveta

• detoqsikaciuri

Terapiis Catareba:

_ diuretikebi

_ natriumis

bikarbonati

_ dializi

_ simptomuri Terapia

mogvianebiTi gverdiTi efeqti

saWiroebs:

• specialur koreqcias an

• Terapiis moxsnas

1. kuW-nawlavis

mxriv:

• gulis reva

• madis daqveiTeba

• pirSi liTonis

gemos SegrZneba

• tkivilebi

mucelSi

• kuWis wva

• kuWis xSiri

moqmedeba

2. cns –is mxriv:

• Zil_RviZilis

SegrZnebis

dakargva

• daRliloba,

moduneba

• Tavis tkivili

• Tavbrusxveva

• ioli tremori

3. Tirkmlis

• wyurvili

• xSiri Sardva

1. kuW-nawlavis mxriv:

gamoxatulia:

• gulisreva

• Rebineba

• diarea

2. cns –is mxriv:

• fascikularuli

kunTovani

SekrTomebi

• hiperefleqsia

• meningizmis

movlenebi

• motoruli Sekaveba

• Zilianiba

• ataqsia

• dizarTria

• cnobierebis abneva

• mexsierebis

daqveiTeba

intoqsikaciis

momatebisas:

• oliguria

• gulsisxlZarRvTa

sistemis daTrgunva

• krunCxviTi sind-mi

• cns-is kerovani

simptomebi

• sopori, koma

1. nevrologiuri;

• myari

msxvilamplitudiani

tremori, romelic ar

reagirebs

qolinolitikebze,

mcirdeba beta-

blokerebis miRebisas

• dizarTria

• taqikinezia

• kunTovani sisuste da

SekrTomebi

2. renaluri

• uSaqro diabeti

• wyurvili

• xSiri Sardva

• diurezis momateba

• niqturia

• qronikuli renaluri

ukmarisobis niSnebi

3. wonis momateba

4. kuWnawlavis mxriv

• diarea

• sakvebis gemos myari

dakargva

5. hipoTireoiduli

Ciyvi (hipertrofia,

miqsedemuroba)

6. paraTireoiduli

jirkvlis

hiperfunqcia

7. gul-

sixlZarRvTa

sistemis mxriv

• eqstrasistoli

a,

• nawilobrivi

blokada

• T kbilis

inversia

8. alergiuli

• qavana

dermatitis

• ekzema

• makulopapulo

zuri

gamonayari

• fsoriazi

9. hematologiuri

• neitrofilia

• eozinofilia

• eriTrocitozi

10. fsiqikuri

• arsebobis

,,avtomaturobis

” fenomeni

• anesTeziuri

subdepresia

11. sxva

• libidos

daqveiTeba

• alopecia

• kbilebis

kariesi

100

8. gaidlainis gadasinjvisa da ganaxlebis vada – 2 weli.

9. gaidlainis miRebis xerxi/wyaro

• guneba-ganwyobis (afeqturi) aSlilobis Sesaxeb arsebobs

samecniero mtkicebulebis safuZvelze Seqmnil rekomendaciaTa

sakmarisi raodenoba. mocemuli gzamkvlevis Semqmnis procesSi

samuSao jgufma moiZia da Seafasa ukve arsebuli praqtikuli

gzamkvlevebi, ramdenime fundamenturi naSromi da eqspertTa

konsensusis jgufis mier mowodebuli rekomendaciebi.

bazisurad gamoyenebuli iqna Semdegi naSromebi:

1 KAPLAN & SADOCK’S SYNOPSIS OF PSYCHIATRY Behavioral sciences/Clinical psychiatry. 9-th edition ; Virginia A. Sadock, M.D. and Benjamin J. Sadock, M.D.(2003 by Lippincott Williams & Wilkins; Philadelphia. USA) (1)

2. ,,The Presentations of Clinical Psychiatry” Robert M. Cohen 2000; (Printed in the UK Redwood Book, Trowbidge, Wilts, UK);(2) 3. ,,THE MERCK MANUAL” 18TH EDITION _ Published by MERCK RESEARCH LABORATORIES _ 2006 (3) 4. ,,Основы Психофармакологии”. Мосолов С. Н. (г. Москва _1996) (4) 5. ,,Клиническое применение современных антидепрессантов”. Мосолов С. Н. (г. Санкт-Петервург _1995) (5) 6. ,,Оксфордское руководство по психиатрии”. Маикл Гельдер, Деннис Гэт, Ричард Мейо., (г. Киев 1997) (6) 7. ,,Классификациа психических и поведенческих расстройств”; MKБ -10; ВОЗ; (г. Санкт-Петербург 1994) (7) 8. ,,Руководство по психиатрии”. Морозов Г. В. (г. Москва _1888) (8) 9. ,,Practice Guidelines for the Treatment of psychiatric Dizorder” QUICK REFERENCE to The American Psychiatric Association (APA); COMPENDIUM 2004; ( APA, Arlington, Virginia); (13) 10. ,,PRESCRIBING GUIDELINES 2005-2006’’, 8th Edition; The South London and Maudsley NHS Trust & Oxleas NHS Trust; David Taylor, Carol Paton, Robert Kerwin; p. 135-190 (Published by Taylor & Francis Group, London and New york); (14) 11. ,, Essential Psychopharmacology _The Prescriber’s Guide”; Stephen M. Stahl, 2005; (Published by Pres syndicate of the University of Cambridge); (15) 12. saqarTvelos kanoni ,,fsiqiatriuli daxmarebis Sesaxeb”_ 2006wlis

14 ivlisi (ssm #30 nawili I 27.07.06) (16)

13. The ICD-10 Classification of Mental and Behavioral Disorders; Diagnostic criteria for research ; World Health Organization; Geneva, 1993; (18) 14. American Psychiatric Association Diagnostic and statistical Manual of Mental disorders (DSM-IV & DSM-IV-TR) (19) 15. Agency for Healthcare Policy Research: Evidence Report on Treatment of

Depression—Newer Pharmacotherapies. San Antonio Evidence-Based Practice Center.

Washington, DC, AHCPR, Evidence-Based Practice Centers, 1999 (150)

16. American Psychiatric Association: Practice Guideline for the Treatment of Patients

With Bipolar Disorder (Revised). Am J Psychiatry 2002; (151)

17. American Psychiatric Association: Practice Guideline for the Treatment of Patients

With Major depressive Disorder ; Second Edition (152)

101

18. American Psychiatric Association: Practice Guideline for Psychiatric Evaluation of

Adults. Am J Psychiatry 1995; 152(Nov suppl): (153)

• moxda fundamenturi naSromebisa da arsebuli rekomendaciebis

Targmna, Sejereba da adaptirebuli variantis SemuSaveba, romelic,

erTi mxriv, pasuxobs saerTaSoriso moTxovnebs, xolo, meore

mxriv, iTvaliswinebs saqarTvelos samedicino dawesebulebaTa

rogorc adamianur, ise teqnikur resursebs.

