5 P sy c h ia t r y issN 2413-6077. iJMMr 2017 Vol. 3 issue 1 International Journal of Medicine and Medical Research 2017, Volume 3, Issue 1, p. 5–10 copyright © 2017, TSMU, All Rights Reserved Corresponding author: Olena Venger, Department of Neurol- ogy, Psychiatry, Narcology and Medical Psychology, I. Hor- bachevsky Ternopil State Medical University, 1 Maidan Voli, Ternopil, Ukraine, 46001 Phone number: +380352435774 E-mail: venger_ol@tdmu.edu.ua O. P. Venger et al. dOI 10.11603/IJMMR.2413-6077.2017.1.7039 ImPROVEmENT IN ThE APPROAchEs TO ThE TREATmENT Of EmIGRANTs ANd RE-EmIGRANTs WITh dEPREssIVE dIsORdERs O. P. Venger, Y. I. Mysula, L. V. Shkrobot I. HORBACHEVSKY TERNOPIL STATE MEDICAL UNIVERSITY, TERNOPIL, UKRAINE Background. Social and clinical relevance of emigration and re-emigration is determined by a significant amount of Ukrainians that emigrate and re-emigrate. Clinical features of depressive disorders have not been studied;as well as risk factors and antiriscs of various forms of depression have not been established yet. Development of comprehensive approaches to the treatment and rehabilitation of these patients is an effective way of resolving of this problem and is of significant scientific, practical, medical and social importance. Objective. The development of measures for treatment of depressive disorders in emigrants and re-emigrants is based on investigation and analysis of clinical-psychopathological phenomenology of depression. Methods. We examined 196 emigrants, 191 re-emigrants and 198 not emmigrants with final clinical diagnosis of depressive disorder according to ICD-10 criteria. Examination was conducted by means of depression rate according to M. Hamilton, the Montgomery-Asberg and Symptom Checklist-90-Revised and the scale of life quality by WHO QOL-26. Statistical analysis of the results was performed using nonparametric methods: Mann-Whitney test, Wilcoxon criterion of signs. Results. It was found that the maximum content of organic acids is accumulated in grass Hyssopus officinalis L. (Lamiaceae), and the minimal is in the leaves of Chrysánthemum xhortorum L. variety Apro (Asteraceae). The dominance of aliphatic acids was determined by means of gas chromatography. Benzoic is predominant among aromatic acids. Conclusions. The suggested therapy schemes proved higher effectiveness compared with the traditional one, and also allowed to improve the life quality of emigrants and re-emigrants. KEy wORDS: depressive disorders; emigrants; re-emigrants; clinical-psychopathological features. Introduction Emigration and re-emigration is one of the most important and actual public and social matter. The number of Ukrainian emmigrants is estimated up to 6.5–7 million people, what is about 15% of the population, and tends to in- crea se [7]. Re-emigration (coming back of emigrants) is independent medical and social problem; its amounts are comparable with mig- ration. Migration is a traumatic factor, provoking manifestation and exacerbation of endogenous mental disorders [1]. In the structure of perso- nality changes in emigrants, emotional instabi- lity, anxiety, social introversion, behavioral conformity, suspicion, poor integration of per- so nality traits as emotivity and frustration, low level of frustrational tolerance are detected. Among mental disorders associated with emi- gra tion, psyhodisadaptative states, post- traumatic stress disorder, neurasthenia, pro lon- ged depressive reaction and moderate de- pressive episode are the most common. however, despite the significance of the problem of emigration and re-emigration important issues related to the course of de- pressive disorders in emigrants and re-emi- grants are have not been studied, treatment- rehabilitation programs have not been deve- loped and implemented for emigrants and re-emigrants with depressive disorders. The aim of the study is the development and improvement of measures for treatment of de- pres sive disorders in emigrants and re-emigrants due to investigation and analysis of clinical-psy- chopathological phenomenology of depression. Methods We examined 196 persons who for at least one last year lived outside Ukraine and planned to return abroad soon (emigrants); and 191 persons who at least a year lived outside Ukrai- 6 P sy c h ia t r y issN 2413-6077. iJMMr 2017 Vol. 3 issue 1O. P. Venger et al. ne and over the last year have returned for permanent residence in Ukraine (re-emigrants). Also we included 198 persons which were permanently living in the Ukraine, and never traveled abroad for long stay (not emmigrants). All of the patients were treated in the Ternopil Regional Municipal Clinical Psychoneurological Hospital for the period from 2010–2014 years, with established final clinical diagnosis of depressive disorder according to ICD-10 cri teria. Psychogenic depressive disorder (ICD-10 codes F43.21 and F43.22) was established in 69 of not emigrants, 68 of emigrants and 67 re-emigrants, endogenous (ICD-10 codes F31.3, F31.4, F32.1, F32. 