Appendices A–E

APPENDIX A

MONITORING AND EXAMINATION STANDARDS

This appendix presents standard protocols for safety monitoring in the use of psychotropic medications and for monitoring the medical condition of psychiatric patients.

A.1. Metabolic monitoring during antipsychotic therapy

Atypical antipsychotics — especially olanzapine, quetiapine, clozapine — increase the risk of metabolic syndrome (weight gain, dyslipidemia, insulin resistance, diabetes).

Monitoring chart (APA/ADA 2004, ADA/APA/AACE/NAASO consensus):

If abnormality is detected:

1. Weight gain ≥7%: consider medication switch (aripiprazole, ziprasidone — metabolically neutral);
2. HbA1c ≥6.5% or fasting glucose ≥7.0 mmol/L: referral to a diabetes specialist
3. LDL ≥3.4 mmol/L: Diet, statin.

Specific monitoring for clozapine (due to agranulocytosis):

ANC indicators:

• ≥2.0 × 10⁹/L Normal — continue treatment;
• 1.5–2.0 × 10⁹/L (warning zone): monitoring twice a week until the value stabilizes or rises;
• <1.5 (red zone): clozapine is stopped immediately, hematology consultation;
• In benign ethnic neutropenia the thresholds are 0.5 × 10⁹/L lower: 1.0–1.5 — warning, <1.0 — medication discontinued, hematologist intervention.

ECG monitoring with antipsychotics:

• QT interval prolongation risk: specifically ziprasidone, haloperidol IV, ondansetron combination;
• Baseline ECG in patients with risk factors (heart disease, electrolyte disturbance, >65 years);
• QTc >500 ms or >60 ms increase from baseline — Medication change;
• Medications increasing risk: thioridazine, chlorpromazine, haloperidol (IV, high dose).

Hyperprolactinemia:

• Risperidone, amisulpride, paliperidone — high risk;
• Symptoms: amenorrhea, galactorrhea, sexual dysfunction, osteoporosis.
• Baseline prolactin; repeat if symptoms recur.

A.2. Lithium monitoring

Narrow therapeutic window — level 0.6–1.2 mEq/L, >1.5 toxic.

Signs of lithium intoxication:

• Tremor (more severe);
• Bradycardia, arrhythmia; confusion;
• Diarrhea, vomiting;
• Slow, confused speech;
• Ataxia;
• Seizures — in severe cases.

Check the level when the clinical state changes (e.g., dehydration, NSAID, ACE inhibitor, thiazide addition, kidney function change).

A.3. Anticonvulsants (valproate, carbamazepine, lamotrigine)

Valproate:

Critical: because of the risk of neural tube defects and cognitive impairment in the child, valproate should be prescribed to women of childbearing potential only if the conditions of the Pregnancy Prevention Programme are met (other options evaluated first, negative pregnancy test, effective contraception, specialist supervision, signed risk acknowledgement, annual review); in bipolar disorder it is contraindicated in pregnancy.

Carbamazepine:

• CBC, liver — baseline, 1 month, quarterly;
• HLA-B*1502 test in patients of Asian origin (Stevens–Johnson risk);
• Level drop due to auto-induction in the first 4 weeks — check level.

Lamotrigine:

• Slow titration — Stevens–Johnson syndrome risk;
• Starting 25 mg/day (weeks 1–2), 50 mg/day (weeks 3–4), then to target dose;
• Along with valproate: doses halved (25 mg every other day) — valproate slows lamotrigine metabolism;
• If a skin reaction occurs — immediately discontinue.

A.4. Monitoring of SSRIs and SNRIs

• Hyponatremia risk — especially in elderly, in those using diuretics;
• Baseline Na, after 1 month, then with symptom;
• Increased suicidality, especially with onset in patients under 25 — close monitoring during first 1–2 months;
• QTc prolongation — escitalopram, citalopram (at high doses);
• Serotonin syndrome (MAOI or triptan, etc., in combination) — symptom education.

A.5. Benzodiazepine use

• Maximum duration: 2–4 weeks;
• Long-term use carries a high risk of dependence;
• Reduction schedule (tapering): gradual, usually 10–25% every 2 weeks (Pottie 2018); with long-term use slower — 5–10% every 2–4 weeks;
• Withdrawal symptoms (rebound anxiety, insomnia, tremor) are normal and temporary.

