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ерекше алавдаушылык тудырады. Кептеген колданыстагы усыныстарда кан куюдын шектеулi стратегиясы непз ретiнде кабылданады, ал дэлелдер децгеш темен болып калады. Кептеген зерттеушшер гемоглобин децгешнщ индикаторыныц жетiлмегендiгiн канныц куйылуыныц коздыргышы деп атап етл, ейткенi ол оттепнщ жеткiзiлуiн кажет етпейдi. М^ныц 6api анемия кезшде оттепнщ берiлуiн зерттеуге жэне осыган байланы -сты кан к¥юдыц тиiмдiлiгiне багытталган зерттеулердщ кажеттiлiгi мен мацыздылыгын керсетедi.
Клт свздер: цан цую, трансфузиялыц шектеу стратегиясы, трансфузиялыц либе-ралды стратегия, анемия.
MODERN BLOOD TRANSFUSION STRATEGIES
*A.A. Arynov, Zh.K. Chingisova, V.V. Chursin
Kazakh medical university of continuing education, Almaty
SUMMARY
This review article describes main studies about blood transfusion strategies. Most studies showed the clinical safety of restrictive transfusion strategy. However, in some studies a restrictive transfusion strategy increase the risk of mortality and complications, especially in patients with cardiovascular disease, neurosurgical patients. Most of current guidelines suggest restrictive strategy despite low quality of evidence. Many authors suggest that the use of hemoglobin transfusion thresholds may be an imperfect. Hemoglobin level does not reflect oxygen delivery. Further studies are required to research oxygen delivery in anemic patient and blood transfusion triggers.
Key words: blood transfusion, restrictive transfusion strategy, liberal transfusion strategy, anemia.
UDC: 615.099.036.2 DOI: 10.24411/1995-5871-2020-10090
THE CLINICAL CASE OF BIPOLAR DISORDER COMPLICATED BY THE SYNTHETIC
STIMULANT ADDICTION
*1 M.V. Prilutskaya, 1 A.R. Kerimbayeva, 2 E.M. Manarbekov
1 Pavlodar branch of Semey medical university, Pavlodar 2 NCJSC «Semey medical university», Semey
SUMMARY
Background: The profound addictive NPS effects have the potential to change the course of parallel mental pathology, causing additional risks for those patients who are on basic antidepressant and antipsychotic therapy.
*mariyapril2407@gmail com
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The aim of this paper is to obtain the preliminary insight into clinical cross talks between NPS addiction and endogenous affective disorders by describing a clinical case of NPS (synthetic stimulant) addiction associated with index bipolar disorder.
Results: The described clinical picture of mental abnormalities demonstrated the course of bipolar disorder Type II, which is distinguished by milder clinical features and by lower probability of developing a drug addiction. The course of stimulant addiction was marked with intensive craving symptoms and low adherence to a rehabilitation program. Bipolar disorder revealed precipitation of severe affective symptoms and medication resistance while co-existing with addiction pathology.
Discussion: The extreme toxic potency and immense variety of synthetic drugs in association with endogenous mental mediator disparities lead to the severe clinical symptoms that can hardly be predicted and assessed. The substance addiction influences the course of endogenous pathology diminishing medication compliance and changing the classic clinical affective symptoms.
Conclusions: The case highlights the fact that it is critical for psychiatrists, including those working with the drug addiction, to consider the challenges of double diagnoses especially in light of NPS emergence.
Key words: new psychoactive substances, addiction, bipolar disorder.
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Background. Drug addiction is a mental disorder that includes variable clinical symptoms and abnormalities. Behavioral problems and social disadaptation are the most prevalent and noticeable signs of addictive pathology. The crisis in personal and social life of an addict is reflected in problems at school and work, neglected appearance, money issues, while also being considerably exaggerated -among other factors - by stigma and comorbid mental disorders. According to the National Institute of Drug Abuse, multiple national population surveys in the U.S. have found that about half of those who experience a mental illness during their lives will also experience a substance use disorder and vice versa [1]. These mental health diagnoses include the following: generalized anxiety disorder, panic disorder, post-traumatic stress disorder, attention-deficit hyperactivity disorder, depression and bipolar disorder, antisocial personality disorder. The crosstalk between substance use and psychiatric comorbidity lies in common pathogenetic pathways, as well as exaggerated psychological vulnerability and social marginalization of people suffering from double diagnoses. As a result, clinical picture of the comorbidity can be complicated by symptom overlap and symptom fluctuations, where the primary agent or pathological cause is hard to identify.