• rekomendaciaTa moZieba xorcieldeboda klinikuri rekomendaciebis

saerTaSoriso reestrebSi, eleqtronuli monacemebis bazebSi

internetis gamoyenebiT.

EDUCATIONAL SOURCES FOR DEPRESSION AND BIPOLAR DISORDER Internet Mental Health National Foundation for Depressive Illness,

Inc.

http://www.mentalhealth.org P.O. Box 2257

New York, NY 10116

National Alliance for the Mentally Ill (800) 239-1265

Colonial Place Three, 2107 Wilson Blvd. http://www.depression.org

Suite 300

Arlington, VA 22201 NIMH Public Inquiries

(703) 524-7600 Depression Information Program

NAMI HelpLine: (800) 950-NAMI [6264] 6001 Executive Blvd., Rm. 8184

http://www.nami.org MSC 9663

Bethesda, MD 20892-9663

National Depressive and Manic-Depressive Association

(301) 443-4513 TTY Line: (301) 443-8431

730 N. Franklin St., Suite 501 http://www.nimh.nih.gov

Chicago, IL 60610-7204

(312) 642-0049 National Mental Health Association

(800) 826-3632 1021 Prince St.

http://www.ndmda.org Alexandria, VA 22314-2971

(703) 684-7722

TTY Line: (800) 433-5959

http://www.nmha.org

102

klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi

wyaroebi da meTodebi

• Lifelong learning in Psychiatry _ Psychiatryonlain • Wikipeia, the free encyclopedia _ www.en.wikipedia.org/wiki/. • koxreinis biblioTeka - The Cochrane Library 2006, Issue 4 • amerikis samedicino biblioTekis mier Seqmnili eleqtronul

bibliografiul monacemTa baza - MEDLINE

publikaciebis CarTvis/gamoricxvis kriteriumebi

• kvlevebi Semdegi dizainiT: randomizirebuli sakontrolo kvlevebi,

sistematuri mimoxilvebi da meta-analizi, erTmomentiani, kohortuli

kvlevebi

• rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 15

wliani SezRudva. Tumca zogjer gamoyenebuli iyo ufro adreuli

publikaciebi, romlebic dResac aqtualuria da safuZvlad udevs

sxva Tanamedrove mtkicebulebebs.

• dadgenili iyo enobrivi SezRudvebi, radganac samuSao jgufs

SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod

inglisur da rusul enebze.

moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi

• samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi.

Catarebuli Ziebis Sedegad miRebuli iyo guneba-ganwyobis (afeqturi)

aSlilobisis arsebuli ramdenime meToduri rekomendacia, romlebic

Seicavda jgufis miznis Sesaferis saWiro informacias. • rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas

gamoyenebuli iyo saqarTvelos Sromis, janmrTelobisa da socialuri

dacvis saministros mier mowodebuli mtkicebulebebis donisa da

rekomendaciebis xarisxis sqema.

mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema

done mtkicebulebis siZlieris

done (Muir Gray) xarisxi rekomendaciis xarisxi

(Cook et al) I Zlieri mtkicebuleba,

eyrdnoba minimum erT

sistemur mimoxilvas,

romelic efuZneba swori

dizainis mqone

randomizebul

kontrolirebad kvlevas

A eyrdnoba I donis

mtkicebulebas da

Sesabamisad mtkiced

rekomendebulia

II Zlieri mtkicebuleba,

eyrdnoba minimum erTi

swori dizainis mqone

randomizebul

kontrolirebad kvleva

B eyrdnoba II donis

mtkicebulebas da

Sesabamisad mtkiced

rekomendebulia

III klinikuri kvleva

randomizaciis gareSe,

kohortuli da

SemTxveva-kontrolis

kvlevebi

C eyrdnoba III donis

mtkicebulebas

SeiZleba CaiTvalos

Sesabamisad

103

IV araeqsperimentuli

multicentruli

kvlevebi

D eyrdnoba IV da V

donis mtkicebulebas

saWiroebs konsesuss

Va avtoritetul

profesionalTa

mosazreba

Vb klinikuri gamocdileba,

aRwerilobiTi kvlevebi

an eqspertTa angariSi

10. alternatiuli gaidlaini ar arsebobs

11. gamoyenebuli literatura

1. KAPLAN & SADOCK’S SYNOPSIS OF PSYCHIATRY Behavioral sciences/Clinical psychiatry. 9-th edition ; Virginia A. Sadock, M.D. and Benjamin J. Sadock, M.D.(2003 by Lippincott Williams & Wilkins; Philadelphia. USA)(Va);

2. The Presentations of Clinical Psychiatry; Robert M. Cohen 2000; (Printed in the UK Redwood Book, Trowbidge, Wilts, UK);(Va);

3. THE MERCK MANUAL 18TH EDITION _ Published by MERCK RESEARCH LABORATORIES _ 2006 (Va);

4. Основы Психофармакологии. Мосолов С. Н. (г. Москва _1996) (Va); 5. Клиническое применение современных антидепрессантов. Мосолов С. Н. (г. Санкт-

Петервург _1995) (Va); 6. Оксфордское руководство по психиатрии. Маикл Гельдер, Деннис Гэт, Ричард Мейо.,

(г. Киев 1997) (Va); 7. Классификациа психических и поведенческих расстройств; ICD -10; ВОЗ; (г. Санкт-

Петербург 1994); 8. Руководство по психиатрии. Морозов Г. В. (г. Москва _1888) ; 9. Шкала для оценки депрессии и тревоги _ научная литература по коаксилу; 10. Hamilton Depression Raiting Scale _ HDRS http:/pacient-reseach.elsevier.com/Hamilton

M. _ HDRS; 11. Beck-Depression-Inventory _ BDI http:/www.minddisorders.com/A-Br/Beck-Depression-

Inventory.html; 12. Beck-Depression-Inventory http://en.wikipedia.org/wiki/Beck-Depression-Inventory#BDI; 13. Practice Guidelines for the Treatment of psychiatric Dizorder QUICK REFERENCE to

The American Psychiatric Association (APA); COMPENDIUM 2004; (APA, Arlington, Virginia); (Va);

