From cf5429308df3da423318598dad222f3296538ada Mon Sep 17 00:00:00 2001 From: Anton Vilenchyk Date: Sat, 25 Apr 2026 23:44:42 +0300 Subject: [PATCH] =?UTF-8?q?feat(special):=206=20special=20population=20&?= =?UTF-8?q?=20disorder=20entries=20=E2=80=94=20batch=208?= MIME-Version: 1.0 Content-Type: text/plain; charset=UTF-8 Content-Transfer-Encoding: 8bit NEUROP-quality comprehensive entries for special populations and underrepresented disorder areas, all in 'Фармакотерапия (Общее)' category. PREGNANCY/LACTATION: - special_pregnancy_neurop (alias preg_full) — Mohr NEUROP 2022 comprehensive, trimester-by-trimester guidance, RID values, dose adjustments during pregnancy, postpartum protocol, Ukraine-specific resources GERIATRIC: - special_aged_neurop (alias geropsy_full) — Stuhec & Stoppe NEUROP 2022, age-related PK/PD, Beers Criteria 2023, STOPP-START, BPSD management, delirium prevention, de-prescribing protocol INTELLECTUAL DISABILITY (NEW — no equivalent existing): - special_id_psychopharm (alias id_pharma) — de Kuijper NEUROP 2022, challenging-behavior framework, FBA, ethical 'chemical restraint' concerns, preferred AP (risperidone/aripiprazole), de-prescribing emphasis, Ukraine context (institutional care over-prescribing) FORCED MIGRATION (NEW, highly relevant for Ukraine 2022+): - special_forced_migration (alias migration_mh) — Burger & Pogarell NEUROP 2022, WHO mhGAP tiered intervention, Ukrainian refugee context (6M IDP + 6M abroad), cultural barriers, language considerations, trauma-informed care, PHQ-9/PCL-5/GAD-7 universal screening, Ukrainian resources EATING DISORDERS (NEW — no equivalent): - special_eating_disorders (alias ed_pharma) — Borges/Lewis/Bentley/Himmerich NEUROP 2022, AN/BN/BED/ARFID coverage, fluoxetine 60 mg for BN (FDA), lisdexamfetamine for BED (FDA), refeeding syndrome management, CBT-E first-line emphasis, Ukrainian involuntary feeding legal framework SEXUAL DISORDERS (NEW — no equivalent): - special_sexual_disorders (alias sex_pharma) — Malandain/Chagraoui/Thibaut NEUROP 2022, ED/HSDD/PE/SSRI-induced SD, PDE5 inhibitors, flibanserin/ bremelanotide, switch strategies for AD-induced SD, antipsychotic-induced SD (switch to partial agonists) Stats: 174 → 180 entries (+6), 729 → 747 citations. --- categories/farmakoterapiya-obshchee.json | 382 ++++++++++++++++++++++ docs/database.js | 386 ++++++++++++++++++++++- 2 files changed, 766 insertions(+), 2 deletions(-) diff --git a/categories/farmakoterapiya-obshchee.json b/categories/farmakoterapiya-obshchee.json index 70160cb..000b7fb 100755 --- a/categories/farmakoterapiya-obshchee.json +++ b/categories/farmakoterapiya-obshchee.json @@ -522,5 +522,387 @@ "Bazire S. Psychotropic Drug Directory 2020/21, Lloyd-Reinhold Publications", "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part I Basic Principles + Part XIV Implementation" ] + }, + { + "id": "special_pregnancy_neurop", + "cmd_alias": "preg_full", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Беременность и лактация: comprehensive psychopharm (Mohr NEUROP 2022)", + "tags": [ + "беременность", + "лактация", + "pregnancy", + "ssrI", + "SNRI", + "sertraline", + "fluoxetine", + "quetiapine", + "Mohr", + "perinatal", + "NICE", + "RID", + "relative infant dose", + "postpartum" + ], + "related": [ + "preg_overview", + "preg_antidepressants", + "preg_antipsychotics", + "preg_mood_stabilizers", + "preg_lactation", + "preg_benzo_anxio", + "drug_sertraline", + "drug_fluoxetine", + "drug_quetiapine", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Систематический подход к фармакотерапии перинатального периода. Принципы NEUROP/Mohr (2022, p.4355): риск нелеченой болезни VS риск медикамента; минимальная эффективная доза; preferred agents с large registry data; close monitoring пре- и постнатально.", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ОБЩИЕ ПРИНЦИПЫ (NEUROP/Mohr):\n\n1. Нелеченая mental illness в беременности — СВОЙ РИСК для матери и плода:\n • Premature delivery, low birth weight\n • Postpartum depression (60% recurrence у женщин с MDD off meds)\n • Postpartum psychosis (особенно BAR)\n • Suicide — 2-я причина maternal mortality (UK)\n • Малопitание матери, alcohol/substance abuse как самолечение\n\n2. РИСК vs ПОЛЬЗА — calculation, не absolute avoidance\n\n3. Pre-conception PLANNING — идеально, but rare reality:\n • Switch к safer agent ДО pregnancy если возможно\n • Folate 5 мг/сут pre-conception если AED-вальпроат, carbamazepine\n\n4. Use ESTABLISHED registry-data agents:\n • Antidepressants: sertraline, fluoxetine — best data\n • Antipsychotics: olanzapine, quetiapine — preferred\n • Mood stabilizers: lamotrigine — best teratogenic profile" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "I ТРИМЕСТР (organogenesis) — main teratogenic risk window:\n\nANTIDEPRESSANTS:\n• Сертралин — preferred (largest data, kardiac risk minimal)\n• Флуоксетин — preferred (oldest data, минимальные signals)\n• ⚠ ПАРОКСЕТИН — Class D (Ebstein anomaly при I триместре) — switch до conception\n• Венлафаксин, дулоксетин — limited data\n• Бупропион — neutral signals\n• ⚠ ИМАО — AVOID (no registry, hypertensive risk)\n\nANTIPSYCHOTICS:\n• Олanzapine, quetiapine — preferred (good data)\n• Рисперидон, hал operidol — также используется\n• Klozapine — usable if needed (TRS), но monitor neonatal granulocytes\n• ⚠ Aripiprazole, lurasidone — limited data\n\nMOOD STABILIZERS:\n• Ламотриджин — preferred (no major teratogenic signal, dose adjustments needed because levels ↓ в pregnancy ~50%)\n• ⚠ ВАЛЬПРОАТ — STRONGLY AVOID (12% NTD, 20% pregnancy adverse outcomes; FDA black box; EU restriction)\n• ⚠ Карбамазепин — TERATOGENIC (NTD spina bifida 1%); folate 5 мг/сут\n• Литий — Ebstein anomaly risk historically overestimated; current data ~1.2-1.5x baseline; usable если необходим (особенно при суицидальной BAR)\n\nBDZ:\n• Diazepam, alprazolam — Class D; preferable lorazepam если необходим (short T½, predictable)\n• Avoid in I triméстре if possible; в III — neonatal withdrawal/floppy infant", + "neuro": "II–III ТРИМЕСТР:\n\n• Folate continued (1 mg general; 5 мг if на AEDs)\n• Vitamin D, omega-3 supplementation\n• Регулярный мониторинг настроения (PHQ-9 q4 нед)\n• Подготовка к delivery + postpartum plan ДО родов\n\nIII ТРИМЕСТР SPECIFIC:\n• ⚠ Neonatal adaptation syndrome (poor neonatal adaptation, PNAS):\n – SSRI/SNRI: 30% babies с tremor, jitteriness, irritability, feeding issues — обычно self-limited 2 нед\n – BDZ: floppy infant\n – Антиpsychotics: EPS, withdrawal\n• ⚠ PPHN (persistent pulmonary hypertension of newborn):\n – Особенно SSRI в III триместре (relative risk ~2x baseline; absolute 1-3 / 1000)\n – Switch dose ↓ before delivery — controversial, обычно continue\n\nDOSE ADJUSTMENTS DURING PREGNANCY:\n• ↑ volume of distribution → plasma levels ↓\n• Renal clearance ↑\n• CYP3A4 induced, CYP2D6 induced — variable\n• Lamotrigine: levels ↓ ~50% к III триместру — adjust dose\n• Lithium: levels variable; close monitoring каждые 4 нед\n\nLACTATION (Mohr NEUROP):\n• RID (Relative Infant Dose) <10% обычно safe; <1% near-ideal\n• AGENTS С RID <2% (ideal): sertraline 0.5-2%, fluoxetine 1-7%, escitalopram 5-6%, paroxetine 1-3%, миртазапин 1.6%, olanzapine 1.6%, quetiapine 0.1%\n• Avoid в lactation: ламотриджин (RID 9-18%, but data uncertain), литий (RID 12-30% — monitor infant), флувоксамин (limited)", + "tactic": "ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ:\n\nPRE-CONCEPTION (если есть luxury planning):\n• Switch на safest agent (e.g. paroxetine → sertraline)\n• Folate 5 мг/сут × 3 мес pre-conception если на AEDs\n• Discuss timing с пациентом (active illness vs euthymia)\n• Plan for postpartum — risk of relapse без meds\n\nDURING PREGNANCY:\n• Monitor mood каждые 4 нед\n• Plasma levels q4-6 нед for narrow-window meds (lithium, lamotrigine)\n• Combine с psychotherapy — CBT/IPT for MDD\n\nDELIVERY:\n• Anesthesia plan — discuss с anesthesiologist (BDZ depo, ketamine, etc)\n• Pediatric/NICU consultation\n• Avoid breastfeeding immediately если high-RID agent (e.g. lithium)\n\nPOSTPARTUM:\n• ↓ Volume of distribution → restore pre-pregnancy doses or adjust based on levels\n• High recurrence risk — KEEP меды если before pregnancy were stabilizing\n• Postpartum psychosis в BAR — emergency, hospitalize, ECT if needed\n• Bonding support, social support — критично\n\nДОКУМЕНТАЦИЯ:\n• Письменное обсуждение risk/benefit с пациентом\n• Подпись согласия на терапию беременности\n• Регистрация в реестрах (если возможно — UK Bumps, Motherisk, etc)\n\n⚠ В Украине отсутствуют национальные registry — clinical decision-making relies on NEUROP/Maudsley/UK Teratology Information Service references" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Mohr P. Psychopharmacological Agents During Pregnancy and Nursing. NEUROP 2022 (p.4355)", + "MotherToBaby (Organization of Teratology Information Specialists)", + "UK Bumps (Best Use of Medicines in Pregnancy)" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_aged_neurop", + "cmd_alias": "geropsy_full", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Геронтопсихиатрия: comprehensive psychopharm (Stuhec & Stoppe NEUROP 2022)", + "tags": [ + "пожилые", + "aged", + "gериatricsky", + "Stuhec", + "Stoppe", + "полипрагмазия", + "Beers Criteria", + "STOPP-START", + "деменция", + "BPSD", + "делирий", + "фалл", + "ортостаз", + "cognitive", + "metabolic" + ], + "related": [ + "gero_anticholinergic", + "gero_polypharmacy", + "gero_dementia_overview", + "gero_bpsd", + "gero_delirium_vs_dementia", + "drug_risperidone", + "drug_haloperidol", + "drug_lorazepam", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Систематический