2, F33.1 and F33.2) – in 65, 66 and 63 persons accordingly, organic (ICD-10 code F06.3) – in 64, 62 and 61 people accordingly. Examination was conducted by means of depression rate accor- ding to M. Hamilton [8], the Montgomery- Asberg [9] and questionnaire of psychopatho- logical symptoms severity Symptom Checklist- 90-Revised [10] and the scale of life quality by WHO QOL-26. Statistical analysis of the results was performed by non parametric methods: Mann-Whitney test, Wilco xon a criterion of signs. Results The determined in our study clinical-psy cho- pathological and patopersonal changes in emigrants and re-emigrants prove the necessity of improvement of psychiatric help for this group of patients. Today in Ukraine the absence of targeted treatment and rehabilitation pro- grams for re-emigrants and emigrants deter- mines the necessity of development of funda_ mental principles, aims and approaches to the treatment of depressive disorders in these patients. Considering the clinical-psychopathological and patopersonological features evidenced during the examination of the emigrants and re-emigrants with depressive disorders of different genesis, we recommended the follo- wing schemes of medicational therapy and psychotherapy. The suggested scheme of treatment and rehabilitation due to the principles of an inte- grated, individual and differentiated approach, ensure the staging and continuity of treatment and rehabilitation. Its objectives defined as more rapid elimination of depressive disorders (depression, anxiety-depressive, asthe nic-de- pressive, apatho-depressive syndromes), maxi- mal recovery and social functioning of patients, prevention of recurrence of depressive disor- ders, providing early socia lization and social adaptation considering the features found in the emigrants and re-emi grants, engaging families and public organi zations. Clinical features of depressive disorders (depressed mood, anhedonia, fatigue, anxiety, agitation, etc.), social desadaptation and disor ders of microsocial interaction, abnormal beha vioral patterns associated with the presence of de- pres sive disorders, as well as factors of emig- ration and re-emigration were defined as the- rapy goals. The suggested scheme was realized in four stages that consisted of succession and con- tinuity of treatment and diagnostic measures. the first stage – diagnostical – included clinical psychopathological assessment of disorders that were evidenced in the patient’s psycho- emotional sphere, analysis of anamnesis, clinical symptoms, dynamics and prognosis of the disease, the relationship of clinical and psycho- social factors. The second stage – complex treatment – included a compound of biological therapy and psychotherapy aimed to relieve depressive disorder, normalization of emotional state, social adaptation and readap tation. Antidepressant therapy at this stage included prescription of agomelatine in a daily dose of 25 mg for the emigrants suffering from psycho- genic depressive disorders, for the patients with endogenous depressive disorders – quetiapin in a daily dose of 200 mg, for the emigrants with depressive disorders of organic genesis – fluo- xe tinein a daily dose of 20 mg, for the re-emi- grants with psychogenic depressive disorders – mirtazapine in a daily dose of 30 mg, for the re-emigrants with endogenous depressive disorders – combination of fluoxetine and rispe- ridone in a daily dose of 20 mg and 2 mg accordingly, for the re-emigrants with depressive disorders of organic genesis – fluoxetine in daily dose of 20 mg. Differentiated psychotherapeutic correction for the emigrants included rational use of psychotherapy, cog nitive behavioral therapy and group psycho therapy, and for the emigrants suffering from psychogenic de pres- sive disorder – also psyho educational therapy. Psychotherapeutic inter ven tions for the re- emigrants consisted of rational, family, cogni- tive-behavioral therapy; the focus was on working with the automatic thoughts and dysfunctional beliefs. The crite rion of treatment efficacy was stable (at least two weeks) norma- lization of emotional state, disappearance of clinical signs of depressive disorder, working out adequate emotional response to real-life circumstances, including emigration (re-emi- 7 P sy c h ia t r y issN 2413-6077. iJMMr 2017 Vol. 3 issue 1 O. P. Venger et al. gra tion), disactualization of destructive and formation of constructive pat terns of behavior. The third stage – rehabilita tion – aimed at forming stable adequate emo tional-behavioral pattern, maximum adaptation and readaptation of a patient, preventing of depressive disorder relapse, while medicamental therapy was similar to that used during the treatment with the appropriate dosage correc tion due to the actual condition of the patient. Differentiated psychotherapeutic work included the use of cognitive-behavioral therapy for the emigrants, and a combination of cognitive-behavioral therapy, family therapy and auto genous training for the re-emigrants. At this