Preface

Address to the reader

Dear colleague — physician, clinical psychologist, psychotherapist, resident, student.

This book grew out of an absence. I have been seeing patients for twenty-three years, and for most of that time I ran into the same wall: the diagnosis was clear — but the criteria that confirm it sat in one source, the order of investigation in another, the treatment algorithm in a third, and the prognosis nowhere at all. That road had to be retraced for every patient.

The search made the burden heavier, not lighter. On the first page of results an obsolete classification, a pharmaceutical brochure and somebody’s evidence-free “method” stand side by side. Telling which one has a study behind it and which has only marketing takes hours you do not have: the patient is sitting opposite you and expects an answer now. Teaching residents made this plainer still — a wrong decision usually comes not from ignorance but from trusting the first source that appears.

I looked for a ready-made solution for a long time. I did not find one, so I had to write it. Everything in this book follows from a single principle: one structured section for every disorder. Criteria, differential diagnosis, investigation, treatment, prognosis and the most persistent myths are presented together, with the codes of three classifications and a named source behind every claim. Only what can be verified goes in; the rest is called by its name in a section of its own.

What you have in front of you is “Clinical Psychiatry: Standards of Diagnosis and Therapy”, a systematic clinical psychiatry reference built on ICD-11 and cross-checked against ICD-10 and DSM-5-TR. It was not written to be read through; it was written to be used. The patient is sitting opposite you and you have ten minutes. Every chapter is built the same way — eleven sections in a fixed order — so that you never have to hunt for what you need.

The book is built on ICD-11. When that classification came into force in 2022, it changed more than the codes: it rewrote how we look at personality disorder, what we mean by trauma, and the old boundary between the organic and the functional. At the same time I have not abandoned the post-Soviet clinical school — the tradition of Popov and Vid. Where the international guideline is stronger, it is cited; where the classical school sees more clearly, that is said as well. Disagreements are not smoothed over; they are named.

Two of the protocols presented here are my own: the treatment algorithm for nocturnal enuresis in children and a two-stage strategy for psychogenic depression. Both are modifications of existing international guidelines, and I classify their level of evidence as IV — expert clinical experience rather than randomized controlled trials. I state this explicitly so that the reader knows precisely what the evidence base is. I invite you to test them, challenge them, and trial them in your own practice.

One final request: please do not treat this book as the last word. Psychiatry evolves rapidly, and I intend this text to be a living document. If you identify an error or an omission, I would welcome your feedback. The next edition will be stronger for it.

ABOUT THE AUTHOR

The author of this book is Kenan Ragimov, a psychiatrist and psychotherapist with 23 years of clinical experience (since 2003). He graduated from Azerbaijan State Medical University in 2001 and completed his internship the same year at Clinical Psychiatric Hospital No. 2 in Baku. From 2001 to 2003 in Saint Petersburg, at the V. M. Bekhterev Psychoneurological Research Institute, he completed his clinical residency with honors: in the department of psychotherapy for neuroses under Professor B. D. Karvasarsky, Chief Psychotherapist of the Russian Federation and an internationally recognized specialist, and in the department of psychotherapy for psychoses under Professor V. D. Vid, one of the first psychoanalysts in the post-Soviet region certified by the International Psychoanalytical Association (IPA). Over 23 years of practice he has treated more than 1,000 patients with depressive disorders and more than 1,000 children with nocturnal enuresis; in 2025 alone his clinical team successfully treated more than 250 children. Since 2020 he has been the founder of the RAGIMOFF Professional School of Psychology; since 2021, the authorized representative in Azerbaijan of the Karvasarsky Institute in Saint Petersburg and head of its continuing professional education program in clinical psychology; and since 2022, an ambassador of the International Psychotherapy Association (IPAS). The two clinical protocols developed by the author and presented in this book — the treatment of nocturnal enuresis in children and a two-stage strategy for treating psychogenic depression — represent modifications of international evidence-based guidelines (NICE, APA, WFSBP) grounded in the author’s long-term clinical experience and retrospective observations. They aim at higher clinical effectiveness in a shorter time than the standard international protocols; the level of evidence should be regarded as IV (expert clinical experience). The author’s recommendations rest on clinical expertise and 23 years of uninterrupted practice; readers are invited to test them, evaluate them and, where necessary, adapt them in their own practice.

INTRODUCTION

About this book

This book is a systematic presentation of the modern standards of clinical psychiatry, brought together in a single format for everyday clinical work. The book is built on the 11th revision of the International Classification of Diseases (ICD-11) and integrates its structure, diagnostic criteria and treatment approaches in a way adapted to the clinical tradition of the post-Soviet psychiatric school.

The book has been prepared as a reference guide for practicing physicians — psychiatrists, psychotherapists, neurologists, primary care physicians, clinical psychologists, final-year medical students and residents.

What this book is and why it was written

This book is a clinical reference guide, not a theoretical psychiatry textbook. It presents the diagnostic criteria, clinical manifestations and treatment protocols for each mental disorder in a standardized format. A detailed pathophysiological, neurobiological or historical account of each topic lies beyond the scope of this book; the aim is to enable the physician to find the necessary information quickly and accurately in the presence of the patient.

The reasons for writing the book:

There is a lack of a modern reference guide in which the three classifications in current use are presented side by side. Much of the literature available to the practicing physician consists of translations or textbooks based on the school of the late twentieth century. The innovations of ICD-11 (in force since 2022) and DSM-5-TR (2022) have not been systematically reflected in such literature.

Bringing diagnostic classifications into a unified system. In clinical practice, physicians encounter ICD-10 (still used by the Ministry of Health for official statistics), ICD-11 (the new standard) and DSM-5-TR (the classification predominant in international scientific publications). This book presents all three systems in parallel so that the physician can use the correct code and terminology in different contexts.

Integration of the official clinical protocols of Azerbaijan. The protocols prepared by the Public Health and Reforms Center of the Ministry of Health and approved by decisions of the board of the Ministry of Health — schizophrenia, 2009; anxiety disorders, 2013; obsessive-compulsive disorder (OCD), 2015; depression — constitute the local clinical basis of this book. The concordances and differences between international recommendations — from the National Institute for Health and Care Excellence (NICE) of the United Kingdom, the American Psychiatric Association (APA), the World Federation of Societies of Biological Psychiatry (WFSBP) and the World Health Organization (WHO) — and the official Azerbaijani protocols are noted separately.

Legal and ethical guidance. The rights and duties of the physician — both psychiatrist and clinical psychologist — are presented in a separate section within the framework of the Law of the Republic of Azerbaijan “On Psychiatric Care” of 12 June 2001 and the Law “On Psychological Assistance”. Behavior towards a patient with suicidal ideation, the grounds for involuntary hospitalization and the rules for applying compulsory medical measures are real clinical situations that require an answer. This book answers them.

Why ICD-11?

WHO adopted ICD-11 in 2019, and its official implementation began in 2022. ICD-11 has brought profound paradigm changes in the chapter on mental disorders:

Complex post-traumatic stress disorder (cPTSD) (6B41) — a new official diagnosis;

Prolonged grief disorder (6B42) — an independent diagnosis added to ICD-11;

Transition of personality disorders from a categorical system to a dimensional system — a major conceptual innovation;

Replacement of somatoform disorders with bodily distress disorder (BDD);

Removal of gender incongruence from the psychiatric chapter;

Gaming disorder has been defined as an official diagnosis;

Compulsive sexual behavior disorder (CSBD) has been added as a new category;

Transfer of attention-deficit/hyperactivity disorder (ADHD) to the group of neurodevelopmental disorders;

Placement of hypochondriasis in the group of obsessive-compulsive and related disorders;

Abolition of the organic–functional dichotomy.

These changes require reassessment both in nosology and in treatment standards.