подход к фармакотерапии в пожилом возрасте. Принципы NEUROP/Stuhec & Stoppe (2022, p.4417): START-LOW-GO-SLOW, минимизация полипрагмазии, careful screening for BPSD, проверка cognitive impact, регулярная reassessment.", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ВОЗРАСТНЫЕ ИЗМЕНЕНИЯ — фармакокинетические:\n\n• ↓ Renal clearance (СКФ ↓ ~10%/decade после 40 лет)\n• ↓ Hepatic blood flow и phase I metabolism (oxidative); phase II (glucuronidation) preserved\n• ↑ Volume of distribution для lipophilic drugs (↑ fat tissue) → ↑ T½ (BDZ, AP, AD all longer T½ in elderly)\n• ↓ Plasma albumin → ↑ free fraction (clinical relevance variable)\n• ↑ BBB permeability → ↑ CNS sensitivity\n• ↓ Receptor density / sensitivity (variable)\n\nPHARMACODYNAMIC SENSITIVITY:\n• Anticholinergics: ↑↑ delirium, cognitive decline, falls\n• BDZ: ↑↑ falls, paradoxical agitation, cognitive\n• АП: ↑ EPS, delirium, falls, mortality (FDA Black Box при деменции)\n• ↑ ortostatic hypotension в response to α-blockers\n\nCOMORBIDITY:\n• ≥3 хронические болезни — обычно >70 лет\n• Polypharmacy (≥5 meds) — ~50% >65 лет\n• Each additional med = +12% adverse drug events\n• Cognitive impairment — мониторинг compliance труднее" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "BEERS CRITERIA 2023 (American Geriatrics Society) — препараты-AVOID:\n\n• ⚠ ВСЕ TCA (амитриптилин, имипрамин, кломипрамин) — anticholinergic, falls, cardiac\n – Exception: nortriptyline в low-dose может быть acceptable\n• ⚠ Бензодиазепины — falls, cognitive, delirium (в любом dose, любая T½, любой возраст ≥65)\n – Exception: short-term (≤4 нед) для acute intervention\n• ⚠ FGAs (chlorpromazine, levomepromazine) — anticholinergic + ortostaz\n• ⚠ Все Z-drugs (zolpidem, zopiclone) — falls, complex sleep behaviors\n• ⚠ Antihistamines first-gen (дифенгидрамин, hydroxyzine) — anticholinergic\n• ⚠ Trihexyphenidyl, бенztropine — anticholinergic\n• ⚠ Метильдопа — depression, ортостаз\n• Tramadol — серотониновый, judgement, hyponatremia\n\nSTOPP-START Criteria (European):\n• ATC-group specific recommendations\n• STOPP — drugs to STOP\n• START — drugs that should be started but often missed\n\nPREFERRED AGENTS в гериатрии:\n• MDD: сертралин, эсциталопрам, mirtazapine (особенно если weight loss/insomnia issue), venlafaxine, бупропион\n• Anxiety: SSRI (как MDD); buspirone (no falls, no cognitive)\n• Insomnia: trazodone 25-100 мг, mirtazapine 7.5-15 мг (off-label sleep), мелатонин 1-5 мг\n• Psychosis (НЕ деменция): рисперидон 0.5-2 мг, кветиапин 25-200 мг, оланзапин 2.5-7.5 мг\n• Delirium: рисперидон 0.5-2 мг (1-я линия per NEUROP), галоперидол 0.5-2 мг\n• BAR: ламотриджин (best tolerability), литий с ↓ дозой и careful monitoring\n• AD/деменция: ингибиторы холинэстеразы (donepezil, rivastigmine, galantamine), мемантин", + "neuro": "ПРОТОКОЛ ПРИ ВВОДЕ ЛЮБОГО ПСИХОТРОПА У ПОЖИЛОГО:\n\n1. Pre-treatment assessment:\n • Cognitive baseline (MMSE/MoCA)\n • Falls history\n • Renal/hepatic function (СКФ, ферменты)\n • Cardiac (ECG, BP лёжа+стоя)\n • Polypharmacy review\n • Anticholinergic burden (ACB scale)\n\n2. START LOW, GO SLOW:\n • Дозы: 1/2 от взрослой starting\n • Up-titrate каждые 2-4 нед (vs 1-2 нед в young)\n • Target effect — может быть ниже взрослой\n\n3. Мониторинг каждые 1-3 мес первого года:\n • Cognitive function\n • Side effects\n • Drug levels (TDM где applicable)\n • Comorbidity progression\n\n4. RE-ASSESSMENT регулярно:\n • Эффективность (continue if helping)\n • De-prescribing если no longer needed\n\nDELIRIUM PREVENTION (особенно после operation/hospital admission):\n• Минимизировать anticholinergic burden\n• Регулярный sleep-wake cycle\n• Orientation cues (clock, calendar)\n• Family presence\n• Avoid restraints\n\nBPSD (Behavioral and Psychological Symptoms of Dementia):\n• Non-pharma FIRST: environmental modification, sensory adaptation, routine\n• Если необходимо: Risperdone 0.25-1 мг (Black Box: ↑mortality cerebrovascular events) — short-term ≤12 нед\n• Citalopram 10-30 мг (CitAD trial) — для agitation\n• Avoid: BDZ (worsen delirium, falls); FGA (anticholinergic + EPS)\n\nDEPRESCRIBING (PROVIDED no longer needed):\n• Постепенный таперинг — медленнее чем в young\n• Monitor for relapse + withdrawal\n• If relapse — restart with same agent", + "tactic": "ОБЯЗАТЕЛЬНЫЕ ПРАКТИКИ:\n\n1. РЕВИЗИЯ ПОЛИПРАГМАЗИИ q3-6 мес:\n • Каждый med — на каждой ревизии\n • Каждый — show indication, target effect, plan для discontinuation\n\n2. CBT-FOR-INSOMNIA — first line для chronic insomnia (vs hypnotics) у пожилых\n\n3. ENGAGE FAMILY/CARERS:\n • Information about side effects\n • Compliance support\n • Early signs of toxicity\n\n4. BLACK BOX awareness:\n • Антипсихотики при деменции — ↑ mortality (cerebrovascular events)\n • Использовать только если risk justified\n • Документировать обсуждение\n\n5. NUTRITION & HYDRATION:\n • Proper hydration — особенно при diuretics, lithium\n • Vitamin D, B12, folate — частые deficiencies в пожилых\n • Protein intake adequate\n\n6. SCREENING для не diagnosed conditions:\n • Depression often masked as somatic complaints\n • Anxiety often masked as agitation/sleep issues\n • Substance use (alcohol especially) — частая, мало обсуждается" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Stuhec M., Stoppe G. Psychopharmacotherapy in Aged Patients. NEUROP 2022 (p.4417)", + "American Geriatrics Society 2023 Beers Criteria", + "STOPP-START Criteria v3 (O'Mahony 2023)", + "CitAD trial (Porsteinsson 2014) — citalopram for AD agitation" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_id_psychopharm", + "cmd_alias": "id_pharma", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Антипсихотики при умственной отсталости (de Kuijper NEUROP 2022)", + "tags": [ + "umственная отсталость", + "intellectual disability", + "ID", + "deinstitutionalization", + "behavioral problems", + "de Kuijper", + "challenging behavior", + "aripiprazole", + "risperidone", + "ethical", + "capacity" + ], + "related": [ + "drug_risperidone", + "drug_aripiprazole", + "drug_olanzapine", + "gero_anticholinergic", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Применение АП при умственной отсталости — высокая частота, низкая evidence-base, серьёзные ethical questions. NEUROP/de Kuijper & Lenderink 2022 (p.4561) — единственная систематизированная глава по теме. ⚠ ID-специфика отсутствует в guidelines (NICE/CANMAT/etc) для adults.", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ЭПИДЕМИОЛОГИЯ:\n• 30-40% adults с ID получают АП — даже в absence psychotic disorder\n• Большинство — для \"challenging behavior\" (aggression, self-injury, rip behaviors)\n• Очень мало placebo-controlled RCT в ID-population\n• ⚠ Большая часть назначений — long-term, без re-assessment, без de-prescribing\n\nЭТИЧЕСКИЕ ПРОБЛЕМЫ:\n• Capacity для consent — assessable но variable\n• \"Chemical restraint\" vs therapeutic — fine line\n• Family/guardian role в decision-making\n• ⚠ Ill-defined \"behavioral problems\" — может быть communication of pain, sensory overload, frustration, etc — НЕ всегда mental illness\n\nDIFFERENTIAL DIAGNOSIS challenging behavior:\n1. Соматический (pain, GI, dental, infection, constipation)\n2. Sensory (vision, hearing, sensory overload)\n3. Environmental (changes, lack of routine, abuse/neglect)\n4. Communication frustration\n5. Mental illness (depression, anxiety, psychosis, OCD, autism comorbidity)\n6. Drug side effects (особенно от AED)\n\n⚠ FUNCTIONAL ASSESSMENT (FBA — Functional Behavioral Analysis) — STANDARD before starting medication." + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "АП В ID (de Kuijper 2022):\n\nПРЕДПОЧТИТЕЛЬНЫЕ:\n• Risperidone 0.25-3 мг — наибольшая evidence-base в ID; FDA approved для irritability в autism (children)\n• Aripiprazole 2-15 мг — partial agonist; меньше метаболических побочек; FDA approved для autism irritability\n• Olanzapine 2.5-10 мг — если sedation desired; ⚠ метаболика\n• Haloperidol 0.5-3 мг — short-term для severe aggression; ⚠ EPS, особенно в ID where TD risk higher\n\n⚠ ИЗБЕГАТЬ:\n• Хлорпромазин, тизерцин — anticholinergic burden, sensitivity higher в ID\n• Высокие дозы — sedation maskes underlying issue\n• БДЗ длительно — paradoxical agitation в ID up to 30%\n\nDOSING PRINCIPLES в ID:\n• Start lower than typical adult (often 25-50%)\n• Slow titration\n• Specific behavior target (not generic 'agitation')\n• Time-limited trial (e.g. 8-12 нед) — if no clear benefit, taper\n\n⚠ CARDINAL RULES:\n1. Never use AP без specific behavior target документированной\n2. Always combine с FBA-driven behavioral intervention\n3. Re-assess every 6 мес — \"is this still needed?\"\n4. Document decision-making с input от family/multidisciplinary team\n\nДРУГИЕ ИНДИКАЦИИ:\n• Coexisting AD/anxiety: SSRI (sertraline, fluoxetine) — preferred\n• Coexisting OCD-like behaviors: SSRI; clomipramine if SSRI failed\n• Coexisting epilepsy: лечить epilepsy first; AED selection — valproate, lamotrigine\n• Coexisting bipolar: литий или valproate; AED choice based on epilepsy comorbidity", + "neuro": "DE-PRESCRIBING в ID (KEY emphasis NEUROP):\n\n• Many adults with ID на АП \"forever\" without indication\n• De-prescribing studies: ~50% can successfully taper without behavior worsening\n• Slow taper (10-25% q4-6 нед)\n• Alternative interventions in place (FBA, environmental, sensory)\n• Family/staff buy-in critical\n\nMONITORING при long-term использовании:\n• Метаболика q3-6 мес (как all АП users)\n• EPS / TD assessment q6 мес — Abnormal Involuntary Movement Scale (AIMS)\n• Cognitive — может быть сложно baseline; track functional changes\n• Behavior — track frequency, intensity, antecedents\n• Drug interactions — особенно если on AED", + "tactic": "ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ (NEUROP-aligned):\n\n1. ТРИАЖ challenging behavior:\n • Соматический workup PERVOIE\n • Environmental review\n • FBA performed by qualified specialist\n\n2. Если медикамент необходим:\n • Specific target behavior — определена\n • Consent / capacity assessed\n • Multidisciplinary team agreement\n • Time-limited trial\n\n3. Choice:\n • Risperidone OR aripiprazole as первая линия (NEUROP)\n • Low dose, slow titration\n • Single drug — avoid polypharmacy\n\n4. Re-assessment:\n • At 8-12 нед — clear benefit?