Baldacchino and Corkery (2006) defined comobidity as "the presence or coexistence of additional diseases with reference to an initial diagnosis or to the index condition that is being examined" [2]. The Substance Abuse and Mental Health Services Administration (SAMSHA) uses the term "co-occurring disorders". The WHO specified drug addiction with parallel mental issues with the term "dual diagnosis" underlining the high frequency of co-occurrence and a range of pathogenetic commonalities.
The double-diagnosis includes two categories of clinical interactions: concurrent and successive ones. Against the backdrop of psychiatric disorders, substance use with the intention of self-medication can act as a mitigating factor in the development of primary mental issues. For instance, people with depression symptoms alleviate affective and cognitive symptoms by using amphetamine-type drugs [3, 4]. Meanwhile, the aggravating impact of substance use on basic mental problems is described in medical literature rather often and explicitly [5-7]. Every clinician who works with patients suffering from dual diagnosis is aware of a range of challenges raised by diagnostic, treatment and rehabilitation restrictions related to this category of patients. As an illustration, schizophrenic patients with psychotic
symptoms occurring after amphetamine intake can be ambiguously related to only one of the diagnostic clusters, unless a clinician comprehensively scrutinizes the history of symptom sequences and makes an assumption about a possible dual diagnosis [5].
Treatment strategies concerning substance use with mental disorders are limited by the lack of evidence-based recommendations and poor approaches toward rehabilitation for the group of patients in question. Increased treatment intensity is underlined as a general principle of clinical management by a wide range of concerned specialists and expert groups that develop standardized protocols and guidelines for dual diagnosis. While conceived as an umbrella term, the dual diagnosis poses challenges for the development of reliable tailored recommendations and practical steps due to the heterogeneity of the possible combinations of drugs and mental disparities.
The complications that distinguish the patients with dual diagnosis from those with monodiagnosis are poor treatment compliance, aggressive and violent behavior, frequent emergency room visits, psychotic episodes, suicidal thinking [8].
In this context, the emergence of novel psychoactive substances introduces new challenges for drug addiction specialists, especially for those working with dual diagnosis. The profound addictive NPS effects have the potential to change the course of parallel mental pathology, causing additional risks for those patients who are on basic antidepressant and antipsychotic therapy.
To the best of our knowledge, the literature data have mostly described the clinical cases and observational studies with acute clinical symptoms of NPS intoxications in patients with bipolar disorder [9]. Meanwhile, the information concerning the course of NPS addiction against the backdrop of bipolar affective pathology is sparse.
Given that, the aim of this paper is to obtain the preliminary insight into clinical cross talks between NPS addiction and endogenous affective disorders by describing a clinical case of NPS (synthetic stimulant) addiction
associated with index bipolar disorder.
Case presentation.
Presenting symptoms. A 33-year-old Russian man was admitted to a narcological hospital complaining about the urge to use the "skorost" synthetic stimulants, along with mood swings, irritability and poor appetite. The patient was a graduate psychologist that had been unemployed for the last 6 months. He was unmarried and lived with the parental family as a dependent. Having a 6-year history of psychiatric treatment for bipolar and schizoaffective disorders, he was referred to a rehabilitation program with symptoms of stimulant addiction for the first time in his life.
The history of life and the course of bipolar disorder. He had a premorbid personality of being introverted and melancholic, which has distinguished him from his peers since school years. The patient did not have history of any developmental delays and concerns, brain injury, and did not have a noteworthy trauma history. His family was unremarkable for psychiatric illness or substance use disorder. The patient described his parents as dominating and controlling, which, in his opinion, may have limited his autonomy and assertiveness. The first depressive episode with sadness, loss of energy, feelings of hopelessness or worthlessness, diminished interests and pleasure, psychomotor retardation, declined ability to think or concentrate was registered at the age of twenty. It had lasted two weeks and ceased after psychological support sessions without any medication interventions. The second depressive episode occurred after an 8-month intermission period without any preceding mental distresses and somatic abnormalities and was of a longer duration. The intensity of the episode was characterized with debilitated social interests, decreased ability to concentrate, think, or make decisions, and persistent anhedonia. Melancholic features were not exhibited within the given depression episode. An intense feeling of dullness and internal emptiness substantially marked the general self-perception and accounted for progressive social isolation and disadaptation. The 6-week episode was treated
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with Venlafaxine 75 mg within an outpatient program. Further depressive episodes were recorded every other year and associated with the patient's non-compliant attitude toward the basic antidepressant therapy.
