General Principles of Mental Disorder Treatment

Evolution of treatment approaches

Before the onset of the 20th century, endogenous diseases were practically untreatable, and psychotherapy remained the main effective method. A famous historical example is the successful treatment of the composer S.V. Rachmaninoff's depression by Dr. N.V. Dahl in 1900.

A breakthrough occurred in the past century thanks to the development of general biological approaches and the introduction of psychopharmacotherapy. This radically changed the appearance of psychiatric hospitals and initiated the widespread development of outpatient care. While the first drugs caused severe side effects that limited social adaptation, the agents introduced in the final decades of the 20th century made it possible to conduct safe, long-term preventative treatment.

Insulin Coma Therapy (ICT)

The method was proposed by M. Sakel, who had been studying the effects of insulin on mental disorders since 1927. Initially, it was hypothesized that the induced seizures were the therapeutic factor, but it was later discovered that the therapeutic effect is produced by profound hypoglycemia itself.

There are two main ways to administer ICT:

• Traditional: the drug is administered subcutaneously. The dosage is smoothly increased from 4 IU to 40–100 IU. Coma develops slowly, usually within 10–20 days. A standard course includes 25–30 comas.
• Forced: methodology of the Moscow Research Institute of Psychiatry. Insulin is administered intravenously via drip infusion, allowing the comatose state to be achieved as early as the first day.

To abort the state, a glucose solution is administered intravenously to the patient, and after regaining consciousness, they are given sweet syrup and a carbohydrate-rich breakfast. It is strictly forbidden to use prolonged-release forms of insulin.

Contraindications include severe cardiovascular pathologies, malignant tumors, diabetes mellitus, peptic ulcer disease in the acute stage, and pregnancy. Today, the method is used extremely rarely and, in accordance with the laws of the Russian Federation, requires the patient's strict written consent.

Electroconvulsive Therapy (ECT)

The method was first used in 1938 by U. Cerletti and L. Bini. Today, ECT is recognized as one of the safest and most effective options for aborting acute states. The procedure is performed using modern brief-pulse devices with the mandatory use of anesthesia and muscle relaxants (suxamethonium iodide).

Electrode placement options:

1. Bilateral: characterized by higher efficacy and a lower total electrical dose, but increases the risk of temporary cognitive impairment (since the effective dose exceeds the threshold by only 1.5–2.5 times).
2. Unilateral: considered a safer approach, but somewhat inferior in efficacy.

ECT is indicated for severe endogenous depressions, febrile catatonia, and drug resistance. Pregnancy (in a physiological course) is not a contraindication. Criteria for an ineffective session include weak tonic contractions, seizure duration of less than 18 seconds, heart rate below 120 beats per minute, and unclear suppression of EEG activity.

Other Non-Pharmacological Methods

In addition to ICT and ECT, other general biological methods are used in modern practice:

• Extracorporeal detoxification methods: based on the hypothesis regarding the role of toxins in the development of psychosis. Hemodialysis has proven to be of low efficacy, but hemosorption and plasmapheresis work well in acute endogenous psychoses with catatonic or affective-delusional symptoms. Laser blood irradiation can serve as an alternative.
• Pynotherapy: administration of pyrogenal stimulates the body's reactivity. It helps with neuroleptic resistance in schizophrenia patients and for managing withdrawal symptoms in alcoholism.
• Sleep deprivation: sleep restriction (complete for one night or reduced to 3–4 hours) is used as an adjunct to antidepressants in the treatment of depression.
• Light therapy: exposure to intensive light (from 2500 lux) is indicated for seasonal winter depressions, most commonly seen in women aged 30–50.

Class and exam questions

What else to study on this topic

• History of the introduction of key drug groups (neuroleptics, antidepressants, lithium salts).
• Complications of insulin coma therapy: epileptiform seizures and prolonged coma.
• Criteria for evaluating seizure efficacy in electroconvulsive therapy (EEG and ECG data).
• Mechanisms of action of sleep deprivation and risks of exacerbation in delusional psychoses.

Other topics in "Chapter 17. Therapy of Mental Disorders. Basic Principles of Prevention and Rehabilitation"

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