\n • Если да — q6 мес reassessment\n • Plan for de-prescribing built in\n\n5. ⚠ DOCUMENT EVERYTHING:\n • Indication\n • Target behavior\n • Trial date / response\n • De-prescribing plan\n\nCONTEXT FOR UKRAINE/POST-SOVIET:\n• High prevalence of \"chemical restraint\" в institutional care\n• Limited specialized ID services\n• Often AP prescribed без FBA или specific target\n• Opportunity для practice quality improvement" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "de Kuijper G., Lenderink A.W. Antipsychotic Drug Prescription and Behavioral Problems in Individuals with Intellectual Disability. NEUROP 2022 (p.4561)", + "NICE NG11 — Challenging behaviour and learning disabilities (2015, updated 2019)" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_forced_migration", + "cmd_alias": "migration_mh", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Mental health forced migration: PTSD, депрессия, психозы (Burger & Pogarell NEUROP)", + "tags": [ + "forced migration", + "беженцы", + "refugees", + "internally displaced", + "ВПО", + "украинский контекст", + "PTSD", + "депрессия", + "миграция", + "адаптация", + "language barrier", + "Burger", + "Pogarell", + "trauma" + ], + "related": [ + "alg_combat_ptsd_circuits", + "ptsd_checklist", + "combat_acute_reactions", + "drug_sertraline", + "drug_paroxetine", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Forced migration = особый клинический контекст: высокая частота травматизации, языковые/cultural barriers, неопределённость legal status, прерванный социальный support. ОЧЕНЬ актуально для Украины 2022+ (внутренне-перемещённые лица, refugees в Европе). NEUROP/Burger & Pogarell 2022 (p.4583).", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ЭПИДЕМИОЛОГИЯ:\n• Forced migration → 5-6× ↑ риск depression, PTSD, anxiety vs general population\n• PTSD: 30-40% в среди forcibly displaced (vs 7-9% в general)\n• MDD: 30-40%\n• Психотические эпизоды: ↑ риск 2-3×\n\nUKRAINIAN CONTEXT (2022+):\n• 6 миллионов internally displaced (UN OCHA 2024)\n• ~6 миллионов refugees в Europe\n• 2-летние данные: накопление мental health burden, ↓ access to specialized care\n• Гендерная specifics: 90% adult refugees в Europe — женщины (мужчины 18-60 — мобилизация-возможна)\n\nЧАСТЫЕ MENTAL HEALTH PRESENTATIONS:\n1. Acute Stress Reaction → PTSD (трехfaшний переход)\n2. Adjustment disorder с depression / anxiety\n3. Complex PTSD (sequential trauma + cultural displacement)\n4. Re-traumatization в host country (xenophobia, discrimination)\n5. Substance use disorders (как coping)\n6. Somatization — особенно где stigma вокруг mental illness\n7. Psychotic episode triggered by accumulated stress\n\nBARRIERS to care:\n• Language\n• Cultural concepts of distress (idioms — somatic vs psychiatric)\n• Stigma\n• Practical: housing, work, schools, legal — иerarchically приоритеtнее MH\n• Distrust of authority figures (включая medical) given trauma history\n• Limited interpreter availability\n• Health system not navigated by refugees" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "TIERED INTERVENTION (per NEUROP + WHO mhGAP):\n\nTIER 1 — basic services + protection:\n• Safe shelter, food, water, security\n• Family reunification\n• Legal status clarity\n• Без этого MH treatment effectiveness резко ↓\n\nTIER 2 — community + family supports:\n• Peer support groups\n• Community centers с trained facilitators\n• Cultural mediators\n• Faith-based supports\n\nTIER 3 — focused (non-specialized) supports:\n• Brief psychotherapy from trained non-specialists\n• Problem-solving therapy\n• Group interventions for common conditions\n\nTIER 4 — specialized services:\n• Trauma-focused therapy (EMDR, NET, CPT-trauma)\n• Pharmacotherapy для PTSD/MDD/psychosis\n• Specialized child/adolescent services\n• Acute psychiatry для эмерgencies\n\nPHARMACOTHERAPY — same as general PTSD/MDD with adjustments:\n\n• PTSD-related: sertraline 50-200 мг, paroxetine 20-50 мг (FDA approved)\n – Venlafaxine 75-225 мг — alternative if SSRI fail\n – Prazosin 1-15 мг для nightmares\n – Avoid BDZ (риск misuse + не помогают core PTSD; см. alg_combat_ptsd_circuits)\n\n• MDD: sertraline / fluoxetine — global accessibility data\n – Avoid drugs with complex titration или narrow window — поскольку follow-up может быть erratic\n\n• Psychosis: olanzapine, risperidone — broad accessibility\n – Long-acting injectables — useful если mobility / displacement makes daily compliance hard\n\n• ⚠ CULTURAL ADJUSTMENT:\n – Side effects (sexual dysfunction, weight gain) могут быть особенно distressing depending on culture\n – Disclose про ожидаемые SE — for compliance\n – Use formulations available в host country (avoid switching between brands мid-treatment)", + "neuro": "PRACTICAL ASPECTS:\n\nPSYCHO-EDUCATION:\n• \"This is a normal reaction to abnormal circumstances\"\n• Нормализация symptoms (sleep disturbance, hyperarousal, intrusions) — это не \"безумие\"\n• Когда необходимо специализированное лечение\n\nLANGUAGE:\n• Trained MH interpreters — preferred (vs random bilingual person)\n• Translated screening tools (PHQ-9, PCL-5, GAD-7) available для основных languages\n• Watch for language-loss as marker of trauma severity (especially children)\n\nCONTINUITY OF CARE:\n• Mobile-friendly tools (apps, telehealth)\n• Documentation that can be shared если patient relocates\n• Referral pathways в host country\n\nFAMILIES + CHILDREN:\n• Children especially vulnerable; intervene EARLY\n• Parents need their own support to support children\n• School-based screening + intervention — most cost-effective\n\nUkrainian-SPECIFIC RESOURCES (2024):\n• Друг.Друг (psychological help platform — created by Ukrainian psy professionals)\n• Lifelong (psychotherapy network)\n• МОЗ України psychological support hotline\n• \"How are you?\" national mental health initiative", + "tactic": "ОБЯЗАТЕЛЬНЫЕ ПРАКТИКИ ДЛЯ КЛИНИЦИСТА:\n\n1. SCREENING универсальный — каждый migrant patient:\n • PHQ-9 (depression)\n • PCL-5 (PTSD)\n • GAD-7 (anxiety)\n • SUD screen (AUDIT, DAST)\n • Suicide ideation\n\n2. TRAUMA-INFORMED CARE principles:\n • Safety первично\n • Choice — пациент имеет control over treatment decisions\n • Avoid re-traumatization (e.g. unnecessary detailed history)\n • Cultural humility\n\n3. КОЛЛАБОРАЦИЯ С СОЦИАЛЬНЫМИ службами — поскольку housing/legal/work issues often more acute than MH\n\n4. ⚠ DOCUMENTATION:\n • Может understanding быть нужна для asylum case — document trauma history accurately и compassionately\n • Consent для sharing — explicit\n\n5. SELF-CARE ДЛЯ КЛИНИЦИСТА:\n • Vicarious traumatization — risk при работе с trauma populations\n • Supervision, peer support\n\nCONTEXT FOR УКРАИНА 2024+:\n• Эта тема — приоритет для Ukrainian psychiatric profession\n• Многие colleagues themselves displaced or work с displaced patients\n• Continuing education: WHO mhGAP Humanitarian Intervention Guide, IASC MHPSS Guidelines" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Burger M., Pogarell O. Forced Migration and Mental Health Care. NEUROP 2022 (p.4583)", + "WHO mhGAP Humanitarian Intervention Guide (2015, updated 2024)", + "IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007)", + "UNHCR Operational Guidance: MH and Psychosocial Programming for Refugee Operations (2013)" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_eating_disorders", + "cmd_alias": "ed_pharma", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Расстройства пищевого поведения: фарма (Borges, Lewis, Bentley, Himmerich NEUROP 2022)", + "tags": [ + "eating disorders", + "анорексия", + "нервная анорексия", + "булимия", + "binge eating disorder", + "BED", + "ARFID", + "оланзапин", + "флуоксетин", + "лиздексамфетамин", + "topiramate", + "Borges", + "Himmerich" + ], + "related": [ + "drug_olanzapine", + "drug_fluoxetine", + "drug_lisdexamfetamine", + "drug_topiramate", + "pharma_tdm", + "pharma_receptors" + ], + "description": "EDs — расстройства с ВЫСОКОЙ medical mortality (анорексия — самая высокая смертность среди психиатрических расстройств). Pharma — adjunct к psychotherapy (CBT-E first-line для большинства EDs). NEUROP/Borges et al 2022 (p.4127).", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ЭПИДЕМИОЛОГИЯ:\n• Anorexia nervosa: 0.5-1% lifetime в женщин\n• Bulimia nervosa: 1-2% lifetime\n• Binge Eating Disorder (BED): 1-2.8% lifetime — most common ED\n• ARFID (Avoidant/Restrictive Food Intake Disorder): новая DSM-5 категория, prevalence неясно\n\n⚠ MEDICAL EMERGENCIES в EDs:\n• AN с BMI <13 — refeeding syndrome risk\n• AN с bradycardia <40, arrhythmias, ↓K+\n• BN с frequent purging — hypokalemia, esophagitis (Mallory-Weiss)\n• Все — bone density loss, cardiac arrhythmias, sudden death\n\nDIAGNOSTIC RECONSIDERATION:\n• EDs часто misdiagnosed как primary anxiety, depression, OCD\n• Comorbid anxiety/depression очень частые\n• Detective work — ask specifically