As for 2014, the first hypomania symptoms emerged after regular depressive episodes. That time, the patient reported talkativeness, an increase in goal-directed activities that did not cause marked impairment in social functioning. The elevated productivity was expressed in the poetry writing, recreational drug experimenting and spiritual online forum surfing. The duration of hypomania was no longer than 7-9 days. In 2018, the patient experienced the deteriorated course of depressive episode, which included suicidal ideations and delusional thoughts about self-guilt and uselessness. The resistance and severity of affective symptoms resulted in the transformation of formal diagnosis newly formulated as schizoaffective disorder. Psychological distress (e.g. the breakup of a personal relationship) as well as first episodes of NPS use were associated with the intensification of endogenous pathology in question. The reduction of the symptoms was achieved with a combination of Amisulpride 100 mg and Fluvoxamine 50 mg under directly observed therapy (DOT) while patient was admitted for differential diagnoses to the Republican Center of Mental Health for a two-month course. Upon discharge, the mood remained to be stabilized with the same medication. Meanwhile, the development of synthetic stimulant addiction contributed to the progressive mental and social instability.
The history of drug addiction. The patient started using of substances (alcohol and tetrahydrocannabinoids on social occasions) at the age of 18 years. He described the episodes of cannabis intoxication as periods with substantial emotional elevation and visual hallucinations. At the time, he reported the use of cannabis with investigative motivation to broaden transpersonal awareness. Compared to cannabis, alcohol intoxications brought about relaxation and sedation and was not as preferable as marijuana. Upon the clinical manifestation of bipolar symptoms, the patient
stopped the experiments with cannabis when he noticed the aggravation of depression during the intoxications. He reported drinking alcohol on social occasions at a rate of two times a month with no more than three standard alcohol doses per episode.
At the age of 31, he was introduced to synthetic stimulants referred to as "skorost" at the initial dose of 0.03 grams. He rapidly moved to regular "skorost" use, showing a fast progression, from a monthly use to a day use in less than two months. He administered the drug by smoking and snorting. Being intoxicated, he exhibited psychotic symptoms with audial and visual hallucinations accompanied by inflated self-esteem or grandiosity. Notably, the mood elevation and the feeling of happiness during stimulant intoxications were of the highest intensity and had no subjective similarities with endogenous hypomania sensations previously experienced. The patient denied having any severe intoxication psychoses or somatic failures due to stimulants use. Three months after the onset of use, he noted the decrease in euphoric effects in parallel with the onset of craving symptoms. Although the strong desire to consume the drug dominated in the patient's motivational area in the form of thoughts, it was not followed by the loss of behavioral control and binge drug use. The episodes of intensive craving sensations preceded the acute exacerbation of endogenous depression with resistance toward antidepressants. In the year following the onset of stimulant use, the patient experienced recurrent switches of depressive and hypomaniac episodes and intensive delusional symptoms that warranted the changing of the diagnoses to schizoaffective disorder.
At the present hospitalization, the patient performed the craving symptoms with persistent thoughts and dreams about the drug intake. The patient's blood samples showed that his renal function test, lipid profile test, liver function test, and full blood count test conducted on the first day of hospital admission were within normal limits. We commenced the anticraving therapy with a combination of Carbamazepine 200 mg and cognitive-behavioral sessions. The basic antidepressant
course consisted of Fluvoxamine 50 mg every other day and Amisulpride 50 mg. The 45-day rehabilitation course demonstrated the persistence of craving symptoms giving limited insight into therapy compliance and his double-diagnosis. The patient demonstrated suspected adherence concerns insisting on several occasions that there was nothing wrong with him that would justify being treated alongside "alcoholics and opioid addicts". The patient was discharged after 45 days with the improvement in his clinical situation, including mood stabilization, reduction of craving for stimulants, and progress in social functioning. To date, the patient is considering applying for the position of volunteer psychologist at a public mental health center and attending individual cognitive and behavior therapy (CBT) sessions only for bipolar disorder.