Structure of the book

The book consists of two main parts:

PART I — Introductory sections:

Preface (this section)

Table of contents — based on a hierarchy corresponding to the structure of ICD-11

Introduction to psychopathology — description of symptoms and syndromes (cognition, perception, thinking, mood, behavior, memory, volition, consciousness)

Clinical interview and assessment of mental status — clinical protocol procedure, standards for describing mental status

Legal and ethical aspects — practical guidance for the psychiatrist and clinical psychologist on the basis of Azerbaijani legislation, sample documents

PART II — Mental disorders (according to the structure of ICD-11):

All main groups of Chapter 6 of ICD-11 are presented in separate sections. The same standard structure is retained for each section (a brief overview of the main elements; the full 11-section scheme of the chapter is given in the section “Organization of the chapters”):

Definition and nosology (brief)

Etiology

Epidemiology

Clinical manifestations

Diagnosis (ICD-11 → ICD-10 → Diagnostic and Statistical Manual of Mental Disorders, DSM-5-TR — parallel comparison)

Differential diagnosis

Methods of examination (clinical, laboratory and instrumental)

Treatment (with evidence-based recommendation grades)

Prognosis

References

At the end — References and Appendices:

Complete list of all sources used (Azerbaijani sources, those from the countries of the Commonwealth of Independent States (CIS), international sources)

Clinical scales and questionnaires (Patient Health Questionnaire — PHQ-9, Generalized Anxiety Disorder scale — GAD-7, PTSD checklist — PCL-5, Edinburgh Postnatal Depression Scale — EPDS, Yale-Brown Obsessive Compulsive Scale — Y-BOCS, Columbia-Suicide Severity Rating Scale — C-SSRS and others)

Psychiatric emergencies (algorithm)

Rules of military medical assessment (in Azerbaijan)

Organization and features of the chapters

Organization of the chapters

Each clinical chapter consists of 11 sections:

Definition and brief description — the nature of the disorder, ICD-11 innovations;

History — the transition from classical concepts to the modern approach;

Epidemiology — prevalence, sex, age, comorbidity;

Etiology and pathogenesis — biological, psychological and social factors, the Popov-Vid approach;

Clinical manifestations — clinical forms (where relevant) or features of the clinical presentation;

Diagnosis — diagnostic criteria: ICD-11 Clinical Descriptions and Diagnostic Requirements (CDDR), ICD-10, DSM-5-TR — in comparison; differential diagnosis — in tabular format;

Examination and assessment — clinical interview, screening scales, and laboratory tests;

Treatment — general strategy, phased approach, psychotherapy, pharmacotherapy, and specific clinical situations;

Follow-up and prognosis;

Myths and misconceptions — etiology myths, harmful or ineffective “treatment” methods;

Sources — ICD-11 CDDR 2024, APA, NICE, WFSBP, ISTSS, ISSTD and other international clinical recommendations;

Terminology

Psychiatric terminology has been systematized and is used consistently throughout the book. Many terms reflect adaptations originating from classical Russian-Soviet psychiatry, on which psychiatric education across the post-Soviet space has traditionally been built. International terms are provided in English, with the note “Eng” in parentheses (for terminological clarity).

Integration of the Popov-Vid school

The book “Modern Clinical Psychiatry” by Yu.V. Popov and V.D. Vid (Saint Petersburg: Rech, 2006, 2nd edition) is a classic textbook of post-Soviet clinical psychiatry. Their method — classical nosology, the biopsychosocial model and practical clinical experience — has been integrated into this book wherever it is consistent with contemporary international recommendations. Where differences exist (e.g., the dimensional personality model of ICD-11), this is explicitly indicated.

Treatment standards

For each disorder, treatment is referenced to international clinical guidelines:

American Psychiatric Association (APA) clinical practice guidelines;

National Institute for Health and Care Excellence (NICE);

World Federation of Societies of Biological Psychiatry (WFSBP);

Canadian Network for Mood and Anxiety Treatments (CANMAT)/International Society for Bipolar Disorders (ISBD) — bipolar affective disorder;

International Society for Traumatic Stress Studies (ISTSS);

International Society for the Study of Trauma and Dissociation (ISSTD);

American Academy of Child and Adolescent Psychiatry (AACAP);

National drug lists and guidelines.

Drug names are given both by the international nonproprietary name (INN) and by the trade (brand) name, because drugs on the Azerbaijani market are mostly known by their trade names. Spelling follows American English; the titles of ICD-11 categories (headings, code tables and references) are reproduced in the WHO’s spelling — for example, “generalised”, “behavioural”, “aetiological”, “apnoea”.

The Azerbaijani clinical context

Where appropriate, notes specific to the Azerbaijani context are provided:

Issues of implementation in primary health care;

Cultural characteristics and stigma;

Legal and ethical frameworks;

Constraints on available resources;

Trauma disorders in veterans of the Second Karabakh War;

Instruments whose reliability has been validated in the Azerbaijani language.

Scales and instruments

Appendix B presents the most commonly used screening and assessment instruments either in full text (open-licensed) or in descriptive form (commercially licensed).

Sources and approach

Priority sequence of authoritative sources. For each topic, one principal authoritative guideline is presented first, after which other guidelines are introduced for comparison or supplementation. This approach aims to maintain a balance between academic precision and concreteness and to avoid duplication of information. Principal authoritative guideline selections for each disorder:

Schizophrenia: NICE CG178 (2014) + Clinical Protocol of the Ministry of Health of the Republic of Azerbaijan (2009)

Depression: NICE NG222 (2022) — “Depression in adults: treatment and management” guideline + Clinical Protocol of the Ministry of Health + APA Practice Guideline (2010)

Bipolar disorder: CANMAT/ISBD (2018, updated 2021)

Anxiety disorders: NICE Clinical Guideline 113 (2011/2020). “Generalised anxiety disorder and panic disorder in adults: management”. NICE CG113 (2011) + Clinical Protocol of the Ministry of Health (2013) + WFSBP (2012)

OCD: NICE Clinical Guideline 31 (2005). “Obsessive-compulsive disorder and body dysmorphic disorder”. NICE CG31 (2005, in force) + Clinical Protocol of the Ministry of Health (2015) + APA (2007)

PTSD: NICE NG116 (2018) + ISTSS Prevention and Treatment Guidelines (2019)

Eating disorders: NICE Guideline 69 (2017). “Eating disorders: recognition and treatment”. NICE NG69 (2017) + APA (2023)

Personality disorders: NICE Clinical Guideline 78 (2009). “Borderline personality disorder: recognition and management”. NICE CG78 (borderline personality disorder, 2009), CG77 (antisocial personality disorder, 2009) + APA (2024)

Neurodevelopmental disorders: AACAP Practice Parameters + NICE (NG87 — ADHD, 2018; CG128/CG170/CG142 — autism spectrum disorder)

Psychoactive substance use disorders: NICE CG115 (alcohol) + American Society of Addiction Medicine (ASAM) standards (2020)

Dementia: NICE Guideline 97 (2018). “Dementia: assessment, management and support for people with dementia and their carers”. NICE NG97 (2018)

Domestic authoritative sources:

Clinical protocols developed by the Public Health and Reforms Center (PHRC) of the Ministry of Health of the Republic of Azerbaijan and approved by decisions of the Collegium of the Ministry of Health

Law of the Republic of Azerbaijan of 12 June 2001 “On Psychiatric Care” (as subsequently amended)

Law of the Republic of Azerbaijan “On Psychological Assistance”

The Commonwealth of Independent States (CIS) and the post-Soviet space:

Popov Yu.V., Vid V.D. Modern Clinical Psychiatry. Saint Petersburg: Rech, 2nd ed., 2006 — regarded as a classic post-Soviet source of clinical psychiatry.

How to use this book

Typical clinical use:

When a specific mental disorder is suspected in a patient, the relevant section is found in the table of contents.

Diagnosis (Section 6) — diagnosis is made using ICD-11 criteria.

Differential diagnosis (Subsection 6.4) — exclusion of other possibilities using the table.

Examination methods (Section 7) — a plan is drawn up.

Treatment (Section 8) — recommendations are given with the level of evidence indicated.

For the student:

The lesson topic is looked up in the table of contents.

In each section, the sequence Definition → History → Epidemiology → Etiology → Clinical manifestations → Diagnosis is followed.

Legislative issues are studied in the section on legal and ethical aspects.

For the clinical psychologist:

The legal and ethical aspects section is of particular importance (conditions for involuntary hospitalization, limits of psychological assistance)

The diagnostic sections are intended to help decide on referral of the patient to a psychiatrist.

Disclaimer

This book is a clinical reference guide, but when making a decision in an individual patient:

The individual clinical picture of the patient must always be taken into account

Treatment decisions should be made taking into account patient consent, comorbidities and the local availability of the drug

Drug doses must be confirmed against the current local prescribing information

In legal and ethical matters, the latest effective version of the relevant legislation must be checked.

This book does not replace individual medical advice

Knowledge in the field is updated regularly; the physician should follow updates in international and local recommendations.

WHY THIS BOOK, AND WHY NOW?

The intersection of three strands

In the preceding sections of this Introduction, three distinct but deeply interrelated strands have been identified:

The first strand — the global mental health crisis. More than 1 billion people worldwide live with a mental disorder. Anxiety and depressive disorders have increased substantially over the past 30 years. In most of these disorders, psychosocial factors play a central role, and their main treatment is based on quality psychotherapy. Yet the treatment gap — especially in anxiety and depression — stands at 70–90%.

The second strand — evidence-based clinical psychotherapy. Modern medicine is built on interventions supported by evidence. Clear clinical strategies already exist for each disorder, levels of evidence (A/B/C) have been defined, and international guidelines — NICE, APA, the WHO Mental Health Gap Action Programme (mhGAP), WFSBP — are updated systematically. The clinical psychotherapist — regardless of their primary theoretical orientation — is obliged to apply the most effective strategy for the specific disorder.