14. PRESCRIBING GUIDELINES 2005-2006, 8th Edition; The South London and Maudsley NHS Trust & Oxleas NHS Trust; David Taylor, Carol Paton, Robert Kerwin; (Published by Taylor & Francis Group, London and New york); (Va);

15. Essential Psychopharmacology _The Prescriber’s Guide; Stephen M. Stahl, 2005; (Published by Pres syndicate of the University of Cambridge); (Va);

16. saqarTvelos kanoni ,,fsiqiatriuli daxmarebis Sesaxeb”_14.07.2006 (ssm

#30 nawili I 27.07.06) ; 17. Handbook of Psychiatric Drugs 2005 Edition; Lawrence J. Albers, MD; Rhoda K.Hahn, MD;

Christopher Reist, MD; (Vb); 18. The ICD-10 Classification of Mental and Behavioral Disorders; Diagnostic criteria for

research ; World Health Organization; Geneva, 1993; (18); 19. American Psychiatric Association Diagnostic and Statistical Manual of Mental disorders

(DSM-IV) Fourth Edition (text revision). Washington, DC, APA, 2000;

104

20. Goldman W, McCulloch J, Cuffel B, Zarin DA, Suarez A, Burns BJ: Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. Psychiatr Serv 1998; 49:477–482 ;

21. Thase ME, Reynolds CF, Frank E, Simons AD: Response to cognitive-behavioral therapy in chronic depression. J Psychotherapy Practice and Research 1994; 3:204–214 [B];

22. Conte HR, Karasu TB: A review of treatment studies of minor depression 1980–1981. Am J Psychother 1992; 46:58–74;

23. Keller MD, McCullough JP, Rush AJ, Klein DF, Schatzberg AF, Gelenberg J, Thase ME: Nefazodone HCI, cognitive behavioral analysis system of psychotherapy and combination therapy for the acute treatment of chronic depression, in 1999 Annual Meeting New Research Program and Abstracts. Washington, DC, American Psychiatric Association, 1999, p 178 [A];

24. Parsons B, Quitkin FM, McGrath PJ, Stewart JW, Tricamo E, Ocepek-Welikson K, Harrison W, Rabkin JG, Wager SG, Nunes E: Phenelzine, imipramine, and placebo in borderline patients meeting criteria for atypical depression. Psychopharmacol Bull 1989; 25:524–534 [A];

25. Rosenthal NE, Sack DA, Carpenter CJ, Parry BL, Mendelson WB, Wehr TA: Antidepressant effects of light in seasonal affective disorder. Am J Psychiatry 1985; 142:163–170 [C];

26. Reynolds CF, Frank E, Perel JM, Imber SD, Cornes C, Miller MD, Mazumdar S, Houck PR, Dew MA, Stack JA, Pollock BG, Kupfer DJ: Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA 1999; 281:39–45 [A];

27. Nelson JC, Mazure CM, Bowers MBJ, Jatlow PI: A preliminary, open study of the combination of fluoxetine and desipramine for rapid treatment of major depression. Arch Gen Psychiatry 1991; 48:303–307 [C];

28. Glassman AH, Roose SP: Delusional depression. Arch Gen Psychiatry 1981; 38:424–427; 29. Spiker DG, Weiss JC, Dealy RS, Griffin SJ, Hanin I, Neil JF, Perel JM, Rossi AJ, Soloff PH:

The pharmacological treatment of delusional depression. Am J Psychiatry 1985; 142:430–436 [A];

30. Quitkin FM, Harrison W, Stewart JW, McGrath PJ, Tricamo E, Ocepek-Welikson K, Rabkin JG, Wager SG, Nunes E, Klein DF: Response to phenelzine and imipramine in placebo nonresponders with atypical depression: a new application of the crossover design. Arch Gen Psychiatry 1991; 48:319–323 [A];

31. Liebowitz MR, Quitkin FM, Stewart JW, McGrath PJ, Harrison WM, Markowitz JS, Rabkin JG, Tricamo E, Goetz DM, Klein DF: Antidepressant specificity in atypical depression. Arch Gen Psychiatry 1988; 45:129–137 [A];

32. Quitkin FM, Stewart JW, McGrath PJ, Liebowitz MR, Harrison WM, Tricamo E, Klein DF, Rabkin JG, Markowitz JS, Wager SG: Phenelzine versus imipramine in the treatment of probable atypical depression: defining syndrome boundaries of selective MAOI responders. Am J Psychiatry 1988; 145:306–311 [A];

33. Goodnick PJ, Extein I: Bupropion and fluoxetine in depressive subtypes. Ann Clin Psychiatry 1989; 1:119–122 [C];

34. Pande AC, Birkett M, Fechner-Bates S, Haskett RF, Greden JF: Fluoxetine versus phenelzine in atypical depression. Biol Psychiatry 1996; 40:1017–1020 [A];

35. Sheehan DV, Davidson JR, Manschreck T, Van Wyck Fleet J: Lack of efficacy of a new antidepressant (bupropion) in the treatment of panic disorder with phobias. J Clin Psychopharmacol 1983; 3:28–31 [C];

36. Clomipramine Collaborative Study Group: Clomipramine in the treatment of patients with obsessive-compulsive disorder. Arch Gen Psychiatry 1991; 48:730–738 [A];

37. Jenike MA, Buttolph L, Baer L, Ricciardi J, Holland A: Open trial of fluoxetine in obsessive-compulsive disorder. Am J Psychiatry 1989; 146:909–911 [A];

38. Akiskal HS, Rosenthal TL, Haykal RF, Lemmi H, Rosenthal RH: Characterological depressions: clinical and sleep EEG findings separating subaffective dysthymias from character spectrum disorders. Arch Gen Psychiatry 1980; 37:777–783 [B];

105

39. Nelson JC, Kennedy JS, Pollock BG, Laghrissi-Thode F, Narayan M, Nobler MS, Robin DW, Gergel I, McCafferty J, Roose S: Treatment of major depression with nortriptyline and paroxetine in patients with ischemic heart disease. Am J Psychiatry 1999; 156:1024–1028 [A];

40. Roose SP, Glassman AH, Giardina EG, Walsh BT, Woodring S, Bigger JT: Tricyclic antidepressants in depressed patients with cardiac conduction disease. Arch Gen Psychiatry 1987; 44:273–275 [A];

41. Kuhn R: The treatment of depressive states with G22355 (imipramine hydrochloride). Am J Psychiatry 1958; 115:459–464 [B];

42. Andersen K, Balldin J, Gottfries CG, Granerus AK, Modigh K, Svennerholm L, Wallin A: A double-blind evaluation of electroconvulsive therapy in Parkinson's disease with on-off phenomena. Acta Neurol Scand 1987; 76:191–199 [A];