Discussion. This report presents the case of synthetic stimulant addiction developed against the backdrop of bipolar disorder. Although the national regulation of diagnostic procedures recognizes only the frameworks of the International Statistical Classification of Diseases and Related Health Problems in the mental care sector, the criteria of Diagnostic and Statistical Manual of Mental Disorders enable more accurate diagnosis of bipolar disorder for the given patient. The described clinical picture of mental abnormalities demonstrated the course of bipolar disorder Type II, which is distinguished by milder clinical features and by lower probability of developing a drug addiction. According to Merikangas et al., the lifetime prevalence of any substance use disorder among individuals with bipolar I disorder amounted to 52 percent, and in bipolar II disorder to 37 percent [10]. In the described case, the onset of stimulant use was attributed to the conventional distress situation and did not have not any nonobvious relations to the affective episodes. In a patient like the one presented herein, the impact of bipolar disorder may have contributed substantially to the stress vulnerability [11].
The extreme toxic potency and immense variety of synthetic drugs in association with endogenous mental mediator disparities lead to the severe clinical symptoms that can
hardly be predicted and assessed. Describing the comorbidity between NPS use and mental disorders, an Italian multicenter-observational study ranked bipolar disorder as the most prevalent psychiatric diagnosis in patients with synthetic drug abuse [12]. Martinotti et al. provided this finding with two explanations. On the one hand, NPS as a trigger may precipitate affective psychiatric symptoms deteriorating the course of bipolar disease. On the other hand, NPS use may be a result of addiction vulnarability of bipolar persons, especially in light of unrestricted availability of synthetic drugs on the illegal markets [13]. The toxicological properties of a particular NPS group account for specific clinical symptoms that may affect the course of bipolar disorder. For instance, while psychotic symptoms are associated with the use of tryptamines, methylenedioxypyrovalerone (MDPV), methylphenidate, synthetic cannabinoid receptor agonists and amphetamine-type compounds [14,15], dopaminergic NPS (synthetic cathinones) contribute to the fast development of addictive symptoms with prolonged stimulation, insomnia, agitation [16].
In practice, synthetic stimulant addiction develops within a short time span (up to 4-6 months) of the onset. In the present case, we did not observe the pattern of high-risk "skorost" use, despite the persistently intensive craving symptoms. That finding can be attributed to the alleviating impact of the bipolar pathology. Meanwhile, the reported drug intoxications (e.g. stimulants and cannabinoids) were mostly accompanied by psychotic symptoms. The given features could be explained by two issues: (i) the cross-talks of abnormal mediator physiology in the event of the combination of drug addiction and endogenous disorder; (ii) the heterogenous effects of basic antidepressant medication on addiction syndromes and toxidromes [9].
The substance addiction influences the course of endogenous pathology, diminishing medication compliance and changing the classic clinical affective symptoms, which was distinctly traced in the history of our patient. The "skorost" exposure precipitated
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prolonged episodes of severe depression, which was misdiagnosed as schizoaffective disorder. According to the literature data, bipolar addicts are more at risk of the transition of bipolar type II to bipolar I. In parallel, mania and depression episodes could be intensified and expressed by mixed features (significant agitation, anxiety, or irritability). These implications are relevant to the described clinical case and may jeopardize the patient's chances of stable remission. Moreover, the clinical assessment and medication planning may pose additional challenges in the future due to the mixed affective symptoms of the dual nature. Alternative modes of therapy like mood stabilizers and antirelapse medication may be preferred in combination with outpatient CBT.
Conclusion. The case highlights the fact that it is critical for psychiatrists, including those working with the drug addiction, to consider the challenges of double diagnoses, especially with the advent of NPS. The new cohort of NPS patients is at a higher risk of poisonings and mental instability in comparison to those exposed to traditional drugs. Our clinical report outlines the need for the treatment standards and rehabilitation procedures to be customized for endogenous patients with concurrent NPS problems. Meanwhile, most of the reported clinical observations and described features warrant studies that identify the pathophysiological interactions and factors lying behind the double diagnosis of NPS addiction and bipolar disorder.
REFERENCES
1. Ross S., Peselow E. Co-occurring psychotic and addictive disorders: Neurobiology and diagnosis // Clinical Neuropharmacology. Clin Neuropharmacol, 2012. Vol. 35, № 5. P. 235-243.
2. Baldacchino A. et al. Epidemiological issues in comorbidity: Lessons learnt from a pan-European ISADORA project // Ment. Heal. Subst. Use Dual Diagnosis. Routledge , 2009. Vol. 2, № 2. P. 88-100.