stage, also the measures for rehabilitation and social reintegration of the patients were also useful. The fourth stage – preventive – aimed at main- taining of normal emotional state, effective stress resistance and prevention of depressive disorder recurrence. Medical thera py included treatment of primary disease in cases of depres- sive disorders of organic gene sis and seasonal prevention of depressions of endogenous cha- racter and psychotherapy – techniques of self- regulation, and measures for social adaptation. Comparison analysis of effectiveness was conducted in three main directions: 1. Dynamics of mental state (recovery, significant impro- vement of mental state, improvement of mental state, lack of dynamics of mental state, worse- ning of mental state). 2. Dynamics of pathological manifestations severity according to psycho- metric scales. 3. Dynamics of life quality rate during the treatment. Reassessment performed 6 months after the beginning of the treatment. to evaluate the effictiveness of the sugges- ted treatment, regimens were divided into 6 major groups due to the emigrants and re- emigrants suffering from psychogenic, endo- genous and organic depressive disorders, receiving the suggested treatment and 6 similar in all clinical and social characteristics compa- rison groups. Comparison of the results was conducted in pairs of each clinical group due to the clinical variant and genesis of depressive disorder. Comparing analyzes of effectiveness was conducted in three main directions: dyna- mics of mental state, dynamics of pathological manifestations severity according to psycho- metric rate and dynamics of life quality during treatment. Assessment of mental state dynamics as a result of the conducted therapy proved signifi- cantly higher efficiency of the offered scheme of treatment compared to the traditional one (Fig. 1). In the main group higher quality of treat- ment was achieved: in the group of the emi- grants suffering from psychogenic depressive disorders in 81.2% of the patients clinical recovery, in 9.4% – a significant improvement, in 6.3% – improvement, no dynamics was detec- ted in one patient (3.1%), cases of reverse dyna- mics of depressive disorders under the influen- ce of treatment were not found, while in the control group of patients clinical recovery was achieved in 42.4% of cases, significant impro- vement – in 33.3%, improvement – in 15.2%, no changes – in 6.1%, and in one case (3.0%) in verse dynamics (p<0.05) was evidenced. In the emigrants with endogenous depressive disor- der, who received the suggested scheme of treatment, clinical recovery was achieved in 59.3% of cases, significant improvement – in 21.9%, improvement – in 12.5%, lack of dyna- mics – in 6.3%, in the group of patients receiving traditional therapy clinical recovery was achi- eved in 24.2%, a significant improvement and improvement – in 27.3%, no dynamics was detected in 18.2%, worsening of state – in one case (3.0%) (p<0.05). In the group of emmigrants with depressive disorders of organic genesis, clinical recovery was achieved in 36.6%, a signi- Fig. 1. Comparison of the results of traditional and suggested treatment schemes for the emmigrants, patients with depressive disorders. 8 P sy c h ia t r y issN 2413-6077. iJMMr 2017 Vol. 3 issue 1O. P. Venger et al. ficant improvement – in 40.0%, improvement – in 16.7%, lack of dynamics – in 6.7%, in the comparison group clinical recovery was found in 19.3%, a significant improvement – in 19.3%, improvement – in 32.3%, no explicit dynamics – in 22.6%, worsening of state – in 6.5% (p<0.05). In the re-emigrants with depressive disor- ders higher effectiveness of the suggested scheme was also proved (Fig. 2). In the re-emigrants suffering from psycho- genic depressive disorder treated by the sug- ges ted scheme, clinical recovery was achieved in 71.0% of cases, significant improvement – in 16.1%, improvement – in 9.7%, the lack of dyna- mics occurred in one case (3.2%), the inver se dynamics was not detected, and there-emi- grants with psychogenic depressive disorders who received conventional therapy achieved clinical recovery in 32.2%, a significant impro- vement – in 35.5%, improvement – in 22.6%, no dynamics was detected in 6.5%, inverse dyna- mics – in 3.2% of the patients (p<0.05). In the re-emigrants with endogenous depressive dis- or ders, treated by traditional therapy, clinical recovery was achieved in 51.5% of cases, signi- ficant improvement – in 22.6%, impro vement – in 19.4%, no dynamics was detected in 6.5% of the patients. After the treatment by the sugges- ted clinical therapy, recovery and significant improvement occurred in 19.3%, improvement – in 42.0%, lack of dynamics – in 12.9%, inverse dynamics – in 6.5% of the patients (p<0.05). In the re-emigrants with depressive disorders of organic genesis, the suggested scheme has lead to clinical recovery in 33.3%, a significant improvement – in 36.7%, improvement – in 20.0%, no dynamics was detected in 10.0%, and in the comparison