43. American Psychiatric Association: The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association, 2nd ed. Washington, DC, American Psychiatric Press, 2001;

44. Akiskal HS, Walker P, Puzantian VR, King D, Rosenthal TL, Dranon M: Bipolar outcome in the course of depressive illness: phenomenologic, familial, and pharmacologic predictors. J Affect Disord 1983; 5:115–128 [A];

45. Paykel ES: Depressive typologies and response to amitriptyline. Br J Psychiatry 1972; 120:147–156 [B];

46. Danish University Antidepressant Group: Paroxetine: a selective serotonin reuptake inhibitor showing better tolerance but weaker antidepressant effect than clomipramine in a controlled multicenter study. J Affect Disord 1990; 18:289–299 [A];

47. Delgado PL, Price LH, Charney DS, Heninger GR: Efficacy of fluvoxamine in treatment-refractory depression. J Affect Disord 1988; 15:55–60 [B];

48. Cunningham LA, Borison RL, Carman JS, Chouinard G, Crowder JE, Diamond BI, Fischer DE, Hearst E: A comparison of venlafaxine, trazodone, and placebo in major depression. J Clin Psychopharmacol 1994; 14:99–106 [A];

49. Pitts WM, Fann WE, Halaris AE, Dressler DM, Sajadi C, Snyder S, Ilaria RL: Bupropion in depression: a tri-center placebo-controlled study. J Clin Psychiatry 1983; 44(5, part 2):95–100 [A];

50. Mendels J, Amin MM, Chouinard G, Cooper AJ, Miles JE, Remick RA, Saxena B, Secunda SK, Singh AN: A comparative study of bupropion and amitriptyline in depressed outpatients. J Clin Psychiatry 1983; 44:118–120 [A];

51. Feighner JP, Gardner EA, Johnston JA, Batey SR, Khayrallah MA, Ascher JA, Lineberry CG: Double-blind comparison of bupropion and fluoxetine in depressed outpatients. J Clin Psychiatry 1991; 52:329–335 [A];

52. Claghorn JL, Lesem MD: A double-blind placebo-controlled study of Org 3770 in depressed outpatients. J Affect Disord 1995; 34:165–171 [A];

53. Guelfi JD, White C, Hackett D, Guichoux JY, Magni G: Effectiveness of venlafaxine in patients hospitalized with major depression and melancholia. J Clin Psychiatry 1995; 56:450–458 [A];

54. Fontaine R, Ontiveros A, Elie R, Kensler TT, Roberts DL, Kaplita S, Ecker JA, Faludi G: A double-blind comparison of nefazodone, imipramine, and placebo in major depression. J Clin Psychiatry 1994; 55:234–241 [A];

55. Quitkin FM, McGrath PJ, Stewart JW, Harrison W, Tricamo E, Wager SG, Ocepek-Welikson K, Nunes E, Rabkin JG, Klein DF: Atypical depression, panic attacks, and response to imipramine and phenelzine: a replication. Arch Gen Psychiatry 1990; 47:935–941 [A];

56. Zisook S, Braff DL, Click MA: Monoamine oxidase inhibitors in the treatment of atypical depression. J Clin Psychopharmacol 1985; 5:131–137 [A];

57. Quitkin FM, Rabkin JG, Markowitz JM, Stewart JW, McGrath PJ, Harrison W: Use of pattern analysis to identify true drug response. Arch Gen Psychiatry 1987; 44:259–264 [A];

106

58. Katz MM, Koslow SH, Maas JW, Frazer A, Bowden CL, Casper R, Croughan J, Kocsis J, Redmond E Jr: The timing, specificity and clinical prediction of tricyclic drug effects in depression. Psychol Med 1987; 17:297–309 [C];

59. Price LH, Charney DS, Heninger GR: Variability of response to lithium augmentation in refractory depression. Am J Psychiatry 1986; 143:1387–1392 [C];

60. Kramlinger KG, Post RM: The addition of lithium to carbamazepine: antidepressant efficacy in treatment-resistant depression. Arch Gen Psychiatry 1989; 46:794–800 [C];

61. Prange AJ, Loosen PT, Wilson IC, Lipton MA: The therapeutic use of hormones of the thyroid axis in depression, in The Neurobiology of Mood Disorders. Edited by Post R, Ballenger J. Baltimore, Williams & Wilkins, 1984, pp 311–322 [G];

62. Feighner JP, Herbstein J, Damlouji N: Combined MAOI, TCA, and direct stimulant therapy of treatment-resistant depression. J Clin Psychiatry 1985; 46:206–209 [Vb];

63. Hayes SG: Long-term use of valproate in primary psychiatric disorders. J Clin Psychiatry 1989; 50:35–39 [D];

64. Razani J, White KL, White J, Simpson G, Sloane RB, Rebal R, Palmer R: The safety and efficacy of combined amitriptyline and tranylcypromine antidepressant treatment: a controlled trial. Arch Gen Psychiatry 1983; 40:657–661 [A];

65. Young JPR, Lader MH, Hughes WC: Controlled trial of trimipramine, monoamine oxidase inhibitors, and combined treatment in depressed outpatients. Br Med J 1979; 2:1315–1317 [A];

66. Lauritzen L, Odgaard K, Clemmesen L, Lunde M, Ohrstrom J, Black C, Bech P: Relapse prevention by means of paroxetine in ECT-treated patients with major depression: a comparison with imipramine and placebo in medium-term continuation therapy. Acta Psychiatr Scand 1996; 94:241–251 [A];

67. Paul SM, Extein I, Calil HM, Potter WZ, Chodoff P, Goodwin FK: Use of ECT with treatment-resistant depressed patients at the National Institute of Mental Health. Am J Psychiatry 1981; 138:486–489 [B];

68. Vestergaard P, Schou M, Thomsen K: Monitoring of patients in prophylactic lithium treatment: an assessment based on recent kidney studies. Br J Psychiatry 1982; 140:185–187 [C];

69. Marcus ER, Bradley SS: Combination of psychotherapy and psychopharmacotherapy with treatment-resistant inpatients with dual diagnoses. Psychiatr Clin North Am 1990; 13:209–214 [V];

70. Thase ME, Dubé S, Bowler K, Howland RH, Myers JE, Friedman E, Jarrett DB: Hypothalamic-pituitary-adrenocortical activity and response to cognitive behavior therapy in unmedicated, hospitalized depressed patients. Am J Psychiatry 1996; 153:886–891 [B];