about restriction, binge, purge, body image\n\nTREATMENT FRAMEWORK:\n• PSYCHOTHERAPY = primary treatment (CBT-E for most adults; FBT for adolescents)\n• Pharma = ADJUNCT, не replacement\n• Medical stabilization первая линия при severe AN\n• Multidisciplinary: psychiatrist + psychologist + dietitian + medical doctor (cardiology, endocrinology if needed)" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "PHARMA BY DIAGNOSIS:\n\nANOREXIA NERVOSA (AN):\n• ⚠ PHARMA EFFICACY LIMITED:\n – Большинство RCT — negative\n – Ни один FDA-approved\n – Olanzapine 2.5-10 мг — modest effect on weight gain в RCT (Attia 2019), но modest BMI ↑\n – SSRIs — НЕ помогают для core AN; ⚠ usual dose может быть toxic при low body weight\n – Mirtazapine 15-30 мг — может помочь sleep + appetite (off-label)\n – Avoid stimulants, bupropion (seizure risk + further weight loss)\n\n⚠ ANTIDEPRESSANTS NOT USEFUL FOR CORE AN, но may help comorbid depression POST-weight restoration\n\nBULIMIA NERVOSA (BN):\n• Fluoxetine 60 мг (FDA approved — UNIQUE among SSRI for BN):\n – ↓ binge frequency 50%\n – ↓ purge frequency\n – Higher dose than для MDD (60 vs 20-40)\n• Other SSRIs: sertraline, citalopram — limited data\n• ⚠ Avoid bupropion (seizure risk при БМ)\n• Topiramate 100-200 мг — 2-я линия (off-label) — также weight loss\n\nBINGE EATING DISORDER (BED):\n• Lisdexamfetamine 30-70 мг — FDA APPROVED for BED (2015) — UNIQUE\n – ↓ binge episodes\n – Modest weight loss\n – Schedule II controlled — abuse risk consideration\n• Topiramate 50-200 мг — alternative\n• SSRI (sertraline, fluoxetine) — modest effect, useful если comorbid MDD/anxiety\n\nARFID:\n• Limited data\n• Mirtazapine 15-30 мг — case reports for appetite stimulation\n• Cyproheptadine — antihistamine, appetite stim, off-label", + "neuro": "MEDICAL EMERGENCIES PHARMA:\n\nREFEEDING SYNDROME prevention (severe AN, BMI <14, very low intake):\n• Slow refeeding — start <500 kcal/day, ↑ slowly\n• Phosphate repletion — крitical (RFS = ↓PO4 → cardiac arrest)\n• Thiamine 200-300 мг/day × 5-7 дней\n• Magnesium, potassium — repletion\n• Daily electrolytes первая неделя\n• ECG monitoring\n\nHYPOKALEMIA в BN с purging:\n• KCl PO/IV repletion\n• Magnesium repletion\n• ECG monitoring\n• Address purging behavior\n\nBONE DENSITY LOSS:\n• Calcium 1500 мг/day\n• Vitamin D 2000-5000 IU\n• Estrogen replacement в women с amenorrhea — controversial (transdermal preferred)\n• Bisphosphonates — only if severe + post-weight restoration\n\nBOTH AN/BN — co-management:\n• Psychiatry + Internal medicine + Cardiology (если ECG abnormalities)\n• Endocrinology (osteoporosis, hypogonadism, hypothyroid)\n• Dental (BN — erosion от gastric acid)\n• Gastroenterology (BN — esophageal issues)", + "tactic": "ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ:\n\nДИАГНОСТИКА:\n• High suspicion в anyone с unexplained weight loss/gain\n• Screen всех пациентов с anxiety/depression for ED\n• EAT-26 (Eating Attitudes Test) — screening tool\n• SCOFF questionnaire — quick 5-item screen\n\nLEVEL OF CARE:\n• Outpatient: BMI >17.5, medical stable, motivation\n• Partial hospital: BMI 15-17.5, медицинская stability borderline\n• Inpatient psychiatric: behavioral compliance issues\n• Medical inpatient (priority): BMI <15, electrolyte abnormalities, cardiac instability, suicidality\n\n⚠ INVOLUNTARY FEEDING — медицинский, ethical, legal complex:\n• Justified в life-threatening situations\n• Capacity assessment important\n• Family involvement\n• In Ukraine — закон психіатричної допомоги § 16 — недобровільна госпіталізація possible\n\nPSYCHOTHERAPY referrals:\n• CBT-E для most adults — first-line evidence\n• FBT (Maudsley) для adolescent AN — first-line\n• DBT для comorbid BPD\n• Group support — useful adjunct\n\nFOLLOW-UP:\n• Weekly visits early\n• Monthly после stabilization\n• Long-term: 50% AN remit; 30% chronic; 20% severe persistent\n• BN recovery rates better — 70% recover\n• BED — depends on weight management long-term" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Borges K., Lewis Y.D., Bentley J., Himmerich H. Use of Antipsychotics in the Treatment of Eating Disorders. NEUROP 2022 (p.4127)", + "Attia E. et al. Olanzapine versus placebo in adult outpatients with AN (RCT). Am J Psychiatry 2019", + "McElroy S.L. et al. Lisdexamfetamine for BED. JAMA Psychiatry 2015", + "Walsh B.T. et al. Fluoxetine after weight restoration in AN. JAMA 2006" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_sexual_disorders", + "cmd_alias": "sex_pharma", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Сексуальные расстройства: фарма (Malandain, Chagraoui, Thibaut NEUROP 2022)", + "tags": [ + "sexual disorders", + "эрек", + "disorder", + "HSDD", + "arousal", + "orgasm", + "сильденафил", + "tadalafil", + "флибансерин", + "bremelanotide", + "SSRI-induced", + "sexual dysfunction", + "Malandain", + "Thibaut" + ], + "related": [ + "drug_sertraline", + "drug_paroxetine", + "drug_fluoxetine", + "drug_bupropion", + "drug_mirtazapine", + "drug_vortioxetine", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Сексуальные дисфункции — частые, often medication-induced, недостаточно обсуждаемые. NEUROP/Malandain et al (2022, p.4171). Включает: erectile dysfunction (ED), HSDD (Hypoactive Sexual Desire Disorder), premature ejaculation (PE), delayed orgasm, anorgasmia.", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ЭПИДЕМИОЛОГИЯ:\n• ED: ~50% мужчин 40-70 (mild + moderate + severe)\n• HSDD у женщин: 10% prevalence (уже устранены situational/relational причины)\n• ⚠ SSRI/SNRI-induced sexual dysfunction: 30-70%\n• Antipsychotic-induced sexual dysfunction: 30-60%\n\nFRAMEWORK:\n1. ⚠ ВСЕГДА first — exclude medical causes:\n • Cardiovascular (most common ED cause)\n • Endocrine (DM, hypogonadism, hyperprolactinemia)\n • Neurological\n • Medication-induced\n2. Psychological/relational\n3. Primary sexual disorder\n\nMEDICATION-INDUCED — частая, недо-обсуждаемая cause:\n• Любой serotonergic AD (SSRI, SNRI, clomipramine)\n• Большинство АП — через D2 (hyperprolactinemia) + пром others\n• BDZ — могут ↓ orgasm intensity\n• Bupropion — neutral or pro-sexual\n• Mirtazapine — neutral\n• Antihypertensives (β-blockers, thiazide diuretics)\n• Opioids — chronically depress libido\n• Alcohol" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "PHARMA BY DIAGNOSIS:\n\nERECTILE DYSFUNCTION (ED):\n• PDE5 INHIBITORS — first-line:\n – Sildenafil (Viagra) 25-100 мг 1 ч до акта\n – Tadalafil (Cialis) 5-20 мг 30 мин-2 ч; либо 2.5-5 мг ежедневно (steady-state)\n – Vardenafil 5-20 мг\n – Avanafil 50-200 мг\n – ⚠ ⛔ С нитратами — fatal hypotension\n – ⚠ Caution с α-blockers\n – ⚠ NAION (rare visual loss)\n\n• 2-я линия:\n – Alprostadil intracavernosal или intraurethral\n – Vacuum erection devices\n – Penile prostheses\n\nHSDD у женщин premenopausal:\n• Flibanserin (Addyi) — FDA 2015 — multifunctional 5-HT modulator\n – Daily dosing 100 мг на ночь\n – ⚠ ⛔ С алкоголем — выраженная hypotension\n• Bremelanotide (Vyleesi) — FDA 2019 — melanocortin agonist\n – On-demand SC injection\n\n⚠ Both flibanserin/bremelanotide — controversial, modest effect size, side-effect issues\n\nPREMATURE EJACULATION (PE):\n• Dapoxetine — short-half-life SSRI, on-demand 30-60 мг 1-3 ч до акта (не FDA approved US, EU + many)\n• Off-label: paroxetine 10-20 мг daily; sertraline 25-100 мг; clomipramine 10-25 мг\n• Topical lidocaine/prilocaine cream\n• Tramadol — discouraged (potential abuse)\n\nDELAYED EJACULATION / ANORGASMIA (often SSRI-induced):\n• Switch к non-serotonergic (bupropion, mirtazapine, vortioxetine)\n• Drug holiday (если short T½ SSRI — risky discontinuation)\n• Bupropion 75-150 мг adjunct\n• Sildenafil — может помочь в некоторых случаях\n\nSSRI-INDUCED SEXUAL DYSFUNCTION:\n• Switch к agent с less SD: bupropion (best); mirtazapine; vortioxetine; agomelatine\n• Adjunct bupropion 75-150 мг\n• Adjunct sildenafil (PRN)\n• Drug holiday weekends (controversial)\n• \"Wait it out\" — can resolve спонтанно ~10-20% случаев\n\nANTIPSYCHOTIC-INDUCED SEXUAL DYSFUNCTION:\n• Switch к partial agonist (aripiprazole, cariprazine) — much less SD\n• ↓ Дозу если возможно\n• Cabergoline 0.5 мг 2× недель — для гипер-prolactinemia (but watch cardiac)", + "neuro": "ПОДХОД К ОЦЕНКЕ:\n\n1. CONTEXT:\n • Когда начались symptoms?\n • Связаны ли с медикаментозным начатием?\n • Partner-specific or general?\n • Morning erections present? (= organic vs psychogenic)\n\n2. MEDICAL workup:\n • Routine: glucose, lipids, testosterone (free + total), prolactin, TSH\n • If indicated: cardiology evaluation\n\n3. PSYCHOLOGICAL/RELATIONAL:\n • Couple counseling\n • Sex therapy referral\n\n4. MEDICATION REVIEW:\n • Critical look at all меds — много могут contribute\n • Consider switch если не essential\n\n5. ⚠ Discussion с пациентом — comfort culture-dependent:\n • Many cultures (incl. post-Soviet) — sexual topics taboo\n • Use proxies: \"How is your relationship?\", \"How are things at home?\"\n • Direct asking при rapport built\n\n6. CONFIDENTIALITY in couple settings — patient asks first what to discuss", + "tactic": "ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ:\n\n• ⚠ ASK ABOUT IT routinely — especially in MDD/anxiety/schizophrenia patients on meds\n• Many patients suffer silently — won't bring up unless asked\n• \"Are you having any sexual side effects from the medication?