3. Mclntyre R.S. et al. The Efficacy of Psychostimulants in Major Depressive Episodes // J. Clin. Psychopharmacol. Lippincott Williams and Wilkins, 2017. Vol. 37, № 4. P. 412-418.
4. Malhi G.S. et al. Stimulants for depression: On the up and up? // Australian and New Zealand Journal of Psychiatry. Taylor and Francis Ltd, 2016. Vol. 50, № 3. P. 203-207.
5. Rounsaville B.J. DSM-V Research Agenda: Substance Abuse/Psychosis Comorbidity // Schizophr. Bull. Oxford Academic, 2015. Vol. 41, № 2. P. 391-399.
6. Horsfall J. et al. Psychosocial treatments for people with co-occurring severe mental illnesses and substance use disorders (dual diagnosis): A review of empirical evidence // Harvard Review of Psychiatry. Harv Rev Psychiatry, 2009. Vol. 17, № 1. P. 24-34.
7. Lechner W. V. et al. The prevalence of substance use disorders and psychiatric disorders as a function of psychotic symptoms // Drug Alcohol Depend. Drug Alcohol Depend, 2013. Vol. 131, № 1-3. P. 78-84.
ci 8. Hryb K., Kirkhart R., Talbert R. A call for standardized definition of dual diagnosis. //
^ Psychiatry (Edgmont). Matrix Medical Communications, 2007. Vol. 4, № 9. P. 15-16. § 9. M Salloum lhsan. The Use of Synthetic Cathinones and Tryptamines in a Psychiatric
| Population // J. Forensic Toxicol. Pharmacol. OMICS Publishing Group, 2013. Vol. 02, № 02. ^ 10. Merikangas K.R. et al. Prevalence and correlates of bipolar spectrum disorder in the
World Mental Health Survey Initiative // Arch. Gen. Psychiatry. Arch Gen Psychiatry, 2011. as Vol. 68, № 3. P. 241-251.
| 11. Steen N.E. et al. Increased Systemic Cortisol Metabolism in Patients With Schizophrenia
and Bipolar Disorder // J. Clin. Psychiatry. Physicians Postgraduate Press Inc., 2011. Vol. 72,
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12. Acciavatti T. et al. Novel psychoactive substance consumption is more represented
in bipolar disorder than in psychotic disorders: A multicenter-observational study // Hum. Psychopharmacol. John Wiley and Sons Ltd, 2017. Vol. 32, № 3.
13. Martinotti G. et al. Novel Psychoactive Substances in Young Adults with and without Psychiatric Comorbidities // Biomed Res. Int. Hindawi Limited, 2014. Vol. 2014.
14. Vallersnes O.M. et al. Psychosis associated with acute recreational drug toxicity: A European case series // BMC Psychiatry. BioMed Central Ltd., 2016. Vol. 16, № 1.
15. Oluwabusi O.O. et al. Synthetic Cannabinoid-Induced Psychosis: Two Adolescent Cases // J. Child Adolesc. Psychopharmacol. Mary Ann Liebert, Inc. 140 Huguenot Street, 3rd Floor New Rochelle, NY 10801 USA , 2012. Vol. 22, № 5. P. 393-395.
16. Schifano F. et al. NPS: Medical consequences associated with their intake // Current Topics in Behavioral Neurosciences. Springer Verlag, 2017. Vol. 32. P. 351-380.
npu^Kaa M.B. https://orcid.org/0000-0002-9099-316X; SPIN 7582-3916
KepuMÖaeBa A.P. https://orcid.org/0000-0001-8926-3699
MaHapöeKOB E M. https://orcid.org/0000-0002-3662-3977
СИНТЕТИ КАЛЫК СТИМУЛЯТОРЛАРFА ТЭУЕЛД1Л1КТЕН ТУЫНДАFАН БИПОЛЯРЛЫ Б¥ЗЫЛЫСТЬЩ КЛИНИКАЛЫК,ЖАFДАЙЫ
*1 М.В. Прилуцкая, 1 Э.Р. Кер1мбаева, 2 Е.М. Манарбеков
1 КЕАК «Семей медицина Университет!» Павлодар филиалы, Павлодар ;-сы 2 КЕАК «Семей медицина университет», Семей к-сы
ТYЙIНДI
взектШгк Жаца психобелсендi заттардыц наркогендi эсерi антидепрессанттар-мен жэне антипсихотиктермен базалы; терапия кабылдайтын пациенттер Yшiн косымша кауш тугыза отырып, iлеспелi психикалы; патологияньщ агымын езгерту кабiлетiне ие
Зерттеудщ максаты: синтетикалы; стимуляторлар мен бастапкы биполярлык бузылуларга тэуелдшктщ клиникалы; жагдайын сипаттау аркылы жаца психоактивт заттарга жэне эндогендi аффективтi бузылуларга тэуелдшк арасындагы алгашкы езара эрекеттесу процессш тYсiнуге кол жеткiзу.