A.6. Psychotherapy monitoring

Quality indicators:

• Session duration, frequency;
• Patient symptom scales (PHQ-9, GAD-7, etc.) every 4–6 weeks;
• Functional indicators;
• Assessment of therapeutic alliance (Working Alliance Inventory).
• Achievement of agreed goals;
• Signs of relapse.

Supervision and peer consultation — in complex cases, and whenever the clinician asks for it.

APPENDIX C

PSYCHIATRIC EMERGENCY SITUATIONS

In a psychiatric emergency, time is the scarcest resource. Decisions are measured in minutes and must almost always be made on incomplete information. This appendix is written for precisely those moments: it offers concise, sequenced action lists rather than extended discussion. These lists do not replace clinical judgment; they serve as a safeguard against the step most easily overlooked under pressure.

C.1. Active suicide risk

Assessing suicide risk is a conversation, not a questionnaire. Ask directly: the question does not plant the idea — more often it gives the patient the first chance to say it out loud. What you are listening for above all is how far the intention has taken concrete shape.

Primary assessment:

• Are there suicidal thoughts? Plans? Means?
• How concrete the plan is: when the patient names a time, a place and a means, the risk rises sharply; a general “sometimes I want to die” is of a different order;
• Previous attempts — the strongest predictor;
• Substance intoxication — inhibition decreased;
• Protective factors — family, religious beliefs, future plans.

High risk signs:

• A concrete plan and easy access to the means;
• Recent situational change (loss, severe illness);
• Loneliness and chronic pain;
• Psychosis or severe depression;
• The early phase of recovery from depression — energy returns while mood is still low;
• Adult male, disability, alcohol.

Management:

Low-moderate risk:

• Safety plan — written;
• Reducing access to means (gun removal, medication in small quantities);
• Close outpatient follow-up (a repeat visit within 24–48 hours);
• The crisis line number;
• Family involvement (with consent).

High risk:

• Hospitalization (voluntary or involuntary);
• Close observation — one-to-one if the risk is very high;
• Removal of dangerous means (sharp objects, rope, access to windows);
• Controlled medication intake.

Involuntary hospitalization within the Azerbaijani framework:

• “On psychiatric assistance” Law of the Republic of Azerbaijan;
• A decision on involuntary hospitalization is made by two psychiatrists, followed by the legal procedure;
• After the commission’s decision, a court order within the period established by law (see: “Legal and ethical aspects”).

C.2. Delirium tremens and alcohol withdrawal

Symptoms:

• Tremor — hands, then general;
• Anxiety, agitation;
• Hallucinations — visual and tactile (“insects under the skin”);
• Disorientation;
• Autonomic hyperactivity — tachycardia, hypertension, sweating, hyperthermia;
• Seizures (~5–10%).

Treatment (in ICU or IMU setting):

• Benzodiazepine — diazepam 10–20 mg IV (not IM) every 15–20 min until sedation is achieved; then maintenance regimen;
• Alternative: lorazepam (in those with hepatic dysfunction);
• Thiamine 100–300 mg IV — Prevention of Wernicke’s encephalopathy. Give before glucose administration.
• Fluid and electrolyte replacement;
• Magnesium sulfate, potassium — often low;
• Mortality: ~1–4% in treated inpatients; substantially higher (15–20%) in untreated historical series.

CIWA-Ar scale — for monitoring.

C.3. Serotonin syndrome

Cause: SSRI + MAOI, SSRI + triptan, SSRI + tramadol, SSRI + linezolid, SSRI + methylene blue, etc.

Symptoms:

• Mental change — agitation, confusion;
• Autonomic — tachycardia, hypertension, hyperthermia, sweating;
• Neuromuscular — tremor, hyperreflexia, clonus (lower extremity — specific sign).

Treatment:

• Immediate discontinuation of causative medication
• Support — fluids, electrolytes, cooling;
• In severe cases cyproheptadine 12 mg initial, then 2 mg every 2 hours while symptoms persist, maximum 32 mg/day;
• Invasive intervention (intubation) in severe hyperthermia.

C.4. Neuroleptic malignant syndrome (NMS)

Cause: antipsychotics (especially high potency, e.g., haloperidol), acute initiation or dose increase.

Symptoms (4 main):

• Muscle stiffness (“lead pipe”);
• Hyperthermia (38–42°C);
• Autonomic lability (high blood pressure, tachycardia, sweating);
• Mental state change (confusion → stupor → coma).