The third strand — professional standards and accreditation. Leading international bodies — the International Psychoanalytical Association (IPA), the European Association for Behavioural and Cognitive Therapies (EABCT), the DBT-Linehan Board of Certification (DBT-LBC) and EMDR Europe — have established strict accreditation requirements. Meeting these requirements is an important condition for the patient to receive quality care. In many countries, psychotherapeutic activity is not specifically regulated at the state level: of the 17 European countries reviewed by Van Broeck and Lietaer (2008), only seven had a separate law regulating the title and practice of the psychotherapist; where no such law exists, the bar for quality is set only by professional associations and their accreditation.

At the point where these three strands intersect, one conclusion emerges: the practicing specialist needs a reference book on clinical psychiatry and psychotherapy that is standardized, evidence-based and grounded in modern international guidelines.

Why now?

Three reasons make writing this book now a logical step:

1. The WHO transition to ICD-11. The WHO ICD-11 classification entered into force in 2022 and, after the transition period, becomes the main standard in international health statistics. This classification has substantially restructured the chapter on mental disorders: new nosologies have been added (complex PTSD, prolonged grief disorder and gaming disorder, compulsive sexual behavior disorder and others), some former categories have been reclassified, and a more dimensional approach has been applied throughout the classification system. A systematic reference source bringing these updates together in a single practical format has so far been lacking.

2. The post-pandemic shift in baseline. The COVID-19 pandemic has produced a phenomenon in mental health known as the “new baseline”: levels of depression and anxiety have not returned to the previous norm and have remained persistently elevated. This means an increased burden in clinical practice. The active preparation of specialists and the availability of standardized reference sources are essential conditions for the system to be able to carry this burden.

3. The growth of the specialist base. According to the WHO Mental Health Atlas 2020, between 2014 and 2020 the global median number of mental health workers rose from 9 to 13 per 100,000 population, and over the past 10–15 years the professional community of psychologists, psychiatrists and psychotherapists has expanded markedly. Universities are opening psychology programs, young specialists receive additional training abroad, and private clinical centers are multiplying. However, the growth in the number of specialists is outpacing the renewal of reference literature. Much of the available literature is either outdated (built on ICD-10 and DSM-IV), fragmented (covering only individual disorders), or at a popular level (insufficient for professional clinical use).

Why this book?

The distinctive features of today’s clinical context increase the importance of this book.

A shared professional language. The professional language of clinical psychiatry and psychotherapy — in university lecture halls, in educational literature and in clinical practice — is in the process of renewal: the transition to ICD-11 has changed the names and boundaries of many nosologies. The precise naming of every nosology, the clear formulation of every diagnostic criterion and the standardization of every intervention protocol are all part of this collective process. This book contributes to this process: the standardized presentation of the World Health Organization (WHO) ICD-11 and the American Psychiatric Association (APA) DSM-5-TR side by side with ICD-10; the alignment of terms from international guidelines with the terminology established in clinical practice; and the use, as a basis, of the official wording of the primary sources — the ICD-11 Clinical Descriptions and Diagnostic Requirements (CDDR, 2024), DSM-5-TR and the NICE, APA and WFSBP guidelines. The terminology of this book has been checked against these primary sources.

Professional ties with the international community. The European Association for Behavioural and Cognitive Therapies (EABCT) brings together 56 national cognitive behavioral therapy (CBT) associations and 7 affiliate members from 43 countries, while the DBT-Linehan Board of Certification (DBT-LBC) and EMDR Europe set uniform requirements for training in dialectical behavior therapy (DBT) and eye movement desensitization and reprocessing (EMDR) across national borders. Uniform international standards give the specialist the opportunity to make the widest possible use of training and supervision systems abroad. The clinical terminology of this book maintains consistency with the international professional literature, which facilitates the specialist’s transition to original training materials and accreditation programs.

Transitional context. In many national health systems — above all across the post-Soviet space — earlier psychiatric terminology and approaches are still partly preserved in clinical practice, and official statistics are still reported under ICD-10. At the same time, these systems are on the path of integration into international standards: WHO brought ICD-11 into effect on 1 January 2022, and Member States are moving to it gradually, over a transition period of several years. For clinical practice in the transition period, this book serves as a bridge between modern international standards and local clinical reality.

The author’s clinical experience. This book is not merely a translation or compilation of international sources. It has been enriched by the author’s more than 20 years of clinical practice, observations and developed protocols. The two clinical protocols developed by the author and presented in the relevant sections of the book — a modified alarm therapy for childhood enuresis and a two-stage treatment strategy for psychogenic depression — have been tested over many years in the author’s clinical practice and confirmed by the measurable outcomes obtained. This takes the book beyond a mere reference source and gives it the status of a book of clinical experience.

The target audience of this book

This book has been written for four main categories of readers:

1. Practicing clinical psychiatrists. A presentation of the WHO ICD-11 and DSM-5-TR (APA) criteria for diagnostic accuracy, a psychotherapeutic strategy map for each nosology, and the author’s clinical protocols.

2. Clinical psychologists and psychotherapists. An evidence-based intervention map (see the relevant table), the methodology of the author’s protocols, and the organizational framework of clinical psychotherapy.

3. Medical and psychology students. Systematic, modern reference literature consistent with international standards; literature of this format — three classifications and treatment standards in a single structure — remains rare.

4. Those involved at the management level of the healthcare system and decision-makers. Standardized protocols provide the basis for quality control, specialist training and the optimization of services.

Conclusion

Modern psychiatry and psychotherapy are a rapidly developing field of medicine with a constantly expanding evidence base and regularly updated international standards. The development of this field is one of the most important healthcare tasks ahead — and it is defined as such in the WHO Comprehensive Mental Health Action Plan 2013–2030.

This book is intended to contribute to this development. It does not set out to give ready-made answers; rather, it aims to provide a reliable framework for systematic clinical thinking. Each specialist fills this framework in their own distinctive way in clinical practice — by working with patients, by taking part in international accreditation programs and in the process of professional development.

For patients, in turn, this book can serve as a means to assess the quality of the care they receive, to ask the right questions and to demand evidence-based treatment. In the field of health, and particularly in mental health, an informed patient is an essential condition for quality care.

This Preface creates the necessary context for reading the entire book. The following chapters will present the foundations of psychopathology, the clinical interview and the psychiatric examination, and then a systematic presentation of each major mental disorder according to the WHO ICD-11 and DSM-5-TR classifications.

Baku, 2026

Kenan Ragimov

Author and contributors

Author: Kenan Ragimov (Baku, 2026)

Website: ragimoff.org

Acknowledgements: I am deeply grateful to AZPA, the Department of Psychiatry of Azerbaijan Medical University and the Public Health and Reforms Center of the Ministry of Health for their invaluable efforts in the preparation of the clinical protocols. The organizations that develop international recommendations — the National Institute for Health and Care Excellence (NICE), the American Psychiatric Association (APA), the World Federation of Societies of Biological Psychiatry (WFSBP), the Canadian Network for Mood and Anxiety Treatments (CANMAT), the International Society for Traumatic Stress Studies (ISTSS) and WHO — are thanked for their contributions to the development of evidence-based psychiatry.

Baku, 2026

Acknowledgements

This book has been prepared with the aim of contributing to the development of modern psychiatry. I thank the WHO team for the Clinical Descriptions and Diagnostic Requirements (CDDR), to the specialists who develop international clinical recommendations, to the Popov–Vid post-Soviet psychiatric tradition and to Azerbaijani colleagues — to all of them.

The book has been prepared in a form open to public discussion and will continue to develop. Reviews, remarks and suggestions will be taken into account in subsequent editions.

THE GLOBAL MENTAL HEALTH CRISIS: STATISTICS, TRENDS AND THE TREATMENT GAP

The global picture

In the third decade of the 21st century, the field of mental health faces a crisis of historic proportions. According to the Mental Health Atlas 2024 report published by WHO in 2025, more than 1 billion people worldwide live with a mental disorder. This figure is equal to approximately one seventh of the planet’s total population and is the highest figure recorded in the history of modern medicine.

The impact of mental disorders is not limited to the number of affected individuals alone. According to WHO data, mental disorders account for nearly one-sixth of all years lived with disability (YLD) from diseases worldwide, and in terms of non-fatal burden they are a major factor comparable to cardiovascular diseases. Depression and anxiety disorders alone cost the global economy approximately 1 trillion US dollars per year in the form of lost productivity.

Behind these figures stand concrete clinical realities. In 2021, 359 million people were affected by anxiety disorders (including 72 million children and adolescents), and 332 million people by depressive disorders. Bipolar disorder affects 37 million people, while schizophrenia affects approximately 23 million. However, these figures are modeled estimates; actual prevalence may be higher, because diagnostic infrastructure remains insufficiently developed in many countries.

Trends, 1990–2021

Long-term data from the Global Burden of Disease (GBD) research program confirm the sharp increase over the past 30 years. The following table shows prevalence dynamics for the main nosologies.

