Алгоритм терапии БД и Литература


Терапевтическая тактика для лёгкой, умеренной и тяжёлой депрессии без психотических симптомов при БАР I и БАР II идентична (рис. 5).

У больных, не получающих нормотимик, терапию БД следует начинать с препарата этой группы. Если пациент уже получает нормотимик, рекомендуется попытка увеличения его дозы, присоединение кветиапина или использование сочетанной терапии оланзапином и флуоксетином, или добавление второго нормотимика и присоединение психотерапии. При неэффективности этих терапевтических мероприятий возможно использование сочетанной терапии нормотимиком и антидепрессантом (преимущественно СИОЗС), который назначается на минимально короткий срок. При использовании комбинированной терапии необходимо учитывать возможные лекарственные взаимодействия препаратов.

При неэффективности второго курса терапии возможна смена нормотимика и/или антидепрессанта, либо, в случае затяжных состояний, нарастающей социальной дезадаптации, — решение вопроса о применении ЭСТ (Prudic, 1990). При неэффективности ЭСТ проводят противорезистентные мероприятия, аналогичные тем, которые используются при резистентной депрессии при рекуррентном депрессивном расстройстве.

Рис. 5. Алгоритм терапии биполярной депрессии

Рис. 5. Алгоритм терапии биполярной депрессии

При тяжёлой БД, а также при наличии суицидальных мыслей уже на первом этапе лечения рекомендуется сочетанная терапия нормотимиком и антидепрессантом (The Expert Consensus Guideline Series, 1996) или использование кветиапина или комбинации оланзапина с флуоксетином. При неэффективности первого курса вначале рекомендуется попытка смены антидепрессанта, затем — нормотимика, либо применение ЭСТ.

Таким образом, в настоящее время не существует лекарственного средства, которое в условиях монотерапии могло бы обеспечить все необходимые при БД эффекты, а именно быстрое купирование депрессивной и психотической симптоматики, предотвращение суицидов и профилактику фаз обоих полюсов. Некоторые препараты представляются весьма перспективными, однако количество хорошо спланированных исследований в этой области остается весьма ограниченным. Не существует и единого консенсуса экспертов относительно этапов терапии БД. Также требуют совершенствования подходы к диагностике БД. Решение этих задач позволит существенно облегчить симптомы заболевания, снизить частоту его обострений и значительно улучшить качество жизни больных с БД.

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