Laboratory: creatine kinase (CK) markedly elevated (>1000 U/L), myoglobinuria, leukocytosis, ALT/AST elevated.

Treatment (ICU):

1. Immediate discontinuation of antipsychotics
2. Cooling.
3. Fluids (risk of rhabdomyolysis and acute kidney injury);
4. Dantrolene 1–2.5 mg/kg IV — reduces muscle rigidity;
5. Bromocriptine 2.5–5 mg every 8 hours — dopamine agonist;
6. ECT in non-responsive cases.

Mortality: 5–20%; considerably lower with early recognition and timely treatment.

C.5. Acute dystonia

Cause: antipsychotic initiation, especially potent D2 antagonists.

Symptoms:

• Acute muscle spasms — neck (torticollis), tongue, eyes (oculogyric crisis), spasm of the esophagus;
• Life-threatening — laryngeal spasm.

Treatment:

• Diphenhydramine 50 mg IM/IV — relief within 15 minutes;
• Benztropine 1–2 mg IM/IV;
• Reducing or changing the dose of antipsychotics
• Prophylactic anticholinergic in high-risk patients.

C.6. Acute mania and psychomotor agitation

Management:

• Safe environment — quiet, free from stimuli;
• Verbal de-escalation first step;
• Medication:

- Oral preferred: haloperidol 2–5 mg + lorazepam 1–2 mg;

- IM when indicated: haloperidol 5 mg + lorazepam 2 mg (50/50 syringe) or olanzapine IM 10 mg (not together with a parenteral benzodiazepine);

• Involuntary hospitalization if indicated;
• Physical restraint — only as a last resort, when life is at risk, and only briefly.

C.7. Acute psychosis

Similar to the protocol above. Differential: organic causes, substance intoxication, postpartum psychosis, NMS.

C.8. Catatonia

Symptoms:

• Stupor, mutism;
• Catalepsy (‘waxy flexibility’);
• Negativism;
• Mannerisms, stereotypies;
• Echolalia, echopraxia.

First-line treatment:

• Lorazepam 1–2 mg IV/IM test — Significant response within 1–2 hours → diagnosis and treatment of catatonia;
• If there is a response, increase the dose to 4–24 mg/day;
• No response — ECT as second-line treatment, highly effective;
• Avoiding antipsychotics during acute phase is necessary — they may provoke NMS.

Search for organic causes (encephalitis, epilepsy), mood disorders, schizophrenia, autism, certain substances.

APPENDIX D

MILITARY MEDICAL EXAMINATION (IN AZERBAIJAN)

This appendix provides practical guidance on psychiatric aspects for assessing fitness for military service in the Republic of Azerbaijan.

D.1. Legal basis

• “On military duty and military service” Law of the Republic of Azerbaijan;
• Regulation on military medical examination;
• Ministry of Defense normative acts;
• Table of diseases — divided into two parts: mild and severe degrees, groups A–D.

D.2. Psychiatric assessment structure

Main components of the examination:

• Complaints and history (patient and close relatives);
• Previous medical records;
• Clinical interview and mental status examination;
• Experimental-Psychological Examination (EPE) — by a psychologist;
• Laboratory and instrumental examinations when necessary;
• Differential diagnosis, and assessment of disease severity;
• Conclusion.

Typical psychological tests (used in the EPE):

• MMPI-2 (Minnesota Multiphasic Personality Inventory-2) — personality profile;
• Raven’s Progressive Matrices — intellect;
• Luria tests — memory, attention;
• Wechsler Adult Intelligence Scale (WAIS);
• Rorschach test — a projective method (its contemporary reliability is contested);
• Beck, Hamilton scales — mood.

D.3. Psychiatric disorders and military fitness assessment

Classification by group (adaptation — based on local normative acts):

Group A — fully fit for service

No psychiatric history or minor transient issues.

Group B — fit with minor limitations

• Mild personality traits (below impairment threshold);
• Transient adjustment disorders;
• Mild sleep disturbances;
• Neurotic disorders in remission state.

Group C — fit for service with limitations

• Moderate psychiatric disturbances in partial remission state;
• Specific personality disorders;
• Past PTSD, compensated;
• Moderate neurocognitive dysfunction.