Table 1. Global prevalence dynamics of the main mental disorders, 1990–2021

Source: 1990 and 2019 — GBD 2019 (Lancet Psychiatry, 2022; 9(2): 137–150); the last two columns — change over 1990–2019, calculated from Table 1 of that article; 2021 — GBD 2021 (IHME, 2024), WHO “World mental health today”, 2025, Table 2.1. The 2021 figures take into account adjustments for the COVID-19 pandemic.

¹ The 2021 figures are taken from the new GBD round (GBD 2021). Modeling was updated between rounds, so the 2019 and 2021 columns should not be compared directly; for example, the “increase” in autism spectrum disorder from 28 million to 62 million is mainly the result of the new methodology.

It is clear from the table that, in absolute numbers up to 2019, the largest increases were recorded in depressive disorders (109 million additional cases) and in anxiety disorders (107 million). The age-standardized indicator (that is, the true epidemiological increase remaining after subtracting natural growth associated with population aging) is highest for eating disorders — +15.6%, which is one of the main factors linked to socio-psychological changes involving body image perception, social networks and eating culture in modern society.

The impact of the COVID-19 pandemic

During 2020–2022, the situation in global mental health was at its most acute. According to a meta-analysis published in The Lancet in 2021 (COVID-19 Mental Disorders Collaborators, 2021), during the first year of the pandemic:

The prevalence of depressive disorder (major depressive disorder according to DSM-5-TR, MDD) increased by 27.6% above the expected level.

The prevalence of anxiety disorders increased by 25.6%

53 million additional cases of depression and 76 million additional cases of anxiety were recorded

Even after the direct impact of the pandemic weakened, the figures did not fully return to their pre-pandemic level. Most researchers explain this as the phenomenon of a new baseline: long-term isolation of society, economic uncertainty, changes in intra-family relationships and an increase in chronic stress have become permanent.

The most common disorders by prevalence and growth rate

From a clinical perspective, two different rankings are important: the most widespread disorders in absolute numbers and the fastest-growing disorders by age standardization.

Table 2. Top ten: prevalence 2021, change 1990–2019

Source: prevalence — Global Burden of Disease Study 2021 (GBD; IHME, Seattle), WHO World Mental Health Today, 2025, table 2.1; change — calculated based on GBD 2019 (Lancet Psychiatry, 2022), table 1.

² According to WHO, in 2021 roughly 1 in 127 people worldwide was living with autism spectrum disorder. In the United States (CDC, ADDM Network), the figure among 8-year-old children rose from 1 in 150 in 2000 to 1 in 31 in 2022. Part of the increase is explained by broader diagnostic criteria, greater awareness and early screening, but not all of it: in a Danish study about 60% of the increase was explained by changes in registration and diagnostic practice, and the remainder was left unexplained (Hansen S.N. et al., JAMA Pediatrics, 2015). Observations by clinicians, educators and child-care institutions also point to a genuine increase.

The treatment gap phenomenon

The most acute problem in the field of mental health is not prevalence figures but the gap between the treatment received and the treatment needed. This phenomenon is known in the scientific literature as the treatment gap.

Table 3. Treatment gap — comparison by disorder

Source: WHO Atlas 2024; Alonso J. et al. Treatment gap for anxiety disorders is global. Depression and Anxiety, 2018; 35(3): 195–208; Thornicroft et al., British Journal of Psychiatry, 2017; Kohn R. et al., WHO Bulletin, 2004; 82: 858–866; Lora A. et al., WHO Bulletin, 2012; 90: 47–54; Stein D.J. et al., BMC Psychiatry, 2023; 23: 226.

Behind these figures lies a serious structural difference. Psychotic disorders (schizophrenia, schizoaffective disorder, severe bipolar disorder) — that is, the disorders that are more widely recognized in society — are covered by psychiatric hospital systems, state statistics, and WHO classification. In these disorders, diagnosis is relatively systematic, treatment relatively controlled, and statistics relatively reliable.

Anxiety and depressive disorders, by contrast, are in a completely different situation. These are the “hidden” or “gray zone” disorders:

In most cases, the patient does not consult psychiatric services but general practice, somatic specialists, or neurologists.

When a diagnosis is made, treatment is in most cases limited to symptomatic pharmacotherapy alone

Psychotherapy is either not offered at all or is delivered through widely used non-standard and unproven methods

Long-term monitoring of the patient’s objective status is not carried out systematically

It is this very circumstance that constitutes the core of the global mental health crisis. The numerically greatest burden lies with the “gray zone” disorders, yet the least controlled system is also built around them.

Psychogenic aspect: the root problem

In order to fully understand the clinical meaning of the figures presented above, one fundamental truth must be emphasized: in the vast majority of anxiety and depressive disorders, psychosocial factors play a central role. This means that their primary cause is not neurobiological dysfunction but psychological processes: cognitive distortions, impaired attachment schemas, unresolved mourning processes, self-punitive self-evaluation patterns, and distortions in core beliefs.

Contemporary studies show that in 60–80% of cases psychosocial factors are central to the onset of depressive disorders. The long-term twin studies of Kendler and colleagues (Virginia Twin Registry, 1990–2010) established that more than 60% of episodes of major depressive disorder are triggered by an identifiable stressful life event (Kendler et al., Am J Psychiatry 1999; Arch Gen Psychiatry 2003). A prominent representative of the classical post-Soviet psychiatric school, Prof. V. D. Vid (Saint Petersburg, Bekhterev Institute), advances a similar position in his works: in 60–70% of patients presenting with somatic complaints, no somatic disease is actually detected — the main problem of these patients is psychogenic in origin, yet as a result of misdiagnosis they receive somatic treatment (Popov Yu.V., Vid V.D., Modern Clinical Psychiatry, 2nd edition, 2006).

An important fact confirming this position in a historical and contemporary context is the phenomenon of two diagnoses — “vegetative-vascular dystonia” and “neurocirculatory dystonia” — which were used for decades in the former Soviet Union. These diagnoses were widely made in neurological and cardiology departments, although their etiological basis has not been scientifically confirmed. On psychiatric or psychotherapeutic examination, the same patients corresponded to the categories of somatization disorder (ICD-10: F45.0; ICD-11: 6C20) or adjustment disorder (ICD-10: F43.2; ICD-11: 6B43) and met the criteria for depression or panic disorder. This phenomenon of systematic misdiagnosis is linked to the failure to recognize psychiatric problems in somatic departments — and this situation is also observed in contemporary clinical practice.

In the same way, the vast majority of anxiety disorders are directly linked to psychosocial factors — attachment disorders in childhood, parenting style, traumatic experiences, and complex core beliefs. Leading representatives of the World Psychiatric Association (WPA) and international psychotherapeutic schools (O. Kernberg, G. Gabbard, A. Beck, V. Frankl) consistently emphasize that pharmacological treatment of a depressive episode does not resolve its psychological roots. Therefore, in the treatment of depression, psychotherapeutic intervention is a first-line treatment — in mild and moderate cases in the form of psychotherapy alone, and in severe cases in parallel with pharmacotherapy.

This fact has decisive consequences for treatment strategies. In psychogenic disorder, medication produces a symptomatic effect but does not resolve the root problem. An antidepressant can elevate the patient’s mood, but it does not touch the cognitive structure that compels the patient to self-blame. An anxiolytic can interrupt an anxiety attack, yet it does not change the patient’s core belief that the world is dangerous. When the patient discontinues the medication or encounters a new stressor, the disorder often returns, manifesting in an even more severe form.

The root problem of psychogenic disorders can be resolved only through psychotherapeutic intervention. This does not mean that psychotherapy is superior to pharmacotherapy; it means that the two interventions serve different purposes:

Pharmacotherapy — manages symptoms, stabilizes acute conditions, and acts on the neurobiological component.

Psychotherapy — resolves the psychological roots of the disorder, restructures the cognitive framework, changes behavioral patterns, and reduces the risk of relapse.

These two interventions are not mutually exclusive — they complement each other. However, contemporary healthcare systems, especially in low- and middle-income countries, are almost entirely oriented toward pharmacotherapy. Psychotherapeutic services — even when available — remain in an unstandardized, unlicensed domain lacking quality control. This drives the patient toward one of two risky situations: either the patient receives only symptomatic drug treatment (with the root problem unresolved), or receives uncontrolled, low-quality psychological care (with the risk of the problem worsening).

Conclusion

The figures and trends presented in this chapter lead to one conclusion: the mental health crisis, which currently affects more than 1 billion people worldwide, has shown a sharp increase over the past 30 years and has remained at a new baseline level after the COVID-19 pandemic. The bulk of this burden falls on anxiety and depressive disorders — in these disorders the psychosocial component predominates, and a solution at the root level is possible only through psychotherapeutic intervention.

At the same time, it is precisely for these disorders that the treatment gap is greatest: only 3 of every 10 patients with anxiety disorders receive any treatment, and only 1 receives appropriate treatment. The only way to close this gap is high-quality, standardized, evidence-based psychotherapeutic care.

From this standpoint, the following chapters provide a systematic analysis of evidence-based psychotherapeutic strategies — their classification, clinical applications, and levels of evidence.

