APPENDICES

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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 – Metabolic syndrome increases the risk. (weight gain, dyslipidemia, insulin resistance, diabetes).

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

If abnormality is detected:

• Weight gain ≥7%: consider medication switch (aripiprazole, ziprasidone — metabolically neutral);
• HbA1c ≥6.5% or fasting glucose ≥7: Diabetes Consultation
• 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: weekly monitoring;
• 1.0–1.5: Monitor every 2 days, hematology consultation;
• <1.0: medication discontinued, hematologist intervention.

EKG monitoring with antipsychotics:

• QT interval prolongation risk: specifically ziprasidone, haloperidol IV, ondansetron combination;
• Baseline EKG 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: chlorpromazine, haloperidol (high), thioridazine.

Hyperprolactinemia:

• Risperidone, amisulpride, paliperidone — high risk;
• Symptoms: amenorrhea, galactorrhea, sexual dysfunction, osteoporosis.
• Basal prolactin; with recurrent symptom.

A.2. Lithium monitoring

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

Signs of lithium intoxication:

• Tremor (more severe);
• Tachycardia;
• Diarrhea, vomiting;
• Slow, confused speech;
• Ataxia;
• Convulsion – in severe conditions.

Check level in state change: dehydration, NSAID addition, ACE inhibitor addition, kidney function change.

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

Valproate:

> Critical: valproate postpartum-aged women Due to neural tube defect and cause of cognitive impairment only with effective contraception, after other options have been evaluated first.

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 per week, to target dose within 4–8 weeks;
• Along with valproate: starting dose 12.5 mg — 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 under 25 years — 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 inevitably leads to addiction;
• Reduction schedule (tapering): 25% every 2 weeks, sometimes slower;
• Re-experiencing symptoms. (rebound anxiety, insomnia, tremor) is 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).
• Achieving external goals;
• Signs of relapse.

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

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APPENDIX C

PSYCHIATRIC EMERGENCY SITUATIONS

In an emergency there is no time: the decision is measured in minutes and is almost always made on incomplete information. This appendix is written for those minutes — short lists of what has to be done, not reasoning. The lists do not replace clinical judgement; they protect you from the step that is easiest to miss in a hurry.

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 a different order of thing;
• 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;
• For involuntary hospitalization decision by two psychiatrists and legal procedure;
• 72-hour emergency observation followed by a court order.

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, pressure, sweating, heating;
• Seizures (~5-10%).

Treatment (in ICU or IMU setting):

• Benzodiazepine — diazepam 10–20 mg IV/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. Before glucose administration.
• Fluids and electrolytes Recovery;
• Magnesium sulfate, potassium – often low;
• Mortality: untreated 15-20%, with adequate treatment <1%.

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, 2 mg every hour maximum 32 mg/day;
• Invasive intervention (intubation) in severe hyperthermia.

C.4. Antipsychotic Malignant Syndrome (NMS)

Cause Antipsychotics (especially high potency, haloperidol), acute initiation or dose increase.

Symptoms (4 main):

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

Laboratory: CPK acutely elevated. (>1000), myoglobinuria, leukocytosis, ALT/AST elevated.

Treatment (ICU):

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

Deathfulness: 5-20% with adequate treatment.

C.5. Acute dystonia

Cause Antipsychotic initiation, especially potent D2 antagonists.

Symptoms:

• Acute muscle spasms – neck (torticollis), tongue, eyes (oculogyric crisis), certain esophageal spasm;
• 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:

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

- IM regimen: haloperidol 5 mg + lorazepam 2 mg (50/50 syringe) or olanzapine IM 10 mg;

• Safe environment — quiet, free from stimuli;
• Verbal de-escalation first step;
• Medication:
• Involuntary hospitalization By instruction;
• Physical restraint — only as a last resort, when life is at risk, and only briefly.

C.7. Acute psychosis

Similar protocol as 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 response is obtained — increase to a dose of 4–24 mg/day;
• No answer – ECT Second-line, highly effective;
• Avoiding antipsychotics During acute phase – NMS administration may be provocative.