\" — direct, non-judgmental\n• Document discussion и offered solutions\n\nCAUTIONS:\n\n• PDE5 inhibitor + nitrates = potentially FATAL hypotension\n• PDE5 + α-blockers = hypotension, give time-separated\n• Flibanserin + alcohol = hypotension/syncope\n• Sexual medications через online pharmacies — often counterfeit; advise FDA-approved sources\n\nPATIENT EDUCATION:\n• ED очень medically common, особенно после 40\n• Many treatment options\n• Comorbid CV disease should be evaluated\n\n• HSDD often relational — couple work crucial\n• Hormonal therapy (testosterone supplementation в men; не universally в women) — controversial, careful selection\n\nFOR UKRAINE:\n• Sildenafil generic — accessible\n• Tadalafil generic — accessible\n• Other PDE5 — variable\n• Flibanserin/bremelanotide — limited availability\n• Stigma вокруг discussion — clinician initiative crucial" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Malandain L., Chagraoui A., Thibaut F. Psychopharmacotherapy of Sexual Disorders. NEUROP 2022 (p.4171)", + "Maudsley Prescribing Guidelines — sexual dysfunction chapter" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] } ] \ No newline at end of file diff --git a/docs/database.js b/docs/database.js index f39127b..7c20ed8 100755 --- a/docs/database.js +++ b/docs/database.js @@ -1,7 +1,7 @@ // SYSTEM.CORE.DB v7.0 [ENCYCLOPAEDIA KERNEL] -// Auto-generated by build.py on 2026-04-25T23:31:26 +// Auto-generated by build.py on 2026-04-25T23:44:06 // DO NOT EDIT — source files in database/categories/ -// Entries: 174 | Categories: 20 +// Entries: 180 | Categories: 20 window.PSYCH_DATABASE = [ { @@ -2933,6 +2933,388 @@ window.PSYCH_DATABASE = [ "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part I Basic Principles + Part XIV Implementation" ] }, + { + "id": "special_pregnancy_neurop", + "cmd_alias": "preg_full", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Беременность и лактация: comprehensive psychopharm (Mohr NEUROP 2022)", + "tags": [ + "беременность", + "лактация", + "pregnancy", + "ssrI", + "SNRI", + "sertraline", + "fluoxetine", + "quetiapine", + "Mohr", + "perinatal", + "NICE", + "RID", + "relative infant dose", + "postpartum" + ], + "related": [ + "preg_overview", + "preg_antidepressants", + "preg_antipsychotics", + "preg_mood_stabilizers", + "preg_lactation", + "preg_benzo_anxio", + "drug_sertraline", + "drug_fluoxetine", + "drug_quetiapine", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Систематический подход к фармакотерапии перинатального периода. Принципы NEUROP/Mohr (2022, p.4355): риск нелеченой болезни VS риск медикамента; минимальная эффективная доза; preferred agents с large registry data; close monitoring пре- и постнатально.", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ОБЩИЕ ПРИНЦИПЫ (NEUROP/Mohr):\n\n1. Нелеченая mental illness в беременности — СВОЙ РИСК для матери и плода:\n • Premature delivery, low birth weight\n • Postpartum depression (60% recurrence у женщин с MDD off meds)\n • Postpartum psychosis (особенно BAR)\n • Suicide — 2-я причина maternal mortality (UK)\n • Малопitание матери, alcohol/substance abuse как самолечение\n\n2. РИСК vs ПОЛЬЗА — calculation, не absolute avoidance\n\n3. Pre-conception PLANNING — идеально, but rare reality:\n • Switch к safer agent ДО pregnancy если возможно\n • Folate 5 мг/сут pre-conception если AED-вальпроат, carbamazepine\n\n4. Use ESTABLISHED registry-data agents:\n • Antidepressants: sertraline, fluoxetine — best data\n • Antipsychotics: olanzapine, quetiapine — preferred\n • Mood stabilizers: lamotrigine — best teratogenic profile" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "I ТРИМЕСТР (organogenesis) — main teratogenic risk window:\n\nANTIDEPRESSANTS:\n• Сертралин — preferred (largest data, kardiac risk minimal)\n• Флуоксетин — preferred (oldest data, минимальные signals)\n• ⚠ ПАРОКСЕТИН — Class D (Ebstein anomaly при I триместре) — switch до conception\n• Венлафаксин, дулоксетин — limited data\n• Бупропион — neutral signals\n• ⚠ ИМАО — AVOID (no registry, hypertensive risk)\n\nANTIPSYCHOTICS:\n• Олanzapine, quetiapine — preferred (good data)\n• Рисперидон, hал operidol — также используется\n• Klozapine — usable if needed (TRS), но monitor neonatal granulocytes\n• ⚠ Aripiprazole, lurasidone — limited data\n\nMOOD STABILIZERS:\n• Ламотриджин — preferred (no major teratogenic signal, dose adjustments needed because levels ↓ в pregnancy ~50%)\n• ⚠ ВАЛЬПРОАТ — STRONGLY AVOID (12% NTD, 20% pregnancy adverse outcomes; FDA black box; EU restriction)\n• ⚠ Карбамазепин — TERATOGENIC (NTD spina bifida 1%); folate 5 мг/сут\n• Литий — Ebstein anomaly risk historically overestimated; current data ~1.2-1.5x baseline; usable если необходим (особенно при суицидальной BAR)\n\nBDZ:\n• Diazepam, alprazolam — Class D; preferable lorazepam если необходим (short T½, predictable)\n• Avoid in I triméстре if possible; в III — neonatal withdrawal/floppy infant", + "neuro": "II–III ТРИМЕСТР:\n\n• Folate continued (1 mg general; 5 мг if на AEDs)\n• Vitamin D, omega-3 supplementation\n• Регулярный мониторинг настроения (PHQ-9 q4 нед)\n• Подготовка к delivery + postpartum plan ДО родов\n\nIII ТРИМЕСТР SPECIFIC:\n• ⚠ Neonatal adaptation syndrome (poor neonatal adaptation, PNAS):\n – SSRI/SNRI: 30% babies с tremor, jitteriness, irritability, feeding issues — обычно self-limited 2 нед\n – BDZ: floppy infant\n – Антиpsychotics: EPS, withdrawal\n• ⚠ PPHN (persistent pulmonary hypertension of newborn):\n – Особенно SSRI в III триместре (relative risk ~2x baseline; absolute 1-3 / 1000)\n – Switch dose ↓ before delivery — controversial, обычно continue\n\nDOSE ADJUSTMENTS DURING PREGNANCY:\n• ↑ volume of distribution → plasma levels ↓\n• Renal clearance ↑\n• CYP3A4 induced, CYP2D6 induced — variable\n• Lamotrigine: levels ↓ ~50% к III триместру — adjust dose\n• Lithium: levels variable; close monitoring каждые 4 нед\n\nLACTATION (Mohr NEUROP):\n• RID (Relative Infant Dose) <10% обычно safe; <1% near-ideal\n• AGENTS С RID <2% (ideal): sertraline 0.5-2%, fluoxetine 1-7%, escitalopram 5-6%, paroxetine 1-3%, миртазапин 1.6%, olanzapine 1.6%, quetiapine 0.1%\n• Avoid в lactation: ламотриджин (RID 9-18%, but data uncertain), литий (RID 12-30% — monitor infant), флувоксамин (limited)", + "tactic": "ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ:\n\nPRE-CONCEPTION (если есть luxury planning):\n• Switch на safest agent (e.g. paroxetine → sertraline)\n• Folate 5 мг/сут × 3 мес pre-conception если на AEDs\n• Discuss timing с пациентом (active illness vs euthymia)\n• Plan for postpartum — risk of relapse без meds\n\nDURING PREGNANCY:\n• Monitor mood каждые 4 нед\n• Plasma levels q4-6 нед for narrow-window meds (lithium, lamotrigine)\n• Combine с psychotherapy — CBT/IPT for MDD\n\nDELIVERY:\n• Anesthesia plan — discuss с anesthesiologist (BDZ depo, ketamine, etc)\n• Pediatric/NICU consultation\n• Avoid breastfeeding immediately если high-RID agent (e.g. lithium)\n\nPOSTPARTUM:\n• ↓ Volume of distribution → restore pre-pregnancy doses or adjust based on levels\n• High recurrence risk — KEEP меды если before pregnancy were stabilizing\n• Postpartum psychosis в BAR — emergency, hospitalize, ECT if needed\n• Bonding support, social support — критично\n\nДОКУМЕНТАЦИЯ:\n• Письменное обсуждение risk/benefit с пациентом\n• Подпись согласия на терапию беременности\n• Регистрация в реестрах (если возможно — UK Bumps, Motherisk, etc)\n\n⚠ В Украине отсутствуют национальные registry — clinical decision-making relies on NEUROP/Maudsley/UK Teratology Information Service references" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Mohr P. Psychopharmacological Agents During Pregnancy and Nursing. NEUROP 2022 (p.4355)", + "MotherToBaby (Organization of Teratology Information Specialists)", + "UK Bumps (Best Use of Medicines in Pregnancy)" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_aged_neurop", + "cmd_alias": "geropsy_full", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Геронтопсихиатрия: comprehensive psychopharm (Stuhec & Stoppe NEUROP 2022)", + "tags": [ + "пожилые", + "aged", + "gериatricsky", + "Stuhec", + "Stoppe", + "полипрагмазия", + "Beers Criteria", + "STOPP-START", + "деменция", + "BPSD", + "делирий", + "фалл", + "ортостаз", + "cognitive", + "metabolic" + ], + "related": [ + "gero_anticholinergic", + "gero_polypharmacy", + "gero_dementia_overview", + "gero_bpsd", + "gero_delirium_vs_dementia", + "drug_risperidone", + "drug_haloperidol", + "drug_lorazepam", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Систематический подход к фармакотерапии в пожилом возрасте. Принципы NEUROP/Stuhec & Stoppe (2022, p.4417): START-LOW-GO-SLOW, минимизация полипрагмазии, careful screening for BPSD, проверка cognitive impact, регулярная reassessment.", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ВОЗРАСТНЫЕ ИЗМЕНЕНИЯ — фармакокинетические:\n\n• ↓ Renal clearance (СКФ ↓ ~10%/decade после 40 лет)\n• ↓ Hepatic blood flow и phase I metabolism (oxidative); phase II (glucuronidation) preserved\n• ↑ Volume of distribution для lipophilic drugs (↑ fat tissue) → ↑ T½ (BDZ, AP, AD all longer T½ in elderly)\n• ↓ Plasma albumin → ↑ free fraction (clinical relevance variable)\n• ↑ BBB permeability → ↑ CNS sensitivity\n• ↓ Receptor density / sensitivity (variable)\n\nPHARMACODYNAMIC SENSITIVITY:\n• Anticholinergics: ↑↑ delirium, cognitive decline, falls\n• BDZ: ↑↑ falls, paradoxical agitation, cognitive\n• АП: ↑ EPS, delirium, falls, mortality (FDA Black Box при деменции)\n• ↑ ortostatic hypotension в response to α-blockers\n\nCOMORBIDITY:\n• ≥3 хронические болезни — обычно >70 лет\n• Polypharmacy (≥5 meds) — ~50% >65 лет\n• Each additional med = +12% adverse drug events\n• Cognitive impairment — мониторинг compliance труднее" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "BEERS