CLINICAL STRATEGIES OF PSYCHOTHERAPY

Concept of clinical psychotherapy

Until the mid-twentieth century, psychotherapeutic activity was organized mainly within the framework of school traditions. A psychoanalyst regarded themselves as a psychoanalyst, a behavior therapist regarded themselves as a behaviorist, and a Gestalt therapist regarded themselves as a Gestalt therapist; each treated their patients with the method of their own school — regardless of the patient’s diagnosis. In this approach, the therapist’s method was regarded as more important than the patient’s disorder: the tool was considered primary, and the problem secondary.

From the late 20th century to the early 21st century, a fundamental change occurred in clinical thinking. The principles of evidence-based medicine began to be applied to the psychotherapeutic field as well, and a new paradigm took shape. The foundation of this paradigm is the concept of clinical psychotherapy: whatever the therapist’s primary school, they bear the responsibility for applying the most effective, evidence-based strategy for the specific disorder.

This principle can be explained with a simple example. Suppose a therapist has received psychoanalytic training and has undergone five years of personal analysis. A 7-year-old child suffering from nocturnal enuresis is brought to the therapist. The classical psychoanalytic approach may attempt to explain the child’s symptom as an expression of the Oedipus complex, of parental relations, or of childhood trauma. Regardless of the degree of truth in this explanation, from the standpoint of clinical outcome this approach is ineffective: nocturnal enuresis is successfully treated in more than 70% of cases by means of alarm therapy — that is, an evidence-based behavioral intervention. Giving a psychoanalytic interpretation does not eliminate the child’s symptom; it prolongs the duration of treatment and leads to the inefficient use of parental resources.

Clinical psychotherapy is unambiguous on this matter: enuresis is treated according to a behavioral protocol, regardless of the therapist’s school. In the same way, panic disorder is treated with cognitive behavioral therapy, borderline personality disorder with dialectical behavior therapy or schema therapy, simple phobias with exposure therapy, and post-traumatic stress disorder (PTSD) with eye movement desensitization and reprocessing or trauma-focused cognitive behavioral therapy. This choice rests not on the therapist’s personal preference but on the scientific evidence accumulated for the specific disorder.

This approach has two practical implications. First, the patient’s interests take precedence over school affiliation: the patient has the right to receive the best treatment for their own disorder rather than care determined by the therapist’s personal professional history. Second, a need arises for transdiagnostic competence in the specialist’s professional conduct: the therapist must be able to work not only with the methods of a single school but with a variety of evidence-based protocols.

Psychotherapeutic schools and their mechanisms

Modern clinical psychotherapy encompasses dozens of schools and methods. Below is a brief description of those most important from the standpoint of clinical practice.

Cognitive behavioral therapy (CBT). This approach, developed by Aaron Beck (depression, the 1960s) and Albert Ellis, the founder of Rational Emotive Behavior Therapy (REBT), works at the cognitive level. The main postulate is that it is not the event itself but the appraisal of the event that determines the emotional reaction. In therapy, the patient learns to recognize automatic thoughts and cognitive distortions (catastrophizing, black-and-white thinking, personalization, jumping to conclusions, and so on), to examine them, and to replace them with more functional alternatives. The behavioral component — exposure, behavioral activation, and habit practice — reinforces cognitive change. It is the psychotherapeutic method with the broadest body of evidence.

Dialectical behavior therapy (DBT). Marsha Linehan developed it in the 1980s for patients with chronic suicidal tendencies and borderline personality disorder. It is a continuation of CBT but adds specific modules for patients with emotional dysregulation, deficits in tolerance, and problems of impulsivity: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Standard DBT consists of weekly individual sessions, group skills-training sessions, telephone coaching, and consultations with the therapist team.

Schema therapy. Developed by Jeffrey Young in the 1990s, this approach combines CBT, Gestalt therapy, attachment theory, and psychodynamic elements. It is especially effective for personality disorders and for chronic, treatment-resistant cases of depression and anxiety. It identifies and rewrites early maladaptive schemas (for example, abandonment, mistrust, and defectiveness) and the associated modes (child mode, harsh parent mode, and healthy adult mode).

Eye movement desensitization and reprocessing (EMDR). Francine Shapiro developed it in 1987. It is a structured eight-phase protocol for the reprocessing of traumatic memories by means of bilateral stimulation (eye movements or alternating tactile/auditory stimulation). It is recommended by WHO as a first-line intervention for PTSD. The method is effective in complex trauma and phobias with a traumatic component, as well as in cases in which depression and anxiety have a traumatic component.

Interpersonal therapy (IPT). Gerald Klerman and Myrna Weissman developed it in the 1970s for depression. It links the patient’s symptoms to one of four interpersonal domains: grief, role conflicts, role transitions, and interpersonal deficits. It is structured and brief (12–16 sessions) and demonstrates efficacy equal to that of CBT for depression.

Acceptance and commitment therapy (ACT). This therapy is a third-wave CBT approach developed by Steven Hayes in the 1980s. It is aimed not at changing the content of thoughts but at changing one’s relationship to them. It develops psychological flexibility: living a life in accordance with one’s values, openness to painful emotions, and cognitive defusion. It is effective in chronic pain, depression, anxiety, addiction disorders, and existential crises.

Mindfulness-based cognitive therapy (MBCT). Zindel Segal, Mark Williams, and John Teasdale developed it for the prevention of recurrent depression. It combines CBT with Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR) program. For patients with three or more previous episodes of major depressive disorder, it yields prophylactic outcomes equal to or better than those of pharmacotherapy.

Psychodynamic psychotherapy is a method that emerged from classical psychoanalysis but has been adapted to the modern clinical setting. Several models are in use: Mentalization-Based Treatment (MBT), Transference-Focused Psychotherapy (TFP — Kernberg), and Short-Term Psychodynamic Psychotherapy (STPP). The core mechanism is the study and rewriting of the patient’s unconscious processes, defense mechanisms, relationship patterns, and the influence of early childhood experiences on present-day behavior. It is effective in personality disorders, chronic depression, and relationship problems.

Levels of evidence

The effectiveness of psychotherapeutic methods is assessed on the basis of systematic research, namely randomized controlled trials (RCTs), meta-analyses, and systematic reviews. International clinical guidelines, such as NICE (National Institute for Health and Care Excellence, United Kingdom), the American Psychiatric Association (APA), the World Federation of Societies of Biological Psychiatry (WFSBP), and the World Health Organization (WHO), synthesize this evidence and define levels of evidence:

Level A (high evidence) — efficacy confirmed in multiple independent high-quality RCTs and meta-analyses. The method is considered a first-line intervention for the specific disorder.

Level B (moderate evidence) — efficacy confirmed in several RCTs, but the body of meta-analyses is limited or there are certain inconsistencies among the results. The method is recommended as a second-line or alternative first-line intervention.

Level C (limited evidence) — methods that have demonstrated efficacy only in individual studies or clinical case reports. They may be used when first-line methods fail to produce an effect or are unavailable.

Map of treatment strategies by disorder

The following table presents the psychotherapeutic interventions recommended in international guidelines for the major mental disorders, together with their levels of evidence.

Table 4. Psychotherapeutic strategies — a map by disorder

Source: NICE Clinical Guidelines (2022, 2024); APA Clinical Practice Guidelines (2019, 2024); the WHO Mental Health Gap Action Programme (mhGAP) intervention guide (mhGAP Intervention Guide 2.0, 2016; mhGAP guideline, 2023); WFSBP Treatment Guidelines.

PTSD: per APA (2025), EMDR is second-line (conditional recommendation); per VA/DoD (2023), EMDR is recommended alongside CPT and PE.

Pharmacotherapy and psychotherapy: complementary, not competing

A question that regularly arises in psychiatric practice: medication or psychotherapy? The question itself is wrong, because they are not mutually exclusive.

The correct question is formulated along three dimensions:

1. The nature of the disorder. In severe disorders with a neurobiological component (schizophrenia, severe bipolar disorder, melancholic depression, severe OCD), pharmacotherapy is the mainstay and psychotherapy is complementary. In psychogenic, mild-to-moderate, reactive disorders (adjustment disorder, GAD, social anxiety disorder, simple phobias), psychotherapy is the main intervention, and medication (SSRIs — selective serotonin reuptake inhibitors) is added for an adequate period when necessary.

2. The patient’s condition. If there is an acute suicide risk, severe functional impairment, refusal of food intake, or psychotic elements, pharmacotherapy is superior in the acute phase. After stabilization, psychotherapy assumes the main role.

3. Treatment phase. The acute phase is aimed at stabilizing symptoms; at this stage, pharmacotherapy yields rapid results. Once stabilization is achieved, the phase of addressing the underlying problem begins; in this phase, psychotherapy assumes the leading role. During the prevention phase, psychotherapy prevents relapse, and it is here that its advantage is most clearly evident.