Group D — unfit for service

• Schizophrenia spectrum;
• Bipolar disorder;
• Severe depression;
• Active PTSD/complex PTSD (Karabakh War veterans — separate treatment program);
• Substance use disorders;
• Severe personality disorders;
• Intellectual disability (severe);
• Severe forms of autism spectrum disorder;
• Disorders with active suicide risk;
• Paraphilic disorders (severe, active).

D.4. Post-traumatic stress and veteran assessment

In veterans of the Karabakh War:

• Complex PTSD high prevalence — trauma-focused intervention;
• Alcohol and substance use are comorbid;
• Depression, suicide risk;
• Family dysfunction;
• Moral injury — ethical conflict during war (killing, witnessing);
• Burnout and re-traumatization risk factors.

Specific rehabilitation programs:

• Evidence-based trauma therapies (PE, CPT, EMDR);
• Group therapy for veterans;
• Family therapy;
• Medication (SSRI/SNRI);
• Social rehabilitation (work, education).

APPENDIX E

RELATED NEUROLOGICAL CONDITIONS

Brief description of neurological diseases important for clinical practice in areas intersecting psychiatry and neurology.

E.1. Epilepsy (8A60–8A6Z) and psychiatric manifestations

Epileptic syndromes and psychiatry:

- Interictal personality changes (Geschwind syndrome — hyperreligiosity, hypergraphia, “viscosity”);

- Interictal psychosis — long-standing TLE;

- Postictal psychosis — psychotic episodes within 24–72 hours after a seizure;

- Ictal anxiety and dissociative experiences;

• Temporal lobe epilepsy (TLE) — psychiatric comorbidity most common:
• Absence epilepsy — attention problems, differential with ADHD;
• Juvenile myoclonic epilepsy — high comorbid anxiety, impulsivity.

Psychogenic (non-epileptic) seizures (PNES) — dissociative neurological symptom disorder (6B60.4):

• Video-EEG — gold standard differential;
• PNES frequently comorbid with epilepsy, 10–30%;
• Treatment: CBT-PNES, slow tapering of anticonvulsants.

Psychiatric side effects of antiepileptics:

• Levetiracetam: Aggression, irritability, depression;
• Phenobarbital, primidone: depression, cognitive slowing;
• Topiramate: cognitive dysfunction, depression;
• Lamotrigine: mood stabilizer.

E.2. Headache and psychiatric comorbidity

• Migraine — depression risk 2–4× higher; anxiety disorders;
• Cluster headache — depression, suicide risk;
• Chronic daily headache — analgesic overuse (medication overuse headache — MOH) — frequently comorbid mood disorder;
• Recurrent tension-type headache — associated with intense stress, anxiety.

Management:

• SSRI/SNRI improves many types of headache;
• TCA (amitriptyline) historical standard for migraine prophylaxis;
• Topiramate, valproate (not in women of childbearing age) for prophylaxis;
• CBT is effective for chronic headache;
• Avoidance of opioids and excessive analgesic use.

E.3. Cerebrovascular diseases (stroke)

• Post-stroke depression: 30–40% in the first year;
• Post-stroke mania: Rare, in right frontal or thalamic lesions;
• Pseudobulbar affect (pathological laughing/crying): dextromethorphan-quinidine combination is the established treatment;
• Vascular cognitive disorder/dementia: classified under 6D81;
• Rehabilitation: Multidisciplinary, psychiatric support plays a central role.

E.4. Parkinson’s disease

• Depression: 30–50%;
• Anxiety: 30–40%;
• Dopamine agonist-induced impulse control disorder: 13–36%;
• Psychosis in Parkinson’s disease: mainly visual hallucinations, often induced by levodopa;
• Dementia in Parkinson’s disease: 6D85.0;
• REM sleep behavior disorder: an early marker for Parkinson’s disease.

Treatment characteristics:

• Use of antipsychotics in Parkinson’s disease: quetiapine, clozapine (D2 minimal blockade);
• Haloperidol, risperidone — worsen motor symptoms;
• SSRIs depression;
• Pimavanserin — approved for Parkinson’s disease psychosis in the US.

E.5. Multiple sclerosis (MS)

• Depression: 30–50%;
• Anxiety: 30%;
• Bipolar-like symptoms: 5–10%;
• Pseudobulbar affect;
• Cognitive dysfunction — in most patients;
• Lethargy and fatigue — closely associated with depression, differential diagnosis difficult.