71. Steuer JL, Mintz J, Hammen CL, Hill MA, Jarvik LF, McCarley T, Motoike P, Rosen R: Cognitive-behavioral and psychodynamic group psychotherapy in treatment of geriatric depression. J Consult Clin Psychol 1984; 52:180–189 [B];

72. Thase ME, Simons AD, Cahalane J, McGeary J, Harden T: Severity of depression and response to cognitive behavior therapy. Am J Psychiatry 1991; 148:784–789 [B];

73. Elkin I, Shea MT, Watkins JT, Imber SD, Sotsky SM, Collins JF, Glass DR, Pilkonis PA, Leber WR, Docherty JP, Fiester SJ, Parloff MB: National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Arch Gen Psychiatry 1989; 46:971–982 [A];

74. Pollack MH, Rosenbaum JF: Management of antidepressant-induced side effects: a practical guide for the clinician. J Clin Psychiatry 1987; 48:3–8;

75. Daneman EA: Imipramine in office management of depressive reactions (a double-blind study). Dis Nerv Syst 1961; 22:213–217 [A];

76. O'Leary KD, Beach SR: Marital therapy: a viable treatment for depression and marital discord. Am J Psychiatry 1990; 147:183–186 [A];

77. Blackburn IM, Bishop S, Glen AI, Whalley LJ, Christie JE: The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. Br J Psychiatry 1981; 139:181–189 [A];

107

78. Hersen M, Bellack AS, Himmelhoch JM, Thase ME: Effects of social skill training, amitriptyline, and psychotherapy in unipolar depressed women. Behavior Therapy 1984; 15:21–40 [B];

79. Murphy GE, Simons AD, Wetzel RD, Lustman PJ: Cognitive therapy and pharmacotherapy: singly and together in the treatment of depression. Arch Gen Psychiatry 1984; 41:33–41 [A];

80. Frank E, Kupfer DJ, Perel JM, Cornes C, Jarrett DB, Mallinger AG, Thase ME, McEachran AB, Grochocinski VJ: Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1990; 47:1093–1099 [A];

81. Frank E, Kupfer DJ, Perel JM, Cornes C, Mallinger AG, Thase ME, McEachran AB, Grochocinski VJ: Comparison of full-dose versus half-dose pharmacotherapy in the maintenance treatment of recurrent depression. J Affect Disord 1993; 27:139–145 [A];

82. Prien RF, Kupfer DJ: Continuation drug therapy for major depressive episodes: how long should it be maintained? Am J Psychiatry 1986; 143:18–23 [B];

83. Jarrett DB, Basco MR, Riser R, Ramanan J, Marwill M, Rush AJ: Is there a role for continuation phase cognitive therapy for depressed outpatients? J Consult Clin Psychol 1998; 66:1036–1040 [B];

84. Keller MD, Gelenberg AJ, Hirschfeld RM, Rush AJ, Thase ME, Kocsis JH, Markowitz JC, Fawcett JA, Koran LM, Klein DN, Russell JM, Kornstein SG, McCullough JP, Davis SM, Harrison WM: The treatment of chronic depression, part 2: a double-blind, randomized trial of sertraline and imipramine. J Clin Psychiatry 1998; 59:598–607 [A];

85. Fava GA, Grandi S, Zielezny M, Canestrari R, Morphy MA: Cognitive behavioral treatment of residual symptoms in primary major depressive disorder. Am J Psychiatry 1994; 151:1295–1299 [B];

86. Petrides G, Dhossche D, Fink M, Francis A: Continuation ECT: relapse prevention in affective disorders. Convuls Ther 1994; 10:189–194 [B];

87. Weisler RH, Johnston JA, Lineberry CG, Samara B, Branconnier RJ, Billow AA: Comparison of bupropion and trazodone for the treatment of major depression. J Clin Psychopharmacol 1994; 14:170–179 [A];

88. Isometsa ET, Henriksson MM, Aro HM, Lonnqvist JK: Suicide in bipolar disorder in Finland. Am J Psychiatry 1994; 151:1020–1024 [D];

89. Dilsaver SC, Chen YW, Swann AC, Shoaib AM, Krajewski KJ: Suicidality in patients with pure and depressive mania. Am J Psychiatry 1994; 151:1312–1315 [D];

90. Strakowski SM, McElroy SL, Keck PE Jr, West SA: Suicidality among patients with mixed and manic bipolar disorder. Am J Psychiatry 1996; 153:674–676 [C];

91. Muller-Oerlinghausen B, Wolf T, Ahrens B, Glaenz T, Schou M, Grof E, Grof P, Lenz G, Simhandl C, Thau K, Vestergaard P, Wolf R: Mortality of patients who dropped out from regular lithium prophylaxis: a collaborative study by the International Group for the Study of Lithium-Treated Patients (IGSLI). Acta Psychiatr Scand 1996; 94:344–347 [C];

92. Gutheil TG: The psychology of psychopharmacology. Bull Menninger Clin 1982; 46:321–330 [G];

93. Hammen C, Gitlin M: Stress reactivity in bipolar patients and its relation to prior history of disorder. Am J Psychiatry 1997; 154:856–857 [D];

94. Malkoff-Schwartz S, Frank E, Anderson B, Sherrill JT, Siegel L, Patterson D, Kupfer DJ: Stressful life events and social rhythm disruption in the onset of manic and depressive bipolar episodes: a preliminary investigation. Arch Gen Psychiatry 1998; 55:702–707 [D];

95. Perry A, Tarrier N, Morriss R, McCarthy E, Limb K: Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. Br Med J 1999; 318:149–153 [A];

96. Tohen M, Hennen J, Zarate CM Jr, Baldessarini RJ, Strakowski SM, Stoll AL, Faedda GL, Suppes T, Gebre-Medhin P, Cohen BM: Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features. Am J Psychiatry 2000; 157:220–228 [D];

108

97. Keck PE Jr, McElroy SL, Strakowski SM, West SA, Sax KW, Hawkins JM, Bourne ML, Haggard P: 12-month outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. Am J Psychiatry 1998; 155:646–652 [C];

98. Howland RH: Induction of mania with serotonin reuptake inhibitors. J Clin Psychopharmacol 1996; 16:425–427 [B];

99. Calabrese JR, Suppes T, Bowden CL, Sachs GS, Swann AC, McElroy SL, Kusumakar V, Ascher JA, Earl NL, Greene PL, Monaghan ET (Lamictal 614 Study Group): A double-blind, placebo-controlled, prophylaxis study of lamotrigine in rapid-cycling bipolar disorder. J Clin Psychiatry 2000; 61:841–850 [A];