CRITERIA 2023 (American Geriatrics Society) — препараты-AVOID:\n\n• ⚠ ВСЕ TCA (амитриптилин, имипрамин, кломипрамин) — anticholinergic, falls, cardiac\n – Exception: nortriptyline в low-dose может быть acceptable\n• ⚠ Бензодиазепины — falls, cognitive, delirium (в любом dose, любая T½, любой возраст ≥65)\n – Exception: short-term (≤4 нед) для acute intervention\n• ⚠ FGAs (chlorpromazine, levomepromazine) — anticholinergic + ortostaz\n• ⚠ Все Z-drugs (zolpidem, zopiclone) — falls, complex sleep behaviors\n• ⚠ Antihistamines first-gen (дифенгидрамин, hydroxyzine) — anticholinergic\n• ⚠ Trihexyphenidyl, бенztropine — anticholinergic\n• ⚠ Метильдопа — depression, ортостаз\n• Tramadol — серотониновый, judgement, hyponatremia\n\nSTOPP-START Criteria (European):\n• ATC-group specific recommendations\n• STOPP — drugs to STOP\n• START — drugs that should be started but often missed\n\nPREFERRED AGENTS в гериатрии:\n• MDD: сертралин, эсциталопрам, mirtazapine (особенно если weight loss/insomnia issue), venlafaxine, бупропион\n• Anxiety: SSRI (как MDD); buspirone (no falls, no cognitive)\n• Insomnia: trazodone 25-100 мг, mirtazapine 7.5-15 мг (off-label sleep), мелатонин 1-5 мг\n• Psychosis (НЕ деменция): рисперидон 0.5-2 мг, кветиапин 25-200 мг, оланзапин 2.5-7.5 мг\n• Delirium: рисперидон 0.5-2 мг (1-я линия per NEUROP), галоперидол 0.5-2 мг\n• BAR: ламотриджин (best tolerability), литий с ↓ дозой и careful monitoring\n• AD/деменция: ингибиторы холинэстеразы (donepezil, rivastigmine, galantamine), мемантин", + "neuro": "ПРОТОКОЛ ПРИ ВВОДЕ ЛЮБОГО ПСИХОТРОПА У ПОЖИЛОГО:\n\n1. Pre-treatment assessment:\n • Cognitive baseline (MMSE/MoCA)\n • Falls history\n • Renal/hepatic function (СКФ, ферменты)\n • Cardiac (ECG, BP лёжа+стоя)\n • Polypharmacy review\n • Anticholinergic burden (ACB scale)\n\n2. START LOW, GO SLOW:\n • Дозы: 1/2 от взрослой starting\n • Up-titrate каждые 2-4 нед (vs 1-2 нед в young)\n • Target effect — может быть ниже взрослой\n\n3. Мониторинг каждые 1-3 мес первого года:\n • Cognitive function\n • Side effects\n • Drug levels (TDM где applicable)\n • Comorbidity progression\n\n4. RE-ASSESSMENT регулярно:\n • Эффективность (continue if helping)\n • De-prescribing если no longer needed\n\nDELIRIUM PREVENTION (особенно после operation/hospital admission):\n• Минимизировать anticholinergic burden\n• Регулярный sleep-wake cycle\n• Orientation cues (clock, calendar)\n• Family presence\n• Avoid restraints\n\nBPSD (Behavioral and Psychological Symptoms of Dementia):\n• Non-pharma FIRST: environmental modification, sensory adaptation, routine\n• Если необходимо: Risperdone 0.25-1 мг (Black Box: ↑mortality cerebrovascular events) — short-term ≤12 нед\n• Citalopram 10-30 мг (CitAD trial) — для agitation\n• Avoid: BDZ (worsen delirium, falls); FGA (anticholinergic + EPS)\n\nDEPRESCRIBING (PROVIDED no longer needed):\n• Постепенный таперинг — медленнее чем в young\n• Monitor for relapse + withdrawal\n• If relapse — restart with same agent", + "tactic": "ОБЯЗАТЕЛЬНЫЕ ПРАКТИКИ:\n\n1. РЕВИЗИЯ ПОЛИПРАГМАЗИИ q3-6 мес:\n • Каждый med — на каждой ревизии\n • Каждый — show indication, target effect, plan для discontinuation\n\n2. CBT-FOR-INSOMNIA — first line для chronic insomnia (vs hypnotics) у пожилых\n\n3. ENGAGE FAMILY/CARERS:\n • Information about side effects\n • Compliance support\n • Early signs of toxicity\n\n4. BLACK BOX awareness:\n • Антипсихотики при деменции — ↑ mortality (cerebrovascular events)\n • Использовать только если risk justified\n • Документировать обсуждение\n\n5. NUTRITION & HYDRATION:\n • Proper hydration — особенно при diuretics, lithium\n • Vitamin D, B12, folate — частые deficiencies в пожилых\n • Protein intake adequate\n\n6. SCREENING для не diagnosed conditions:\n • Depression often masked as somatic complaints\n • Anxiety often masked as agitation/sleep issues\n • Substance use (alcohol especially) — частая, мало обсуждается" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Stuhec M., Stoppe G. Psychopharmacotherapy in Aged Patients. NEUROP 2022 (p.4417)", + "American Geriatrics Society 2023 Beers Criteria", + "STOPP-START Criteria v3 (O'Mahony 2023)", + "CitAD trial (Porsteinsson 2014) — citalopram for AD agitation" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_id_psychopharm", + "cmd_alias": "id_pharma", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Антипсихотики при умственной отсталости (de Kuijper NEUROP 2022)", + "tags": [ + "umственная отсталость", + "intellectual disability", + "ID", + "deinstitutionalization", + "behavioral problems", + "de Kuijper", + "challenging behavior", + "aripiprazole", + "risperidone", + "ethical", + "capacity" + ], + "related": [ + "drug_risperidone", + "drug_aripiprazole", + "drug_olanzapine", + "gero_anticholinergic", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Применение АП при умственной отсталости — высокая частота, низкая evidence-base, серьёзные ethical questions. NEUROP/de Kuijper & Lenderink 2022 (p.4561) — единственная систематизированная глава по теме. ⚠ ID-специфика отсутствует в guidelines (NICE/CANMAT/etc) для adults.", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ЭПИДЕМИОЛОГИЯ:\n• 30-40% adults с ID получают АП — даже в absence psychotic disorder\n• Большинство — для \"challenging behavior\" (aggression, self-injury, rip behaviors)\n• Очень мало placebo-controlled RCT в ID-population\n• ⚠ Большая часть назначений — long-term, без re-assessment, без de-prescribing\n\nЭТИЧЕСКИЕ ПРОБЛЕМЫ:\n• Capacity для consent — assessable но variable\n• \"Chemical restraint\" vs therapeutic — fine line\n• Family/guardian role в decision-making\n• ⚠ Ill-defined \"behavioral problems\" — может быть communication of pain, sensory overload, frustration, etc — НЕ всегда mental illness\n\nDIFFERENTIAL DIAGNOSIS challenging behavior:\n1. Соматический (pain, GI, dental, infection, constipation)\n2. Sensory (vision, hearing, sensory overload)\n3. Environmental (changes, lack of routine, abuse/neglect)\n4. Communication frustration\n5. Mental illness (depression, anxiety, psychosis, OCD, autism comorbidity)\n6. Drug side effects (особенно от AED)\n\n⚠ FUNCTIONAL ASSESSMENT (FBA — Functional Behavioral Analysis) — STANDARD before starting medication." + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "АП В ID (de Kuijper 2022):\n\nПРЕДПОЧТИТЕЛЬНЫЕ:\n• Risperidone 0.25-3 мг — наибольшая evidence-base в ID; FDA approved для irritability в autism (children)\n• Aripiprazole 2-15 мг — partial agonist; меньше метаболических побочек; FDA approved для autism irritability\n• Olanzapine 2.5-10 мг — если sedation desired; ⚠ метаболика\n• Haloperidol 0.5-3 мг — short-term для severe aggression; ⚠ EPS, особенно в ID where TD risk higher\n\n⚠ ИЗБЕГАТЬ:\n• Хлорпромазин, тизерцин — anticholinergic burden, sensitivity higher в ID\n• Высокие дозы — sedation maskes underlying issue\n• БДЗ длительно — paradoxical agitation в ID up to 30%\n\nDOSING PRINCIPLES в ID:\n• Start lower than typical adult (often 25-50%)\n• Slow titration\n• Specific behavior target (not generic 'agitation')\n• Time-limited trial (e.g. 8-12 нед) — if no clear benefit, taper\n\n⚠ CARDINAL RULES:\n1. Never use AP без specific behavior target документированной\n2. Always combine с FBA-driven behavioral intervention\n3. Re-assess every 6 мес — \"is this still needed?\"\n4. Document decision-making с input от family/multidisciplinary team\n\nДРУГИЕ ИНДИКАЦИИ:\n• Coexisting AD/anxiety: SSRI (sertraline, fluoxetine) — preferred\n• Coexisting OCD-like behaviors: SSRI; clomipramine if SSRI failed\n• Coexisting epilepsy: лечить epilepsy first; AED selection — valproate, lamotrigine\n• Coexisting bipolar: литий или valproate; AED choice based on epilepsy comorbidity", + "neuro": "DE-PRESCRIBING в ID (KEY emphasis NEUROP):\n\n• Many adults with ID на АП \"forever\" without indication\n• De-prescribing studies: ~50% can successfully taper without behavior worsening\n• Slow taper (10-25% q4-6 нед)\n• Alternative interventions in place (FBA, environmental, sensory)\n• Family/staff buy-in critical\n\nMONITORING при long-term использовании:\n• Метаболика q3-6 мес (как all АП users)\n• EPS / TD assessment q6 мес — Abnormal Involuntary Movement Scale (AIMS)\n• Cognitive — может быть сложно baseline; track functional changes\n• Behavior — track frequency, intensity, antecedents\n• Drug interactions — особенно если on AED", + "tactic": "ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ (NEUROP-aligned):\n\n1. ТРИАЖ challenging behavior:\n • Соматический workup PERVOIE\n • Environmental review\n • FBA performed by qualified specialist\n\n2. Если медикамент необходим:\n • Specific target behavior — определена\n • Consent / capacity assessed\n • Multidisciplinary team agreement\n • Time-limited trial\n\n3. Choice:\n • Risperidone OR aripiprazole as первая линия (NEUROP)\n • Low dose, slow titration\n • Single drug — avoid polypharmacy\n\n4. Re-assessment:\n • At 8-12 нед — clear benefit?