Interferon-beta may worsen depression (evidence conflicting) — monitoring required.

E.6. Traumatic brain injury (TBI)

• Post-concussion syndrome: headache, dizziness, memory issues, mood changes;
• Chronic traumatic encephalopathy (CTE): repeated injuries, sports (boxing, American football);
• PTSD + TBI — very frequently comorbid;
• Personality change (6E68) — in frontal lesions.

E.7. Dementia (detailed in Section 17)

• 6D80 Alzheimer’s;
• 6D81 Vascular;
• 6D82 Lewy body;
• 6D83 Frontotemporal;
• 6D84 Substance-related;
• 6D85.0 With Parkinson’s disease;
• 6D86 Behavioural/psychological disturbances in dementia (BPSD)

E.8. Seizures, movement disorders, and psychiatry

• Tourette syndrome (8A05.00) — In ICD-11, under neurological disorders section, but highly comorbid with ADHD, OCD.
• Wilson’s disease — genetic disorder of copper metabolism; psychiatric presentation (depression, psychosis) is frequent; investigation — ceruloplasmin, 24-hour urinary copper;
• Huntington’s disease — mood disorders, OCD, psychosis, motor chorea.

GENERAL SOURCES AND REFERENCES

Main ICD-11 and DSM-5-TR sources

• WHO. Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR). Geneva: World Health Organization; 2024. ISBN: 9789240077263.
• APA. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR). APA Publishing; 2022.
• First MB, Reed GM, Hyman SE, Saxena S. The development of the ICD-11 Clinical Descriptions and Diagnostic Guidelines for Mental and Behavioural Disorders. World Psychiatry, 2015; 14: 82–90.
• Reed GM, et al. Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry, 2019; 18: 3–19.

Clinical psychiatry textbooks

1. Popov Yu.V., Vid V.D. Modern clinical psychiatry. (Modern Clinical Psychiatry) 2nd edition. Saint Petersburg: Rech, 2006.
2. Boland R, Verduin ML, Ruiz P (eds). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 11th ed. Wolters Kluwer; 2024.
3. Geddes JR, Andreasen NC, Goodwin GM (eds). New Oxford Textbook of Psychiatry. 3rd ed. Oxford UP; 2020.
4. Harrison P, Cowen P, Burns T, Fazel M. Shorter Oxford Textbook of Psychiatry. 7th ed. Oxford UP; 2018.

Sources in Azerbaijani language

1. Ministry of Health of the Republic of Azerbaijan. “Regulatory documents on examination and treatment of mental patients”.
2. “On psychiatric assistance” Law of the Republic of Azerbaijan (2001, with amendments).

Practical clinical guidelines

1. NICE (UK) Clinical Guidelines — psychiatric conditions: CG31 OCD, CG78 BPD, NG222 Depression, CG113 GAD, CG115 Alcohol, CG158 Conduct disorders, NG69 Eating disorders, NG116 PTSD, CG111 Enuresis.
2. APA Practice Guidelines — schizophrenia, BPD, MDD, eating disorders, Alzheimer’s.
WFSBP Guidelines — bipolar, schizophrenia, OCD, PTSD, paraphilic disorders.
3. ISTSS (International Society for Traumatic Stress Studies). PTSD Prevention and Treatment Guidelines. 3rd ed. 2019.
4. CANMAT/ISBD. Canadian Network for Mood and Anxiety Treatments / International Society for Bipolar Disorders Treatment Guidelines. 2018, 2023.
5. AACAP Practice Parameters — child and adolescent psychiatric disorders.

Main peer-reviewed journals

1. American Journal of Psychiatry (APA)
2. World Psychiatry (WPA)
3. Lancet Psychiatry
4. JAMA Psychiatry
5. British Journal of Psychiatry
6. Psychological Medicine
7. Journal of Clinical Psychiatry
8. European Psychiatry

Online resources

1. ICD-11: https://icd.who.int
2. MGH Center for Women’s Mental Health: https://womensmentalhealth.org
3. Cochrane Library: psychiatric systematic reviews
4. UpToDate Psychiatry — a clinical reference resource
5. Psychiatry Online (APA Publishing) — textbooks, guidelines
6. Columbia-Suicide Severity Rating Scale: https://cssrs.columbia.edu

Kenan Ragimov

Baku, 2026

ragimoff.org