100. Brennan PA, Mednick SA, Hodgins S: Major mental disorders and criminal violence in a Danish birth cohort. Arch Gen Psychiatry 2000; 57:494–500 [D];

101. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK: Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. JAMA 1990; 264:2511–2518 [D];

102. Potash JB, Kane HS, Chiu Y-F, Simpson SG, MacKinnon DF, McInnis MG, McMahon FJ, DePaulo JR Jr: Attempted suicide and alcoholism in bipolar disorder: clinical and familial relationships. Am J Psychiatry 2000; 157:2048–2050 [D];

103. Tondo L, Baldessarini RJ, Hennen J, Minnai GP, Salis P, Scamonatti L, Masia M, Ghiani C, Mannu P: Suicide attempts in major affective disorder patients with comorbid substance use disorders. J Clin Psychiatry 1999; 60(suppl 2):63–69 [C];

104. Dunayevich E, Sax KW, Keck PE Jr, McElroy SL, Sorter MT, McConville BJ, Strakowski SM: Twelve-month outcome in bipolar patients with and without personality disorders. J Clin Psychiatry 2000; 61:134–139 [C];

105. Schou M, Juel-Nielson, Stroomgren E, Voldby H: The treatment of manic psychoses by administration of lithium salts. J Neurol Neurosurg Psychiatry 1954; 17:250–260 [B];

106. Goodwin FK, Murphy DL, Bunney WE Jr: Lithium-carbonate treatment in depression and mania: a longitudinal double-blind study. Arch Gen Psychiatry 1969; 21:486–496 [B];

107. Stokes PE, Shamoian CA, Stoll PM, Patton MJ: Efficacy of lithium as acute treatment of manic-depressive illness. Lancet 1971; 1:1319–1325 [B];

108. Small JG, Klapper MH, Milstein V, Kellams JJ, Miller MJ, Marhenke JD, Small IF: Carbamazepine compared with lithium in the treatment of mania. Arch Gen Psychiatry 1991; 48:915–921 [A];

109. Maggs R: Treatment of manic illness with lithium carbonate. Br J Psychiatry 1963; 109:56–65 [B];

110. Bowden CL, Brugger AM, Swann AC, Calabrese JR, Janicak PG, Petty F, Dilsaver SC, Davis JM, Rush AJ, Small JG (Depakote Mania Study Group): Efficacy of divalproex vs lithium and placebo in the treatment of mania. JAMA 1994; 271:918–924 [A];

111. Segal J, Berk M, Brook S: Risperidone compared with both lithium and haloperidol in mania: a double-blind randomized controlled trial. Clin Neuropharmacol 1998; 21:176–180 [A];

112. Berk M, Ichim L, Brook S: Olanzapine compared to lithium in mania: a double-blind randomized controlled trial. Int Clin Psychopharmacol 1999; 14:339–343 [A];

113. Himmelhoch JM, Garfinkel ME: Sources of lithium resistance in mixed mania. Psychopharmacol Bull 1986; 22:613–620 [C];

114. Prien RF, Himmelhoch JM, Kupfer DJ: Treatment of mixed mania. J Affect Disord 1988; 15:9–15 [B];

115. Freeman TW, Clothier JL, Pazzaglia P, Lesem MD, Swann AC: A double-blind comparison of valproate and lithium in the treatment of acute mania. Am J Psychiatry 1992; 149:108–111[A];

116. Kramlinger KG, Post RM: Adding lithium carbonate to carbamazepine: antimanic efficacy in treatment-resistant mania. Acta Psychiatr Scand 1989; 79:378–385 [B];

109

117. Smigan L, Wahlin A, Jacobsson L, von Knorring L: Lithium therapy and thyroid function tests: a prospective study. Neuropsychobiology 1984; 11:39–43 [B];

118. Bocchetta A, Bernardi F, Burrai C, Pedditzi M, Loviselli A, Velluzzi F, Martino E, Del Zompo M: The course of thyroid abnormalities during lithium treatment: a two-year follow-up study. Acta Psychiatr Scand 1992; 86:38–41 [C];

119. Chan HH, Wing Y, Su R, Van Krevel C, Lee S: A control study of the cutaneous side effects of chronic lithium therapy. J Affect Disord 2000; 57:107–113 [D];

120. Vestergaard P, Schou M, Thomsen K: Monitoring of patients in prophylactic lithium treatment: an assessment based on recent kidney studies. Br J Psychiatry 1982; 140:185–187 [C];

121. Gitlin MJ: Lithium-induced renal insufficiency. J Clin Psychopharmacol 1993; 13:276–279 [C];

122. Gelenberg AJ, Kane JM, Keller MB, Lavori P, Rosenbaum JF, Cole K, Lavelle J: Comparison of standard and low serum levels of lithium for maintenance treatment of bipolar disorder. N Engl J Med 1989; 321:1489–1493 [A];

123. Vestergaard P, Licht RW, Brodersen A, Rasmussen NA, Christensen H, Arngrim T, Gronvall B, Kristensen E, Poulstrup I, Wentzer LR: Outcome of lithium prophylaxis: a prospective follow-up of affective disorder patients assigned to high and low serum lithium levels. Acta Psychiatr Scand 1998; 98:310–315 [B];

124. Emrich HM, von Zerssen D, Kissling W: On a possible role of GABA in mania: therapeutic efficacy of sodium valproate, in GABA and Benzodiazepine Receptors. Edited by Costa E, Dicharia G, Gessa GL. New York, Raven Press, 1981, pp 287–296 [B];

125. Brennan MJW, Sandyk R, Borsook D: Use of sodium valproate in the management of affective disorders: basic and clinical aspects, in Anticonvulsants in Affective Disorders. Edited by Emrich HM, Okuma T, Muller AA. Amsterdam, Excerpta Medica, 1984, pp 56–65 [A];

126. Pope HG Jr, McElroy SL, Keck PE Jr, Hudson JI: Valproate in the treatment of acute mania: a placebo-controlled study. Arch Gen Psychiatry 1991; 48:62–68 [A];

127. McElroy SL, Keck PE, Stanton SP, Tugrul KC, Bennett JA, Strakowski SM: A randomized comparison of divalproex oral loading versus haloperidol in the initial treatment of acute psychotic mania. J Clin Psychiatry 1996; 57:142–146 [B];

128. Zajecka JM, Weisler R, Swann AC: Divalproex sodium versus olanzapine for the treatment of mania in bipolar disorder, in American College of Neuropsychopharmacology Annual Meeting Poster Abstracts. Nashville, Tenn, ACNP, 2000 [A];