group of clinical recovery occurred in 13.3%, a significant improvement – 20.0%, improvement – in 40.0%, lack of dyna- mics – in 16.7%, state worsening – in 10.0% of the patients (p<0.05). Discussion Due to the the intended aim and objectives of our study the analisis of the received results made it possible to justify the treatment and rehabilitation programs for the emigrant and re-emigrant patients with depressive disorders. Considering the features of depressive disor- ders in these groups of patients and lack of information on the developed approaches to treatment and rehabilitation, we suggested new therapeutic schemes. Therefore, we invite you to the discussion of scientific research that proved positive results. Analysis of quantitative indices by scale of depression according to M. Hamilton also confirmed significantly higher efficiency of the suggested scheme for both the emigrant and re-emigrant patients with psychogenic, endoge- nous and organic depressive disorders. So, the suggested scheme of therapy for the emigrants suffering from psychogenic depres- sive disorder was significantly more effective against depressed mood, guilt, suici dal inten- tions, early, middle and late insomnia, working capacity and activity, retardation, agitation, mental anxiety, somatic symptoms, genital symptoms and hypochondria. The suggested scheme also promoted to significant decrease of the overall rate of depression and indicators of adynamic, agitated depression, depression with fear and undifferentiated depression. The suggested scheme of treatment en- abled achievement of significantly improved indexes of main subrates of M. Hamilton de- pression scale in the emigrants with endogenous depressive disorders. Significant differences were detected by comparison of the indexes after reasonable treatment of depressed mood, guilt, early, middle and late insomnia, working capacity and activity, retardation, agitation, men tal anxiety, somatic symptoms and hypo- chondria, as well as general indicators of de- Fig. 2. Comparison of the results of traditional and suggested treatment schemes for the re-emigrants with depressive disorders. 9 P sy c h ia t r y issN 2413-6077. iJMMr 2017 Vol. 3 issue 1 O. P. Venger et al. pression, indexes of adynamic, agitated depres- sion, depression with fear and undifferentiated depression. For the emigrants suffering from depressive disorders of organic genesis, the suggested scheme of treatment was significantly more effective against depressed mood, guilt, su icidal intentions, early, middle and late insomnia, working capacity and activity, retardation, agitation, mental anxiety, somatic symptoms, genital symptoms and hypochondria, as well as general indicators of depression, indexes of adynamic, agitated depression, depression with fear and undifferentiated depression. The suggested scheme of treatment also allowed decreasing anxiety in the re-emigrants and the emigrants with depressive disorders of different genesis. For the emigrants suffering from psycho genic depressive disorders, the suggested scheme was significantly more effective against an xious mood, tension, anxiety, insomnia, de pres sed mood, muscle somatic symptoms, somatic sensory symptoms, cardiovascular symptoms, respiratory symptoms, hastro intestional symp- toms, autonomic symptoms, as well as general severity of psychic and somatic anxiety. For the emigrants with endogenous de- pressive disorder, the suggested scheme was significantly more effective against anxious mood, tension, insomnia, depressed mood, muscle somatic symptoms, somatic sensory symptoms, cardiovascular symptoms, respira- tory symptoms, vegetative symptoms, as well as general severity of psychic and somatic anxiety. For the emigrants suffering from depressive disorders of organic nature, the suggested scheme was significantly more effective against anxious mood, tension, anxiety, insomnia, depressed mood, muscle somatic symptoms, cardiovascular symptoms, respiratory symp- toms, vegetative symptoms, as well as general severity of psychic and somatic anxiety. in the re-emigrants the positive influence of the suggested scheme was evidenced. Thus, for the re-emigrants suffering from psychogenic depressive disorder, the suggested scheme was more effective against anxious mood, tension, anxiety, insomnia, cognitive disorders, depres- sed mood, muscle somatic symptoms, somatic sensory symptoms, cardiovascular symptoms, respiratory symptoms, gastrointestinal symp- toms, vegetative symptoms, as well as general severity of psychic and somatic anxiety. The suggested scheme of treatment for the re-emigrants with endogenous depressive disorder, was more effective against anxious mood, tension, anxiety, insomnia, cognitive disorders, depressed mood, muscle somatic symptoms, somatic sensory symptoms, cardio- vascular symptoms, respiratory symptoms, gastrointestinal symptoms, vegetative symp- toms, as well as the general severity of psychic and somatic anxiety. For the re-emigrants with depressive