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

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APPENDIX D

MILITARY-MEDICAL EXPERTISE (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 service call-up” Law of the Republic of Azerbaijan;
• Regulation on military-medical expertise;
• Ministry of Defense Normative acts;
• Table of diseases — divided into halves: mild/severe degrees, groups A–D.

D.2. Psychiatric assessment structure

Main expert examination:

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

Typical psychological tests (EPM):

• MMPI-2 (Minnesota Multiphasic Personality Inventory-2) – personality profile;
• Raven Progressive Matrices — intellect;
• Luria tests — memory, attention;
• Wechsler IQ 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 – useful with limitations

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

Group V — limited during service

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

Group Q – 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;
• Mental retardation;
• Severe forms of autism spectrum;
• Disorders with active suicide risk;
• Paraphilic disorders (severe, active).

D.4. Postpartum trauma and veteran assessment

In veterans of the Karabakh war:

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

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APPENDIX E

RELATED NEUROLOGICAL CONDITIONS

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

E.1. Epilepsy (G40) and psychiatric manifestations

Epileptic syndromes and psychiatry:

- Interictal personality changes (Geschwind syndrome – hyper religiosity, hypergraphia, “viscosity”);

- Inter-ictal psychosis – long-standing TLE;

- Post-ictal 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 (6B64.4):

• 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: Gene stabilizes mood.

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) – mood disorder comorbid frequently;
• Recurrent tension headache — associated with intense stress, anxiety.

Management:

• SSRI/SNRI improves many types of headache;
• TCA (amitriptiline) historical standard for migraine prophylaxis
• Topiramate, valproate prophylactic;
• CBT is effective for chronic headache;
• Avoidance of opioids and excessive analgesic use.

E.3. Cerebrovascular diseases (stroke)

• Post-stroke depression: 30-40% first year;
• Post-stroke mania: Rare, in right frontal or thalamic lesions;
• Pseudobulbar affect (pathological laughing/crying): dextromethorphan-quinidine combination confirmatory treatment is;
• 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; levodopa-induced;
• Dementia in Parkinson's disease: 6D85;
• REM sleep behavior disorder Early marker for Parkinson's disease.

Treatment characteristics:

• Use of antipsychotics in Parkinson's disease: quetiapine, clozapine (D2 minimal blockade);
• Haloperidol, risperidone — worsens motor symptoms;
• SSRIs depression;
• Pimavanserin — Confirmed for Parkinson psychosis in the USA.

E.5. Multiple sclerosis (MS)

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

Interferon-beta therapy Depression worsens – active monitoring.

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 + TBZ — 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 With Parkinson's disease;
• 6D86 Behavioral/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) frequent; investigation – ceruloplasmin, 24-hour urinary copper;
• Huntington's disease — mood disorders, OCD, psychosis, motor chorea.

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GENERAL SOURCES AND REFERENCES

Main ICD-11 and DSM-5 sources

1. WHO. Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR). Geneva: World Health Organization; 2024. ISBN: 9789240077263.
2. APA. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR). APA Publishing; 2022.
3. 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.
4. 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. St. Petersburg: Rech, 2006.
2. Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 11th ed. Wolters Kluwer; 2023.
3. Gelder MG, Andreasen NC, Lopez-Ibor JJ, Geddes JR (eds). New Oxford Textbook of Psychiatry. 3rd ed. Oxford UP; 2020.
4. Cowen P, Harrison P, Burns T. 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, CG90 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.
3. WFSBP Guidelines – bipolar, schizophrenia, OCD, PTSD, paraphilic disorders.
4. ISTSS (International Society for Traumatic Stress Studies). PTSD Prevention and Treatment Guidelines. 3rd ed. 2019.
5. CANMAT/ISBD. Canadian Network for Mood and Anxiety Treatments / International Society for Bipolar Disorders Treatment Guidelines. 2018, 2023.
6. 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

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<div style="text-align: right; font-size: 9pt;">

Kenan Rahimov

Baku, 2026

ragimoff.org

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