129. Tohen MF, Milton DR, Davis AR: Olanzapine versus divalproex for the treatment of acute mania, in Congress Poster Abstracts. Munich, European College of Neuropsychopharmacology, 2000 [A];

130. Bryant AE III, Dreifuss FE: Valproic acid hepatic fatalities, III: US experience since 1986. Neurology 1996; 46:465–469 [B];

131. Ballenger JC, Post RM: Therapeutic effects of carbamazepine in affective illness: a preliminary report. Commun Psychopharmacol 1978; 2:159–175 [A];

132. Kramlinger KG, Phillips KA, Post RM: Rash complicating carbamazepine treatment. J Clin Psychopharmacol 1994; 14:408–413 [C];

133. Muller AA, Stoll KD: Anticonvulsants in affective disorders, in Carbamazepine and Oxcarbazepine in the Treatment of Manic Syndromes: Studies in Germany. Edited by Emrich HM, Okuma T, Muller AA. Amsterdam, Exerpta Medica, 1984, pp 134–147 [B];

134. Frye MA, Ketter TA, Kimbrell TA, Dunn RT, Speer AM, Osuch EA, Luckenbaugh DA, Cora-Locatelli G, Leverich GS, Post RM: A placebo-controlled study of lamotrigine and gabapentin monotherapy in refractory mood disorders. J Clin Psychopharmacol 2000; 20:607–614 [A];

135. Anand A, Oren DA, Berman RM: Lamotrigine treatment of lithium failure in outpatient mania: a double-blind, placebo-controlled trial, in Abstract Book, Third International Bipolar Conference. Edited by Soares JC, Gershon S. Pittsburgh, Munksgaard, 1999, p 23 [A];

110

136. Tohen M, Sanger TM, McElroy SL, Tollefson GD, Chengappa KNR, Daniel DG, Petty F, Centorrino F, Wang R, Grundy SL, Greaney MG, Jacobs TG, David SR, Toma V (Olanzapine HGEH Study Group): Olanzapine versus placebo in the treatment of acute mania. Am J Psychiatry 1999; 156:702–709 [A];

137. Tohen M, Jacobs TG, Grundy SL, McElroy SL, Banov MC, Janicak PG, Sanger T, Risser R, Zhang F, Toma V, Francis J, Tollefson GD, Breier A (Olanzapine HGGW Study Group): Efficacy of olanzapine in acute bipolar mania: a double-blind, placebo-controlled study. Arch Gen Psychiatry 2000; 57:841–849 [A];

138. Tohen M, Zhang F, Feldman PD, Evans AR, Brier A: Olanzapine versus haloperidol in the treatment of acute mania, in 1998 Annual Meeting Syllabus and Proceedings Summary. Washington, DC, American Psychiatric Association, 1998 [A];

139. Sachs GS: Emerging data: atypical antipsychotics in bipolar disorder, in Program and Abstracts of the 52nd Institute on Psychiatric Services. Washington, DC, American Psychiatric Association, 2001 [A];

140. Muller-Oerlinghausen B, Retzow A, Henn FA, Giedke H, Walden J (European Valproate Mania Study Group): Valproate as an adjunct to neuroleptic medication for the treatment of acute episodes of mania: a prospective, randomized, double-blind, placebo-controlled, multicenter study. J Clin Psychopharmacol 2000; 20:195–203 [A];

141. Yatham LN: Safety and efficacy of risperidone as combination therapy for the manic phase of bipolar disorder: preliminary findings of a randomized double blind study (RIS-INT-46). Int J Neuropsychopharmacol 2000; 3(suppl 1):S142 [A];

142. Lenox RH, Newhouse PA, Creelman WL, Whitaker TM: Adjunctive treatment of manic agitation with lorazepam versus haloperidol: a double-blind study. J Clin Psychiatry 1992; 53:47–52 [A];

143. Edwards R, Stephenson U, Flewett T: Clonazepam in acute mania: a double blind trial. Aust NZ J Psychiatry 1991; 25:238–242 [A];

144. Calabrese JR, Bowden CL, Sachs GS, Ascher JA, Monaghan E, Rudd GD (Lamictal 602 Study Group): A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. J Clin Psychiatry 1999; 60: 79–88 [A];

145. Calabrese JR, Bowden CL, McElroy SL, Cookson J, Andersen J, Keck PE Jr, Rhodes L, Bolden-Watson C, Zhou J, Ascher JA: Spectrum of activity of lamotrigine in treatment-refractory bipolar disorder. Am J Psychiatry 1999; 156:1019–1023 [B];

146. Cohn JB, Collins G, Ashbrook E, Wernicke JF: A comparison of fluoxetine, imipramine, and placebo in patients with bipolar depressive disorder. Int Clin Psychopharmacol 1989; 4:313–322 [A];

147. Prien RF, Caffey EM Jr, Klett CJ: Prophylactic efficacy of lithium carbonate in manic-depressive illness: report of the Veterans Administration and National Institute of Mental Health collaborative study group. Arch Gen Psychiatry 1973; 28:337–341 [A];

148. Schulberg HC, Block MR, Madonia MJ, Scott CP, Rodriguez E, Imber SD, Perel J, Lave J, Houck PR, Coulehan JL: Treating major depression in primary care practice: eight-month clinical outcomes. Arch Gen Psychiatry 1996; 53:913–919 [A];

149. Calabrese JR, Kimmel SE, Woyshville MJ, Rapport DJ, Faust CJ, Thompson PA, Meltzer HY: Clozapine for treatment-refractory mania. Am J Psychiatry 1996; 153:759–764 [B];

150. Agency for Healthcare Policy Research: Evidence Report on Treatment of Depression—Newer Pharmacotherapies. San Antonio Evidence-Based Practice Center. Washington, DC, AHCPR, Evidence-Based Practice Centers, 1999;

151. American Psychiatric Association: Practice Guideline for the Treatment of Patients With Bipolar Disorder (Revised). Am J Psychiatry 2002; 159(April suppl);

152. American Psychiatric Association: Practice Guideline for the Treatment of Patients With Major depressive Disorder ; Second Edition;

153. American Psychiatric Association: Practice Guideline for Psychiatric Evaluation of Adults. Am J Psychiatry 1995; 152(Nov suppl):63–80;

111

154. Chambers CD, Johnson KA, Dick LM, Felix RJ, Jones KL: Birth outcomes in pregnant women taking fluoxetine. N Engl J Med 1996; 335:1010–1015 [B];

155. Altshuler LL, Cohen L, Szuba MP, Burt VK, Gitlin M, Mintz J: Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psychiatry 1996; 153: 592–606 [V];