Table 5. Pharmacotherapy and psychotherapy: comparative capabilities

Source: American Psychiatric Association (APA) Clinical Practice Guidelines (2019); NICE (National Institute for Health and Care Excellence) depression guideline NG222 (2022); Cuijpers P. et al., World Psychiatry, 2023.

Organizational significance of clinical psychotherapy

The concept of clinical psychotherapy has another important aspect: it creates the foundation for the standardization of psychotherapeutic care. Evidence-based, disorder-specific protocols resolve three critical issues:

1. Training of specialists. When a specific protocol exists for each disorder, specialist training becomes faster and of higher quality. Instead of learning abstract theory, the student learns specific strategies for specific clinical situations.

2. Quality control. The availability of a standard protocol allows the supervisor to evaluate the specialist’s work in terms of adherence to the protocol. This currently also forms the basis of professional accreditation (see the Accreditation chapter).

3. Statistical analysis and optimization. Standardized protocols enable a comparative evaluation of outcomes. Under standardized conditions, it is determined which protocol is more effective in which patient group. Which modification improves the outcome? Answers to these questions are possible only under conditions of standardized practice.

Given this institutional significance of clinical psychotherapy, the next logical step is to review the international system of quality control for psychotherapeutic care — the accreditation bodies, their requirements, and the current situation in Azerbaijan. This issue will be presented in the final block of this Preface, but first, two clinical protocols by the author are presented — the management of nocturnal enuresis in childhood and of psychogenic depression. These protocols were developed over many years of clinical practice and confirmed by the outcomes obtained.

AUTHOR’S CLINICAL PROTOCOL No. 1: TREATMENT OF NOCTURNAL ENURESIS IN CHILDREN

Modified alarm therapy protocol

K. Ragimov, clinical practice 2018–2025

The essence and place of the protocol

Nocturnal enuresis in children (World Health Organization (WHO) ICD-11: 6C00.0; DSM-5-TR: F98.0) is a condition of involuntary nocturnal urination (enuresis) that persists beyond the age norm (over 5 years). It is observed in approximately 5–10% of 7-year-old children, in 3–5% of 10-year-olds, and in 1–2% of adolescents. The disorder can have a serious negative effect on the child’s self-esteem, social functioning, and intrafamilial relationships.

International clinical guidelines — NICE CG111, the International Children’s Continence Society (ICCS), and the American Academy of Pediatrics (AAP) — recommend alarm therapy (a waking system with a urine sensor) as the first-line intervention for nocturnal enuresis. The standard protocol yields complete remission in 65–75% of cases with a 12–16-week course. However, the standard protocol has a number of gaps:

Evening fluid intake is restricted — this reduces the number of exercises and slows the formation of reflexes.

Going to the toilet before bedtime — since the child goes to sleep with an empty bladder, the disorder occurs less often, and accordingly there are fewer opportunities for correction

The child’s awakening to the alarm device is passively awaited — during deep sleep the child does not wake, and the overlearning stage is used only at the end of the course

A comprehensive system of daily exercises is rarely integrated

The modification presented below was developed for the purpose of eliminating these gaps. The basic principle is a full load at the beginning of the course: fluid loading, forced awakening, awakening and standing the child up in a loud yet caring tone, an immediately reinforced behavioral component, parallel daily training, and motivational support. Outcomes achieved in this retrospective case series: complete remission in 192 of 240 children (80%) by weeks 11–12.

Clinical principles of the protocol

Four principles underlie the modification:

1. Intensive start, not a gradually increasing load. In standard protocols the load is increased gradually, and overlearning (excessive fluid loading) is applied only in the final phase of the course. In this modification, from the first week the child is given 200–400 ml of fluid in the evening (ordinary drinking water or tea; carbonated, sweet, or caffeinated drinks are excluded) at least 1 hour before bedtime, and the child is not allowed to use the toilet before going to bed. The goal is to create the conditions for the voiding event to actually occur, since an event that does not occur cannot be corrected.

Absolute contraindications (fluid loading is not applied):

Renal diseases (chronic renal failure, nephrotic syndrome, etc.)

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Overactive bladder or neurogenic bladder

Epilepsy (especially uncontrolled forms)

Diabetes insipidus

Heart failure

Any serious somatic pathology — a preliminary pediatric examination is required

2. Active parental involvement, not passive waiting. In the standard protocol, the child is expected to wake up independently in response to the alarm device. However, during the deep sleep phase most children do not wake to the sound of the device — this is the most frequently reported gap. In the modification, during the first and second weeks the parent awakens the child — within 5–10 seconds after the device sounds, in a loud but caring tone, turning on the light and washing the child’s face with cool water, bringing the child to a state of full awakening. The aim of this procedure is not to frighten the child — it is to bring the child quickly into a fully alert state; the loudness of the parent’s voice does not amount to shouting or an attack. This ensures the rapid formation of the reflex by creating mild, purposeful stress.

3. Integrated approach — daily exercises at the same time. Nocturnal enuresis is not only a disorder of the bladder–central nervous system reflex; in most cases it is a complex disorder combined with weakness of the pelvic floor muscles and a deficit of behavioral learning. In the modification, daily Kegel exercises (3 times a day, with 10–60 repetitions, increasing weekly) are an integral part of the protocol. This also eliminates the concurrently observed encopresis disorder (ICD-11: 6C01).

4. Motivational support and psychological regulation. A weekly meeting with the parent, assessment of the child’s motivation level, reinforcement of small achievements, and discussion of revised goals are among the key elements of the protocol. The child perceives themselves as an active subject of the process rather than a mechanical passive object.

Stages of the protocol

The protocol consists of 5 stages, each lasting 2 weeks, a total of 10 weeks. Each stage builds on the previous one and progressively shapes the child’s arousal reflexes, pelvic floor muscle tone, and behavioral patterns.

Table 6. Modified alarm therapy protocol — by stage

Source: K. Ragimov, clinical practice 2018–2025, n = 240 children, Baku. Level of evidence IV — retrospective clinical observation (case series). The data derive from this retrospective clinical observation; a randomized trial with a control group is being planned.

Weeks 11–12: consolidation and evaluation

After the 10-week structured protocol, weeks 11–12 are designated as a consolidation stage. During this period, the child:

Independently, without parental intervention, consumes 200–400 ml of fluid at least 1 hour before bedtime every night

Goes to bed without going to the toilet

Wakes at night in response to their own internal signal (without an alarm device), and the bed remains dry

Wakes in the morning completely dry.

Clinical outcomes: in a group of 240 pediatric patients, complete remission (no nocturnal wetting episodes) was recorded in 80% of cases at weeks 11–12. This is higher than the outcome of the international standard alarm protocol (65–75%).

Description of Kegel exercises for the pelvic floor muscles (comprehensive daily program)

The exercise units, which change weekly, target different functional aspects of the pelvic floor muscle group:

Fast contractions (week 3): Rapid contraction and relaxation of the pelvic floor muscles, aimed at developing reflex tone.

Slow contractions (week 4): Sustained contraction — increasing muscle endurance

Maximum retention (week 5): Prolonged contraction cycles aimed at forming stable tone.

Stop–Continue (week 6): An exercise of voluntary interruption and resumption of the urinary stream — learning voluntary control of urination

Programming (week 7): Filling the bladder to a specific volume and managing it

Bridge (week 8): Pelvic lifting exercises — synchronization of the abdominal and pelvic muscles

Squeeze–Cough (week 9): A resistance exercise against stress incontinence is applied.

Lift exercise (week 10): graded contraction — stepwise increasing control of the muscles

Practical recommendations

Essential conditions for the effective implementation of the protocol:

1. Parental motivation is an essential condition. During the first two weeks, parents must wake several times a night and actively awaken the child within 5–10 seconds. This is a heavy burden for the family and requires prior consent. A weekly meeting with the parent is an integral part of the protocol.

2. Reduction of fluid intake is prohibited. Many parents (and some physicians) intuitively recommend reducing evening fluid intake. In this modification, this step is considered unambiguously contraindicated — reflex formation occurs under conditions of full load.

3. Selection of the device. Enuresis alarm devices are of two types: bed-placed and underwear-placed. The second type is more effective, because it signals immediately at the first drop of urine. In this modification, the underwear type is recommended.

4. Concurrently observed encopresis. In approximately 10–15% of children with nocturnal enuresis, encopresis (ICD-11: 6C01) is found concurrently. In this modification, the comprehensive Kegel exercises resolve both disorders at the same time — pelvic floor muscle tone improves the control of both the bladder and the anal sphincter.