dis- orders of organic genesis, the suffested scheme significantly improved the rate of anxious mood, anxiety, insomnia, muscle somatic symp toms, somatic sensory symptoms, cardiovascular symptoms, respiratory symptoms, gastroin- testinal symptoms and severity of psychic and somatic anxiety. the influence of the suggested therapy on the severity of psychopathological symptoms was also more effective compared to the traditional one. For the emigrants suffering from psycho- genic depressive disorders, the suggested scheme proved significantly better results in the rate of somatization, obsessive-compulsive disorders, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety and general indicator (index GSI), the index of symptoms detecting (PSI) and index of distress severity (PDSI). For the emigrants suffering from depressive disorders of organic genesis, the suggested scheme was proved effectiveness in the rate of of somatization, obsessive-compulsive disor- ders, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety and general indicator (index GSI), the index of symptoms detecting (PSI) and index of distress severity (PDSI). In the patients with depressive disorders of different genesis significantly better rates of psychopathological symptoms severity influ- enced by the suggested scheme of therapy were achieved. Thus, the re-emigrants suffering from psychogenic depressive disorders, treated by the suggested scheme achieved more pronoun- ced decrease in the rates of somatization, obsessive-compulsive disorders, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety and general indicator (index GSI), the index of symptoms detecting (PSI) and index of distress severity (PDSI). For the re-emigrants with endogenous depressive disorders, the suggested therapy scheme promoted to more effective decrease in the rates of somatization, obsessive-compul- 10 P sy c h ia t r y issN 2413-6077. iJMMr 2017 Vol. 3 issue 1 sive disorders, interpersonal sensitivity, de- pression, anxiety, hostility, phobic anxiety and general indicator (index GSI), the index of symptoms detecting (PSI) and index of distress severity (PDSI). For the re-emigrants with depressive disor- ders of organic genesis, the suggested treat- ment scheme was more effective for decrease in rates of somatization, obsessive-compulsive disorders, interpersonal sensitivity, anxiety, hostility, phobic anxiety and general indicator (index GSI), the index of symptoms detecting (PSI) and index of distress severity (PDSI). Significant improvement in quality of life during the treatment is an important factor that positively assesses the perspectives of imple- men tation of the suggested treatment re- gimens. Thus, in the group of emigrants suffering from psychogenic depressive disorders, the suggested scheme promoted to achievement of significant improvement of physical health and psychological QOL. For the emigrants with endogenous de- pressive disorders, the use of the suggested scheme of therapy promoted to improvement of QOL in physical health, psychological QOL and environment. For the emigrants suffering from depressive disorders of organic genesis, the suggested scheme was more effective in improvement of QOL in physical health and psychological QOL. The improvement of QOL during the treat- ment by the suggested scheme was also achie- ved in the re-emigrants. Thus, in the re-emi- grants with psychogenic depressive disor ders, significantly higher QOl of physical health and psychological QOL were defined, in the re- emigrants with endogenous depressive disor- ders – of QOL in physical health, psycho logical QOL and environment, in the re-emigrants with depressive disorders of organic origins – of QOL in physical health, psychological QOL and envi- ronment. Thus, the comparative analysis of the suggested treatment schemes for the emigrants and re-emigrants suffering from psychogenic, endogenous and organic depressive disorder proved significantly higher effectiveness com- paring with traditional one. Conclusions the analysis of the influence of the suggeste therapy schemes on the severity of psycho- pathological symptoms also proved higher effectiveness compared with the traditional one; it was evidenced by significant decrease in the rate of somatization, obsessive-compul sive disorders, interpersonal sensitivity, de pression, anxiety, hostility, phobic anxiety, as well as general index, the index of symptoms detection and the index of distress severity. The suggested therapy scheme of also promoted to improvement of life quality of the emigrants and re-emigrants with depressive disorders, significant increase in the rates of their physical health, psychological quality of life and environment compared to the com- parison group. The results allow recommending the de- veloped treatment scheme for implemen tation in the complex treatment of emigrants and re- emigrants suffering from psychogenic, endo- genous and organic depressive disorders. References 1. 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