156. Devanand DP, Sackeim HA, Prudic J: Electroconvulsive therapy in the treatment-resistant patient. Psychiatr Clin North Am 1991; 14:905–923;

157. Schwarz T, Loewenstein J, Isenberg KE: Maintenance ECT: indications and outcome. Convuls Ther 1995; 11:14–23 [B];

158. Thase ME, Simons AD, Reynolds CF: Abnormal electroencephalographic sleep profiles in major depression: association with response to cognitive behavior therapy. Arch Gen Psychiatry 1996; 53:99–108 [B];

159. Bibring E: Psychoanalysis and the dynamic psychotherapies. J Am Psychoanal Assoc 1954; 2:745–770 [G];

160. Spielvogel A, Wile J: Treatment and outcomes of psychotic patients during pregnancy and childbirth. Birth 1992; 19:131–137 [D];

161. McKnew DH, Cytryn L, Buchsbaum MS, Hamovit J, Lamour M, Rapoport JL, Gershon ES: Lithium in children of lithium-responding parents. Psychiatry Res 1981; 4:171–180 [A];

162. Tohen M, Shulman KI, Satlin A: First-episode mania in late life. Am J Psychiatry 1994; 151:130–132 [C];

163. Dion GL, Tohen M, Anthony WA, Waternaux CS: Symptoms and functioning of patients with bipolar disorder six months after hospitalization. Hosp Community Psychiatry 1988; 39:652–657 [C];

164. Coryell W, Scheftner W, Keller M, Endicott J, Maser J, Klerman GL: The enduring psychosocial consequences of mania and depression. Am J Psychiatry 1993; 150:720–727 [C];

165. Denicoff KD, Smith-Jackson EE, Disney ER, Ali SO, Leverich GS, Post RM: Comparative prophylactic efficacy of lithium, carbamazepine, and the combination in bipolar disorder. J Clin Psychiatry 1997; 58:470–478 [B];

166. Cochran SD: Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders. J Consult Clin Psychol 1984; 52:873–878 [A];

167. q. abduSeliSvili, a. begiaSvili: kognitiur _ bihebioruli Terapia;

saqarTvelos fsiqikuri janmrTelobis asociacia; Tbilisi; 2006;

168. Coupland NJ, Bell CJ, Potokar JP: Serotonin reuptake inhibitor withdrawal. J Clin Psychopharmacol 1996; 16:356–362 [D];

169. Mueller TI, Leon AC, Keller MB, Solomon DA, Endicott J, Coryell W, Warshaw M, Maser JD: Recurrence after recovery from major depressive disorder during 15 years of observational follow-up. Am J Psychiatry 1999; 156:1000–1006 [B];

170. Schulberg HC, Block MR, Madonia MJ, Scott CP, Rodriguez E, Imber SD, Perel J, Lave J, Houck PR, Coulehan JL: Treating major depression in primary care practice: eight-month clinical outcomes. Arch Gen Psychiatry 1996; 53:913–919 [A];

171. Kovacs M, Pollock M: Bipolar disorder and comorbid conduct disorder in childhood and adolescence. J Am Acad Child Adolesc Psychiatry 1995; 34:715–723 [C];

172. Mitchell PB, Wilhelm K, Parker G, Austin MP, Rutgers P, Malhi GS: The clinical features of bipolar depression: a comparison with matched major depressive disorder patients. J Clin Psychiatry 2001; 62:212–216 [D];

173. Ashman SB, Monk TH, Kupfer DJ, Clark CH, Myers FS, Frank E, Leibenluft E: Relationship between social rhythms and mood in patients with rapid cycling bipolar disorder. Psychiatry Res 1999; 86:1–8 [C];

174. Angst J, Preisig M: Outcome of a clinical cohort of unipolar, bipolar and schizoaffective patients: results of a prospective study from 1959 to 1985. Schweiz Arch Neurol Psychiatr 1995; 146:17–23 [C];

112

175. Gidal B, Spencer N, Maly M, Pitterle M, Williams E, Collins M, Jones J: Valproate-mediated disturbances of hemostasis: relationship to dose and plasma concentration. Neurology 1994; 44:1418–1422 [C];

176. Hirschfeld RM, Allen MH, McEvoy JP, Keck PE Jr, Russell JM: Safety and tolerability of oral loading divalproex sodium in acutely manic bipolar patients. J Clin Psychiatry 1999; 60:815–818 [A];

177. Sheth RD, Wesolowski CA, Jacob JC, Penney S, Hobbs GR, Riggs JE, Bodensteiner JB: Effect of carbamazepine and valproate on bone mineral density. J Pediatr 1995; 127:256–262 [D];

178. Klein DF: Importance of psychiatric diagnosis in prediction of clinical drug effects. Arch Gen Psychiatry 1967; 16:118–126 [A];

179. Kahn DA: The use of psychodynamic psychotherapy in manic-depressive illness. J Am Acad Psychoanal 1993; 21:441–455 [A];

180. Haas GL, Glick ID, Clarkin JF, Spencer JH, Lewis AB, Peyser J, DeMane N, Good-Ellis M, Harris E, Lestelle V: Inpatient family intervention: a randomized clinical trial, II: results at hospital discharge. Arch Gen Psychiatry 1988; 45:217–224 [A];

181. Clarkin JF, Carpenter D, Hull J, Wilner P, Glick I: Effects of psychoeducational intervention for married patients with bipolar disorder and their spouses. Psychiatr Serv 1998; 49:531–533 [A];

182. Trisha Suppes, M,D., Ph. D & Paul E. Keck, Jr., M.D.: Bipolar Disorder: Treatment & Manegement; Published by Compact Clinicals, Kasas City, MO;

12. avtorTa jgufi

saqarTvelos fsiqikuri janmrTelobis asociacia

⇒ jgufis xelmZRvaneli _ manana bokuCava _ md, fsiqiatriis s/k

institutis konsultanti;

⇒ qeTevan gelaSvili _ wamebis, Zaladobisa da gamoxatuli

stresuli zemoqmedebis msxverplTa fsiqoreabilitaciis centri

`epaTia~; eqimi-fsiqiatri.

eqspertebi:

⇒ Temur silagaZe _ Tssu neiromedicinis departamentis

fsiqiatriis mimarTulebis xelmZRvaneli, asocirebuli

profesori;

⇒ q. gigolaSvili _ ss `m. asaTianis saxelobis fsiqiatriis s/k

institutis~ direqtori klinikis dargSi;

⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros janmrTelobis dacvis

departamenti;

⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros janmrTelobis dacvis

departamenti.