5. In cases of resistance. If there is no progress after week 6 (the end of stage 3), additional medical examination is required:

Urological examination — bladder dysfunction, anatomical anomalies

Neurological status — myelodysplasia, spina bifida occulta, neurogenic bladder

Endocrine indicators — diabetes insipidus, antidiuretic hormone deficiency

Otorhinolaryngological examination — obstructive sleep apnea (particularly in children with adenoid hypertrophy or palatine tonsil enlargement); apnea is closely associated with enuresis and may be the main cause

Psychiatric background — attention-deficit/hyperactivity disorder (ADHD), conduct disorders, acute traumatic events

Pharmacotherapy may be added only when there is an indication confirmed by examination: in detrusor overactivity — oxybutynin; desmopressin — only when a low blood vasopressin level is confirmed by analysis and the nocturnal urine volume is very large. In this modification, desmopressin is not used. If obstructive sleep apnea is diagnosed, adenoidectomy or tonsillectomy may eliminate enuresis.

6. Age limitation. The protocol is designed for children over 5 years of age. Primary nocturnal enuresis before the age of 5 is consistent with the age norm and does not require active intervention.

7. Absolute contraindications to fluid loading. If any of the following conditions are present, the fluid loading protocol is not applied, and the standard NICE CG111 protocol is used:

Renal pathology (chronic renal failure, nephrotic syndrome, urolithiasis)

Syndrome of inappropriate antidiuretic hormone secretion (SIADH; Schwartz–Bartter syndrome)

Epilepsy (particularly cholinergic forms or forms sensitive to water balance)

Heart failure, hypertension

Diabetes mellitus or diabetes insipidus (uncompensated)

Severe endocrine disorders (hypothyroidism, hypoparathyroidism)

Any somatic disease in which a change in fluid balance may affect its course.

The absence of these conditions must be confirmed by a pediatrician or urologist before the protocol is started.

The place of the protocol within clinical psychotherapy

This modification is an application of the principles of clinical psychotherapy using nocturnal enuresis as an example. The evidence-based intervention for the disorder (alarm therapy, the behavioral component, Kegel exercises) was modified on the basis of the author’s clinical experience, and a measurable, reproducible outcome was achieved. The therapist’s primary school of thought is of no importance here — a psychoanalytic therapist, a cognitive behavioral therapy (CBT) therapist, or a Gestalt therapist can learn and apply this protocol in the same way. What matters is a structured, measurable, consistent clinical method.

The next author’s protocol — a two-stage strategy in the treatment of psychogenic depression — demonstrates the same principles of clinical psychotherapy in a more complex disorder that calls for cognitive-emotional work.

AUTHOR’S CLINICAL PROTOCOL No. 2: TREATMENT OF PSYCHOGENIC DEPRESSION

Integration of short-term cognitive restructuring and a long-term preventive strategy

K. Ragimov, clinical practice 2008–2025

The significance and place of the protocol

Psychogenic (reactive) depression — a symptom complex that develops under the influence of psychosocial factors within the framework of an ICD-11 depressive episode — is a depressive disorder associated with a specific life event or chain of events and arising not from a disturbance of neurobiological regulation but from cognitive-emotional processes. According to modern research, 60–80% of cases of major depressive disorder (MDD) are triggered by psychosocial factors: at their onset there is a specific triggering event (loss, relationship breakdown, occupational failure, complex trauma) (Kendler et al., 1999, 2003; Brown and Harris, 1978); this evidence should be supplemented with the modern guidelines (ICD-11, DSM-5-TR, NICE NG222). In the remaining 20–40% of cases, the disorder is endogenous — that is, neurobiological regulation predominates. In practice, however, purely psychogenic or purely endogenous depression is rarely encountered; most depressions are a mixture of psychosocial and neurobiological components in varying proportions. This protocol was developed for cases in which the psychosocial component is dominant.

This distinction is of decisive importance for the treatment strategy. In endogenous depression, the main intervention is pharmacotherapy; psychotherapy plays a complementary role. In psychogenic depression, by contrast, psychotherapy becomes the principal method; where medication is needed, it is used only in the acute phase as a short-term adjunct. Mild and moderate psychogenic depression is in most cases treated with psychotherapy without medication.

In modern clinical practice, however, the situation is the reverse: the vast majority of patients with psychogenic depression are treated with antidepressants alone. Symptoms decrease in the acute phase, but because the root problem remains unresolved, depression recurs after the medication is discontinued or under a new stressor — sometimes in a more severe form.

The protocol presented below was developed for the purpose of filling this gap. It consists of two consecutive stages: short-term cognitive restructuring (resolution of the acute depressive episode, 1–6 sessions) and long-term preventive therapy (psychological vaccination against relapse, 4 consecutive stages). Long-term (17-year) observations of this strategy, developed on the basis of clinical experience, demonstrate stable long-term remission.

Patient stratification

The choice of protocol requires a clear diagnostic stratification in advance. The following table formulates the tactical decisions by patient category.

Table 7. Selection of treatment strategy in depressive disorders

Source: K. Ragimov, clinical practice 2008–2025; the American Psychiatric Association (APA) guideline on the treatment of major depressive disorder (2010); the National Institute for Health and Care Excellence (NICE) guideline NG222 (2022), “Depression in adults: treatment and management”.

The protocol presented below was developed for the first-line category — psychogenic, mild-to-moderate depression. In the second-line category (severe psychogenic), the structure of the protocol is the same, but the pace is slower, and pharmacological support is applied in parallel.

Table 8. Criteria for the mandatory parallel use of pharmacotherapy

When at least one of the following criteria is present, psychotherapy must be carried out in parallel with pharmacotherapy; a psychotherapeutic approach alone is considered insufficient:

Source: NICE Guideline NG222 (2022), “Depression in adults: treatment and management”, 1.5.4–1.5.7; the APA Practice Guideline for the Treatment of Major Depressive Disorder (MDD), 2010, Section 9; the World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders (2013; Part 2 — 2015).

When these criteria are present, the initiation of pharmacotherapy is determined by a specialist. Mild-to-moderate psychogenic depression, when none of the above criteria is present, can be effectively treated with psychotherapy without medication — this aligns with the author’s clinical experience and with the coherent position of contemporary international guidelines.

PART I. SHORT-TERM COGNITIVE RESTRUCTURING (1–6 SESSIONS)

Objective: rapid resolution of the acute depressive episode without the use of medication.

Mechanism: identification of the depressogenic factor (not the situation, but the cognitive attitude) and the consistent application of evidence-based cognitive restructuring techniques.

Initial assessment and chronological history

Two objectives are achieved in the first session:

(a) Diagnostic confirmation. The level of depression is assessed with the PHQ-9 or BDI-II. How many of the 9 DSM-5-TR symptoms are present (depressed mood, anhedonia, sleep disturbances, appetite/weight change, loss of energy, feelings of guilt, impaired concentration, psychomotor changes, suicidal thoughts). If 5–6 symptoms are present, including depressed mood or anhedonia, this corresponds to mild-to-moderate depression, and the protocol may be applied.

(b) Chronological history. Together with the patient, the onset date of the symptoms is determined precisely (the exact week, and where possible the precise date). Then the events that occurred within ±2 months of this date are reviewed:

External events (loss, relationship disruption, change of job, health problem)

Internal events (regret, comparison, an unexpected thought, reading a particular book, recalling a particular conversation)

Minor or seemingly insignificant events — these are often the most important

Objective — to identify the trigger point. This is the specific event or moment of thought that sets off the depressive episode.

Identification of the self-punitive cognitive construct

After identifying the triggering event, the therapist, together with the patient, determines which thought about themselves the patient adopted in the context of this event. This thought is almost always self-punitive in nature:

“I am guilty”

“I do not deserve this”

“I have harmed others”

“I am inadequate”

“I could have saved him, but I did not”

“It happened because of me”

Indicator of the triggering attitude: when uttering this sentence, the patient shows an emotional reaction — their eyes fill with tears, their voice trembles, and tension is observed in the body. This is evidence that this construct indeed plays a central role.

A critical feature: the patient perceives this construct not as a cognitive distortion but as the truth. They do not accept the therapist’s accompanying explanation and typically say: “You do not know the truth. That is actually what happened.” — and once again repeat the same self-punitive sentence. This resistance is the most reliable proof that the construct has been correctly identified.

Cognitive restructuring — sequential techniques

At this stage, a multilayered technique is applied in various sequences. The technique is changed according to the patient’s defense layers.

An important methodological note. The techniques described below are examples intended to illustrate the general principle and are not the only or mandatory form of application. Each technique should be adapted to the cultural, religious, philosophical, cognitive, and emotional characteristics of the specific patient. In clinical psychotherapy, the main principle is not template application but the application of the principle.

The author’s approach is based on a synthesis of the principles of standard cognitive behavioral therapy (CBT) (Beck, Ellis), Schema Therapy (Young), acceptance and commitment therapy (ACT) (Hayes), and culturally adapted CBT (Hwang, 2006; Naeem et al., 2011, 2015). Epidemiological data indicate that in societies with strong religious and moral principles — Pakistan, the Middle East and North Africa (MENA) region, the South Caucasus, the former Soviet Muslim region — guilt and self-punitive judgment patterns are observed more intensively and more frequently. For such patients, cognitive restructuring carried out without consideration of the religious and ethical context is often ineffective, because the main source of the self-punitive construct was formed precisely in this context. The following techniques illustrate the practical application of this principle.