\n • Если да — q6 мес reassessment\n • Plan for de-prescribing built in\n\n5. ⚠ DOCUMENT EVERYTHING:\n • Indication\n • Target behavior\n • Trial date / response\n • De-prescribing plan\n\nCONTEXT FOR UKRAINE/POST-SOVIET:\n• High prevalence of \"chemical restraint\" в institutional care\n• Limited specialized ID services\n• Often AP prescribed без FBA или specific target\n• Opportunity для practice quality improvement" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "de Kuijper G., Lenderink A.W. Antipsychotic Drug Prescription and Behavioral Problems in Individuals with Intellectual Disability. NEUROP 2022 (p.4561)", + "NICE NG11 — Challenging behaviour and learning disabilities (2015, updated 2019)" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_forced_migration", + "cmd_alias": "migration_mh", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Mental health forced migration: PTSD, депрессия, психозы (Burger & Pogarell NEUROP)", + "tags": [ + "forced migration", + "беженцы", + "refugees", + "internally displaced", + "ВПО", + "украинский контекст", + "PTSD", + "депрессия", + "миграция", + "адаптация", + "language barrier", + "Burger", + "Pogarell", + "trauma" + ], + "related": [ + "alg_combat_ptsd_circuits", + "ptsd_checklist", + "combat_acute_reactions", + "drug_sertraline", + "drug_paroxetine", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Forced migration = особый клинический контекст: высокая частота травматизации, языковые/cultural barriers, неопределённость legal status, прерванный социальный support. ОЧЕНЬ актуально для Украины 2022+ (внутренне-перемещённые лица, refugees в Европе). NEUROP/Burger & Pogarell 2022 (p.4583).", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ЭПИДЕМИОЛОГИЯ:\n• Forced migration → 5-6× ↑ риск depression, PTSD, anxiety vs general population\n• PTSD: 30-40% в среди forcibly displaced (vs 7-9% в general)\n• MDD: 30-40%\n• Психотические эпизоды: ↑ риск 2-3×\n\nUKRAINIAN CONTEXT (2022+):\n• 6 миллионов internally displaced (UN OCHA 2024)\n• ~6 миллионов refugees в Europe\n• 2-летние данные: накопление мental health burden, ↓ access to specialized care\n• Гендерная specifics: 90% adult refugees в Europe — женщины (мужчины 18-60 — мобилизация-возможна)\n\nЧАСТЫЕ MENTAL HEALTH PRESENTATIONS:\n1. Acute Stress Reaction → PTSD (трехfaшний переход)\n2. Adjustment disorder с depression / anxiety\n3. Complex PTSD (sequential trauma + cultural displacement)\n4. Re-traumatization в host country (xenophobia, discrimination)\n5. Substance use disorders (как coping)\n6. Somatization — особенно где stigma вокруг mental illness\n7. Psychotic episode triggered by accumulated stress\n\nBARRIERS to care:\n• Language\n• Cultural concepts of distress (idioms — somatic vs psychiatric)\n• Stigma\n• Practical: housing, work, schools, legal — иerarchically приоритеtнее MH\n• Distrust of authority figures (включая medical) given trauma history\n• Limited interpreter availability\n• Health system not navigated by refugees" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "TIERED INTERVENTION (per NEUROP + WHO mhGAP):\n\nTIER 1 — basic services + protection:\n• Safe shelter, food, water, security\n• Family reunification\n• Legal status clarity\n• Без этого MH treatment effectiveness резко ↓\n\nTIER 2 — community + family supports:\n• Peer support groups\n• Community centers с trained facilitators\n• Cultural mediators\n• Faith-based supports\n\nTIER 3 — focused (non-specialized) supports:\n• Brief psychotherapy from trained non-specialists\n• Problem-solving therapy\n• Group interventions for common conditions\n\nTIER 4 — specialized services:\n• Trauma-focused therapy (EMDR, NET, CPT-trauma)\n• Pharmacotherapy для PTSD/MDD/psychosis\n• Specialized child/adolescent services\n• Acute psychiatry для эмерgencies\n\nPHARMACOTHERAPY — same as general PTSD/MDD with adjustments:\n\n• PTSD-related: sertraline 50-200 мг, paroxetine 20-50 мг (FDA approved)\n – Venlafaxine 75-225 мг — alternative if SSRI fail\n – Prazosin 1-15 мг для nightmares\n – Avoid BDZ (риск misuse + не помогают core PTSD; см. alg_combat_ptsd_circuits)\n\n• MDD: sertraline / fluoxetine — global accessibility data\n – Avoid drugs with complex titration или narrow window — поскольку follow-up может быть erratic\n\n• Psychosis: olanzapine, risperidone — broad accessibility\n – Long-acting injectables — useful если mobility / displacement makes daily compliance hard\n\n• ⚠ CULTURAL ADJUSTMENT:\n – Side effects (sexual dysfunction, weight gain) могут быть особенно distressing depending on culture\n – Disclose про ожидаемые SE — for compliance\n – Use formulations available в host country (avoid switching between brands мid-treatment)", + "neuro": "PRACTICAL ASPECTS:\n\nPSYCHO-EDUCATION:\n• \"This is a normal reaction to abnormal circumstances\"\n• Нормализация symptoms (sleep disturbance, hyperarousal, intrusions) — это не \"безумие\"\n• Когда необходимо специализированное лечение\n\nLANGUAGE:\n• Trained MH interpreters — preferred (vs random bilingual person)\n• Translated screening tools (PHQ-9, PCL-5, GAD-7) available для основных languages\n• Watch for language-loss as marker of trauma severity (especially children)\n\nCONTINUITY OF CARE:\n• Mobile-friendly tools (apps, telehealth)\n• Documentation that can be shared если patient relocates\n• Referral pathways в host country\n\nFAMILIES + CHILDREN:\n• Children especially vulnerable; intervene EARLY\n• Parents need their own support to support children\n• School-based screening + intervention — most cost-effective\n\nUkrainian-SPECIFIC RESOURCES (2024):\n• Друг.Друг (psychological help platform — created by Ukrainian psy professionals)\n• Lifelong (psychotherapy network)\n• МОЗ України psychological support hotline\n• \"How are you?\" national mental health initiative", + "tactic": "ОБЯЗАТЕЛЬНЫЕ ПРАКТИКИ ДЛЯ КЛИНИЦИСТА:\n\n1. SCREENING универсальный — каждый migrant patient:\n • PHQ-9 (depression)\n • PCL-5 (PTSD)\n • GAD-7 (anxiety)\n • SUD screen (AUDIT, DAST)\n • Suicide ideation\n\n2. TRAUMA-INFORMED CARE principles:\n • Safety первично\n • Choice — пациент имеет control over treatment decisions\n • Avoid re-traumatization (e.g. unnecessary detailed history)\n • Cultural humility\n\n3. КОЛЛАБОРАЦИЯ С СОЦИАЛЬНЫМИ службами — поскольку housing/legal/work issues often more acute than MH\n\n4. ⚠ DOCUMENTATION:\n • Может understanding быть нужна для asylum case — document trauma history accurately и compassionately\n • Consent для sharing — explicit\n\n5. SELF-CARE ДЛЯ КЛИНИЦИСТА:\n • Vicarious traumatization — risk при работе с trauma populations\n • Supervision, peer support\n\nCONTEXT FOR УКРАИНА 2024+:\n• Эта тема — приоритет для Ukrainian psychiatric profession\n• Многие colleagues themselves displaced or work с displaced patients\n• Continuing education: WHO mhGAP Humanitarian Intervention Guide, IASC MHPSS Guidelines" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Burger M., Pogarell O. Forced Migration and Mental Health Care. NEUROP 2022 (p.4583)", + "WHO mhGAP Humanitarian Intervention Guide (2015, updated 2024)", + "IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007)", + "UNHCR Operational Guidance: MH and Psychosocial Programming for Refugee Operations (2013)" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_eating_disorders", + "cmd_alias": "ed_pharma", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Расстройства пищевого поведения: фарма (Borges, Lewis, Bentley, Himmerich NEUROP 2022)", + "tags": [ + "eating disorders", + "анорексия", + "нервная анорексия", + "булимия", + "binge eating disorder", + "BED", + "ARFID", + "оланзапин", + "флуоксетин", + "лиздексамфетамин", + "topiramate", + "Borges", + "Himmerich" + ], + "related": [ + "drug_olanzapine", + "drug_fluoxetine", + "drug_lisdexamfetamine", + "drug_topiramate", + "pharma_tdm", + "pharma_receptors" + ], + "description": "EDs — расстройства с ВЫСОКОЙ medical mortality (анорексия — самая высокая смертность среди психиатрических расстройств). Pharma — adjunct к psychotherapy (CBT-E first-line для большинства EDs). NEUROP/Borges et al 2022 (p.4127).", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ЭПИДЕМИОЛОГИЯ:\n• Anorexia nervosa: 0.5-1% lifetime в женщин\n• Bulimia nervosa: 1-2% lifetime\n• Binge Eating Disorder (BED): 1-2.8% lifetime — most common ED\n• ARFID (Avoidant/Restrictive Food Intake Disorder): новая DSM-5 категория, prevalence неясно\n\n⚠ MEDICAL EMERGENCIES в EDs:\n• AN с BMI <13 — refeeding syndrome risk\n• AN с bradycardia <40, arrhythmias, ↓K+\n• BN с frequent purging — hypokalemia, esophagitis (Mallory-Weiss)\n• Все — bone density loss, cardiac arrhythmias, sudden death\n\nDIAGNOSTIC RECONSIDERATION:\n• EDs часто misdiagnosed как primary anxiety, depression, OCD\n• Comorbid anxiety/depression очень частые\n• Detective work — ask specifically about restriction, binge, purge, body image\n\nTREATMENT FRAMEWORK:\n• PSYCHOTHERAPY = primary treatment (CBT-E for most adults; FBT for adolescents)\n• Pharma = ADJUNCT, не replacement\n• Medical stabilization первая линия при severe AN\n• Multidisciplinary: psychiatrist + psychologist + dietitian + medical doctor (cardiology, endocrinology if needed)" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "PHARMA BY DIAGNOSIS:\n\nANOREXIA NERVOSA (AN):\n• ⚠ PHARMA EFFICACY LIMITED:\n – Большинство RCT — negative\n – Ни один FDA-approved\n – Olanzapine 2.5-10 мг — modest effect on weight gain в RCT (Attia 2019), но modest BMI ↑\n – SSRIs — НЕ помогают для core AN; ⚠ usual dose может быть toxic при low body weight\n – Mirtazapine 15-30 мг — может помочь sleep + appetite (off-label)\n – Avoid stimulants, bupropion (seizure risk + further weight loss)\n\n⚠ ANTIDEPRESSANTS NOT USEFUL FOR CORE AN, но may help comorbid depression POST-weight restoration\n\nBULIMIA NERVOSA (BN):\n• Fluoxetine 60 мг (FDA approved — UNIQUE among SSRI for BN):\n – ↓ binge frequency 50%\n – ↓ purge frequency\n – Higher dose than для MDD (60 vs 20-40)\n• Other SSRIs: sertraline, citalopram — limited data\n• ⚠ Avoid bupropion (seizure risk при БМ)\n• Topiramate 100-200 мг — 2-я линия (off-label) — также weight loss\n\nBINGE