Нэтижелерк Психикалы; бузылулардыц усынылган керiнiсi клиникалык симптомдардыц жецшдНмен жэне химиялы; тэуелдшктщ дамуыныц темен керсеткiшiмен ерекшеленедi жэне екiншi тYPдегi биполярлы; бузылудыц дамуына сэйкес келдг Стимуляторларга тэуелдiлiк каркынды патологиялы; эуестенумен жэне оцалту багдарламасына бешмдшктщ темендiгiмен ;атар жYредi. Тэуелдi биполярлы; бузылу ^ аффективтi белгшердщ ауырлыгына жэне дэрiлiк терапияга тезiмдiлiкке ие болды.
Талкылау: Белсендi уландыргыш пен кептеген жаца психобелсендi заттардыц ^ эндогендiк патологиямен Yйлесуi ай;ын клиникалы; белгiлердiц пайда болуына * экеледi. Ал оныц барысы мен нэтижесiн болжау ;иын. Химиялы; тэуелдшк эндогендш ^ патологияныц агымына эсер етед^ сэйкестiктi темендетедi жэне аффективт бузылу ^ белгiлерiн езгертедi. а
^орытындылар: ¥сынылган жагдай ;ос диагнозбен жумыс жасайтын « наркологтарга бiрiктiрiлген патологияныц клиникалы; сын-катерлерiн назарга алу жэне | талдау Yшiн, эаресе жаца психобелсендi заттардыц пайда болу жагдайында мацызы зор ^ екенш атап керсетедi. §
КЫт свздер: психобелсендг заттар, тэуелдшк, биполярлыц бузылыс.
МЕДИЦИНСКИЙ УНИВЕРСИТЕТ НЕПРЕРЫВНОГО ОБРАЗОВАНИЯ
КЛИНИЧЕСКИЙ СЛУЧАЙ БИПОЛЯРНОГО РАССТРОЙСТВА, ОСЛОЖНЕННОГО ЗАВИСИМОСТЬЮ ОТ СИНТЕТИЧЕСКИХ СТИМУЛЯТОРОВ
41 М.В. Прилуцкая, 1А.Р. Керимбаева, 2 Е.М. Манарбеков
1 Павлодарский филиал НАО «Медицинский университет Семей», г. Павлодар 2 НАО «Медицинский университет Семей», г. Семей
АННОТАЦИЯ
Актуальность: Значительный наркогенный эффект новых психоактивных веществ (НПВ) обладает способностью изменять течение сопутствующей психической патологии, создавая дополнительные риски для пациентов, принимающих базовую терапию антидепрессантами и антипсихотиками.
Цель настоящего исследования: достигнуть первичного понимания взаимодействия между зависимостью от НПВ и эндогенными аффективными расстройствами путём описания клинического случая сочетания зависимости от синтетических стимуляторов и первичного биполярного расстройства.
Результаты: Представленная картина психических расстройств соответствовала развитию биполярного расстройства второго типа, которое отличается мягкостью клинических симптомов и более низкой вероятностью развития химической зависимости. Течение зависимости от стимуляторов сопровождалось интенсивным патологическим влечением и низкой приверженностью реабилитационной программе. Биполярное расстройство под воздействием зависимости имело значительную тяжесть аффективных симптомов и устойчивость к медикаментозной терапии.
Обсуждение: Выраженная токсичность и большое разнообразие НПВ в ассоциации с эндогенной патологией приводит к появлению выраженных клинических симптомов, течение и исход которых достаточно сложно предсказать. Химическая зависимость влияет на течение эндогенной патологии снижая комплаенс и изменяя клинику аффективных нарушений.
Выводы: Представленный случай подчёркивает важность для наркологов, работающих с двойными диагнозами, принимать во внимание и анализировать клинические вызовы сочетанной патологии, особенно в свете появления НПВ.
Ключевые слова: новые психоактивные вещества, зависимость, биполярное расстройство.
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