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.

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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