EATING DISORDER (BED):\n• Lisdexamfetamine 30-70 мг — FDA APPROVED for BED (2015) — UNIQUE\n – ↓ binge episodes\n – Modest weight loss\n – Schedule II controlled — abuse risk consideration\n• Topiramate 50-200 мг — alternative\n• SSRI (sertraline, fluoxetine) — modest effect, useful если comorbid MDD/anxiety\n\nARFID:\n• Limited data\n• Mirtazapine 15-30 мг — case reports for appetite stimulation\n• Cyproheptadine — antihistamine, appetite stim, off-label", + "neuro": "MEDICAL EMERGENCIES PHARMA:\n\nREFEEDING SYNDROME prevention (severe AN, BMI <14, very low intake):\n• Slow refeeding — start <500 kcal/day, ↑ slowly\n• Phosphate repletion — крitical (RFS = ↓PO4 → cardiac arrest)\n• Thiamine 200-300 мг/day × 5-7 дней\n• Magnesium, potassium — repletion\n• Daily electrolytes первая неделя\n• ECG monitoring\n\nHYPOKALEMIA в BN с purging:\n• KCl PO/IV repletion\n• Magnesium repletion\n• ECG monitoring\n• Address purging behavior\n\nBONE DENSITY LOSS:\n• Calcium 1500 мг/day\n• Vitamin D 2000-5000 IU\n• Estrogen replacement в women с amenorrhea — controversial (transdermal preferred)\n• Bisphosphonates — only if severe + post-weight restoration\n\nBOTH AN/BN — co-management:\n• Psychiatry + Internal medicine + Cardiology (если ECG abnormalities)\n• Endocrinology (osteoporosis, hypogonadism, hypothyroid)\n• Dental (BN — erosion от gastric acid)\n• Gastroenterology (BN — esophageal issues)", + "tactic": "ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ:\n\nДИАГНОСТИКА:\n• High suspicion в anyone с unexplained weight loss/gain\n• Screen всех пациентов с anxiety/depression for ED\n• EAT-26 (Eating Attitudes Test) — screening tool\n• SCOFF questionnaire — quick 5-item screen\n\nLEVEL OF CARE:\n• Outpatient: BMI >17.5, medical stable, motivation\n• Partial hospital: BMI 15-17.5, медицинская stability borderline\n• Inpatient psychiatric: behavioral compliance issues\n• Medical inpatient (priority): BMI <15, electrolyte abnormalities, cardiac instability, suicidality\n\n⚠ INVOLUNTARY FEEDING — медицинский, ethical, legal complex:\n• Justified в life-threatening situations\n• Capacity assessment important\n• Family involvement\n• In Ukraine — закон психіатричної допомоги § 16 — недобровільна госпіталізація possible\n\nPSYCHOTHERAPY referrals:\n• CBT-E для most adults — first-line evidence\n• FBT (Maudsley) для adolescent AN — first-line\n• DBT для comorbid BPD\n• Group support — useful adjunct\n\nFOLLOW-UP:\n• Weekly visits early\n• Monthly после stabilization\n• Long-term: 50% AN remit; 30% chronic; 20% severe persistent\n• BN recovery rates better — 70% recover\n• BED — depends on weight management long-term" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Borges K., Lewis Y.D., Bentley J., Himmerich H. Use of Antipsychotics in the Treatment of Eating Disorders. NEUROP 2022 (p.4127)", + "Attia E. et al. Olanzapine versus placebo in adult outpatients with AN (RCT). Am J Psychiatry 2019", + "McElroy S.L. et al. Lisdexamfetamine for BED. JAMA Psychiatry 2015", + "Walsh B.T. et al. Fluoxetine after weight restoration in AN. JAMA 2006" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, + { + "id": "special_sexual_disorders", + "cmd_alias": "sex_pharma", + "type": "matrix", + "category": "Фармакотерапия (Общее)", + "title": "Сексуальные расстройства: фарма (Malandain, Chagraoui, Thibaut NEUROP 2022)", + "tags": [ + "sexual disorders", + "эрек", + "disorder", + "HSDD", + "arousal", + "orgasm", + "сильденафил", + "tadalafil", + "флибансерин", + "bremelanotide", + "SSRI-induced", + "sexual dysfunction", + "Malandain", + "Thibaut" + ], + "related": [ + "drug_sertraline", + "drug_paroxetine", + "drug_fluoxetine", + "drug_bupropion", + "drug_mirtazapine", + "drug_vortioxetine", + "pharma_tdm", + "pharma_receptors" + ], + "description": "Сексуальные дисфункции — частые, often medication-induced, недостаточно обсуждаемые. NEUROP/Malandain et al (2022, p.4171). Включает: erectile dysfunction (ED), HSDD (Hypoactive Sexual Desire Disorder), premature ejaculation (PE), delayed orgasm, anorgasmia.", + "matrix": { + "past": [ + { + "title": "Контекст", + "desc": "ЭПИДЕМИОЛОГИЯ:\n• ED: ~50% мужчин 40-70 (mild + moderate + severe)\n• HSDD у женщин: 10% prevalence (уже устранены situational/relational причины)\n• ⚠ SSRI/SNRI-induced sexual dysfunction: 30-70%\n• Antipsychotic-induced sexual dysfunction: 30-60%\n\nFRAMEWORK:\n1. ⚠ ВСЕГДА first — exclude medical causes:\n • Cardiovascular (most common ED cause)\n • Endocrine (DM, hypogonadism, hyperprolactinemia)\n • Neurological\n • Medication-induced\n2. Psychological/relational\n3. Primary sexual disorder\n\nMEDICATION-INDUCED — частая, недо-обсуждаемая cause:\n• Любой serotonergic AD (SSRI, SNRI, clomipramine)\n• Большинство АП — через D2 (hyperprolactinemia) + пром others\n• BDZ — могут ↓ orgasm intensity\n• Bupropion — neutral or pro-sexual\n• Mirtazapine — neutral\n• Antihypertensives (β-blockers, thiazide diuretics)\n• Opioids — chronically depress libido\n• Alcohol" + } + ], + "current": { + "title": "Тактика и принципы", + "pheno": "PHARMA BY DIAGNOSIS:\n\nERECTILE DYSFUNCTION (ED):\n• PDE5 INHIBITORS — first-line:\n – Sildenafil (Viagra) 25-100 мг 1 ч до акта\n – Tadalafil (Cialis) 5-20 мг 30 мин-2 ч; либо 2.5-5 мг ежедневно (steady-state)\n – Vardenafil 5-20 мг\n – Avanafil 50-200 мг\n – ⚠ ⛔ С нитратами — fatal hypotension\n – ⚠ Caution с α-blockers\n – ⚠ NAION (rare visual loss)\n\n• 2-я линия:\n – Alprostadil intracavernosal или intraurethral\n – Vacuum erection devices\n – Penile prostheses\n\nHSDD у женщин premenopausal:\n• Flibanserin (Addyi) — FDA 2015 — multifunctional 5-HT modulator\n – Daily dosing 100 мг на ночь\n – ⚠ ⛔ С алкоголем — выраженная hypotension\n• Bremelanotide (Vyleesi) — FDA 2019 — melanocortin agonist\n – On-demand SC injection\n\n⚠ Both flibanserin/bremelanotide — controversial, modest effect size, side-effect issues\n\nPREMATURE EJACULATION (PE):\n• Dapoxetine — short-half-life SSRI, on-demand 30-60 мг 1-3 ч до акта (не FDA approved US, EU + many)\n• Off-label: paroxetine 10-20 мг daily; sertraline 25-100 мг; clomipramine 10-25 мг\n• Topical lidocaine/prilocaine cream\n• Tramadol — discouraged (potential abuse)\n\nDELAYED EJACULATION / ANORGASMIA (often SSRI-induced):\n• Switch к non-serotonergic (bupropion, mirtazapine, vortioxetine)\n• Drug holiday (если short T½ SSRI — risky discontinuation)\n• Bupropion 75-150 мг adjunct\n• Sildenafil — может помочь в некоторых случаях\n\nSSRI-INDUCED SEXUAL DYSFUNCTION:\n• Switch к agent с less SD: bupropion (best); mirtazapine; vortioxetine; agomelatine\n• Adjunct bupropion 75-150 мг\n• Adjunct sildenafil (PRN)\n• Drug holiday weekends (controversial)\n• \"Wait it out\" — can resolve спонтанно ~10-20% случаев\n\nANTIPSYCHOTIC-INDUCED SEXUAL DYSFUNCTION:\n• Switch к partial agonist (aripiprazole, cariprazine) — much less SD\n• ↓ Дозу если возможно\n• Cabergoline 0.5 мг 2× недель — для гипер-prolactinemia (but watch cardiac)", + "neuro": "ПОДХОД К ОЦЕНКЕ:\n\n1. CONTEXT:\n • Когда начались symptoms?\n • Связаны ли с медикаментозным начатием?\n • Partner-specific or general?\n • Morning erections present? (= organic vs psychogenic)\n\n2. MEDICAL workup:\n • Routine: glucose, lipids, testosterone (free + total), prolactin, TSH\n • If indicated: cardiology evaluation\n\n3. PSYCHOLOGICAL/RELATIONAL:\n • Couple counseling\n • Sex therapy referral\n\n4. MEDICATION REVIEW:\n • Critical look at all меds — много могут contribute\n • Consider switch если не essential\n\n5. ⚠ Discussion с пациентом — comfort culture-dependent:\n • Many cultures (incl. post-Soviet) — sexual topics taboo\n • Use proxies: \"How is your relationship?\", \"How are things at home?\"\n • Direct asking при rapport built\n\n6. CONFIDENTIALITY in couple settings — patient asks first what to discuss", + "tactic": "ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ:\n\n• ⚠ ASK ABOUT IT routinely — especially in MDD/anxiety/schizophrenia patients on meds\n• Many patients suffer silently — won't bring up unless asked\n• \"Are you having any sexual side effects from the medication?\" — direct, non-judgmental\n• Document discussion и offered solutions\n\nCAUTIONS:\n\n• PDE5 inhibitor + nitrates = potentially FATAL hypotension\n• PDE5 + α-blockers = hypotension, give time-separated\n• Flibanserin + alcohol = hypotension/syncope\n• Sexual medications через online pharmacies — often counterfeit; advise FDA-approved sources\n\nPATIENT EDUCATION:\n• ED очень medically common, особенно после 40\n• Many treatment options\n• Comorbid CV disease should be evaluated\n\n• HSDD often relational — couple work crucial\n• Hormonal therapy (testosterone supplementation в men; не universally в women) — controversial, careful selection\n\nFOR UKRAINE:\n• Sildenafil generic — accessible\n• Tadalafil generic — accessible\n• Other PDE5 — variable\n• Flibanserin/bremelanotide — limited availability\n• Stigma вокруг discussion — clinician initiative crucial" + }, + "future": [ + { + "title": "Практические рекомендации", + "desc": [ + "Malandain L., Chagraoui A., Thibaut F. Psychopharmacotherapy of Sexual Disorders. NEUROP 2022 (p.4171)", + "Maudsley Prescribing Guidelines — sexual dysfunction chapter" + ] + } + ] + }, + "lastUpdated": "2026-04-25", + "sources": [ + "Riederer P., Laux G. (eds.). NeuroPsychopharmacotherapy. Springer, 2022 — Part XIII Applied + Part XIV Implementation", + "Maudsley Prescribing Guidelines in Psychiatry, 14th ed.", + "Stahl S.M. Prescriber's Guide, 7th ed. (2021)" + ] + }, { "id": "pharma_receptors", "cmd_alias": "receptors",