Technique 1. “The Legal Court” (an illustrative application of the decentering and reattribution techniques — Beck, 1979)

It is suitable for patients with a rational-legal style of thinking. The event is reconsidered from a legal standpoint:

What action did the patient perform (or fail to perform)?

Is this a crime under existing legislation?

If it is regarded as a crime, under which article should it be punished?

The therapist neither denies nor argues — they investigate together. The patient reaches the conclusion themselves: legally, this is not a crime. Here, many patients receive a formal assessment of their situation for the first time.

The patient’s typical reaction: they leave the legal level and move to the moral and ethical level. “Yes, legally it is not a crime, but morally I am a bad person.” — this transition is natural and expected.

Technique 2. “Moral and Ethical Judgment” (an illustrative application of culturally adapted CBT — Hwang, 2006; Naeem et al., 2011, 2015)

It is suitable for patients with a deep religious and moral system. If the patient is religious, a similar procedure is applied at the moral and ethical level, within the framework of the internal rules of the religious system:

To which category is this action assigned in the patient’s religious tradition?

Which specific sin is it considered to be?

What is the moral and religious punishment for this sin?

Is there a path of repentance and correction?

Here the therapist refers to the internal structure of the patient’s own religion and does not propose any other philosophical or psychological framework. Islam, Christianity, Judaism, and other religions — each has within itself a clearly structured system of rules. When the patient sees the objective application of this system, they often see that the punishment they inflict on themselves is many times greater than the actual sin.

Technique 3. “The Third-Person Perspective” (an illustrative application of the self-compassion technique — Neff, 2003; Gilbert, 2009)

It is a universal technique and can be applied to almost all patients. The patient is asked: if their close friend or a loved one were experiencing the same situation, how would they view them? What words would they say? Would they forgive them?

This technique is an application of cognitive defusion (in ACT terminology) and activates the self-compassion component.

Technique 4. Elements of Schema Therapy (Young, 1990; Young, Klosko, Weishaar, 2003)

It is suitable for patients with early traumatic experiences and chronic maladaptive patterns. The trigger construct often rests on a schema formed at an early age (for example, “being defective,” “unreliability,” “unfairness”). Schema Therapy techniques (imagery rescripting, schema mode dialogue) allow this early schema to be reassessed.

Technique 5. Standard cognitive restructuring techniques of CBT (Beck, 1979; Beck, Rush, Shaw, Emery, 1979)

It is usually used at the basic level in every patient. Socratic questioning, examination of the evidence, formulation of alternative explanations, behavioral experiments.

The outcome of the short-term phase

The successful outcome of this phase is linked to the patient’s key cognition:

“It was not the situation that caused the depression, but the cognitive construct I created in response to it.”

Once this cognition emerges, the mood changes many times faster, because the patient now faces not an insoluble external problem but a changeable internal structure. Sometimes one session — more often 4–5 sessions — is enough to resolve a full acute depressive episode.

However, this is only the first part. Even if the construct itself is changed, the patient’s general tendency to react in a self-punitive way remains unchanged. The same mechanism may start up again under the next trigger. Therefore, long-term preventive therapy is necessary.

PART II. LONG-TERM PREVENTIVE THERAPY — 4 CONSECUTIVE STAGES

Objective: to develop a resilient pattern of responding to stress, frustration, and irritating situations, and to prevent future depressive episodes — that is, to build psychological resilience.

Approach: it is dynamic in character, but it applies the practical component rather than the theory of classical or modern psychoanalysis. The central task is to identify and rewrite, in a structured way, the patient’s pattern of self-punitive responding (in the language of psychoanalysis: the guilt complex).

Stage 1. Insight

Function: the patient’s key cognition.

The patient understands that:

Their reaction was not directed at solving the problem at hand

It was not aimed at overcoming the frustration

On the contrary — it aggravated the situation

The tendency toward self-punitive reaction existed even before the triggering situation

The situation played only a triggering role; it was not the cause

This cognition is the foundation of long-term work. Without it, the subsequent stages cannot be completed.

Stage 2. Confrontation

Function: observation of the pattern.

The therapist and the patient ask together: what was inappropriate and what was abnormal in this process?

The focus of attention changes:

Before: external irritants, situations, people

Now: internal preparation, tendency toward a self-punitive pattern

The patient sees this pattern as a stable manifestation across various life situations.

Confrontation success marker: the patient begins to label their own condition as a “self-punitive pattern” or a “tendency to turn against oneself.” That is, they label their condition as pathological — not the situation.

This resembles a well-known process in the treatment of alcoholism: a person may abuse alcohol for years without calling themselves an alcoholic. When they come to an Alcoholics Anonymous meeting, however, their first exchange is: “Hello, I am an alcoholic.” This is the identification of behavior with illness. A person who accepts the behavior as an illness begins to struggle against it.

Stage 3. Clarification

Function: investigation of the history and extent of the pattern.

This is the most extensive stage. The starting marker of clarification: the patient always names the pattern by the same name and does not mix up the terminology. This means that the internal description of the pattern has become consolidated.

Together with the patient, a chronological review of their life is conducted — stress-inducing and frustration-generating situations are considered. Responding at the two poles is analyzed comparatively:

Table 8a. Poles of responding and their outcomes

Key cognition:

“Looking for someone to blame — my own or another’s — is extremely futile and ineffective. What is needed is to look for a solution, not for someone to blame.”

Self-blame

If there is an objective culprit → this is a social and legal problem and is resolved separately

Psychological task: to shift thinking from the “searching for someone to blame” mode to the “searching for a solution” mode

An important methodological warning — a typical mistake of novice therapists:

Novice therapists often begin to search for a specific childhood trauma episode as the “key” to the pattern — this is an illusion. Addressing a single episode leaves the entire pattern unchanged. The roots of the pattern lie in childhood, yes — but the focus of the work should be on the pattern itself, not on a single episode.

The completion marker of the clarification stage — the decisive point:

The dystonic separation of the pattern from the personality:

Before: the pattern was syntonic with the personality (“I am a responsible person; I take everything upon myself”)

Now: the patient separates the pattern from their own personality

They no longer consider the pattern to be good behavior

They no longer want to live within the pattern

This operation of separating the pattern from the personality = the outcome of the clarification stage

The culmination of stage 3: interpretation

Interpretation — in this model, it is not a separate stage but the culmination of the clarification stage. Classical psychoanalysis offers theoretical interpretations; in this model, by contrast, interpretation is a final, generalizing meta-message formed on the basis of the therapist’s observations:

“I observed how you behaved throughout therapy. I saw such a pattern. It had such an effect on your life. Now you have changed in this way. Now here is what can be done.”

With this message, the patient gains a final understanding in the structure of “what it was / what it is / what is to be done.” This is the preparation for the fourth stage.

Stage 4. Comprehensive working-through

Function: practical consolidation of the new responding pattern.

At this stage, the therapist:

Assigns in-session tasks — exercises aimed at changing the patient’s emotional reactions in the “here and now” (role play, imaginal staging, behavioral experiment)

Assigns homework — for the consolidation of the new behavior in real life

Between sessions, the patient attempts the new way of responding in real-life situations

With each repetition, the effectiveness of the new model increases

The new model finally takes root

Clinical outcome: the patient develops prophylactic resilience against future depressive episodes.

Longitudinal outcomes

The 17-year clinical practice of this protocol is evaluated through longitudinal observations. The following table presents the comparative outcomes.

Table 9. Comparative longitudinal outcomes (17-year follow-up)

Source: K. Ragimov, clinical practice 2008–2025 (combined group, n>1000) — level of evidence IV (clinical expert experience), retrospective observation; Cuijpers et al., World Psychiatry 2020 (psychotherapy — meta-analysis, level of evidence Ia); Bockting et al., Lancet Psychiatry 2018 (long-term effect of antidepressants — systematic review).

A critical observation: patients treated with antidepressants alone — even if they subjectively assess that they have achieved “full remission” — often experience a recurrent depressive episode when faced with new stressful situations, sometimes in a more severe form. In the combined protocol group, by contrast, such events occur rarely.

Resource efficiency

The combined protocol is more economical in terms of resources than pharmacotherapy alone or short-term psychotherapy alone:

For the patient:

Financially: total therapy costs are lower in the long term

In terms of time: the patient does not spend years on depressive episodes and toxic relationships

In terms of resources: the patient keeps their resources free for the realization of their potential, self-development, and the achievement of personal goals

For the healthcare system:

A standardized protocol accelerates specialist training — no 5-year personal psychoanalysis is required to learn the treatment of depression

Short-term training formats make it possible to train a large number of psychologists

The method ceases to be the privilege of “famous” psychotherapists who form a select group

Quality control of the service can be carried out on the basis of a standard criterion — the stage indicator (stage 1 → 2 → 3 → 4 → substages of the 4th stage)

Statistical analysis and optimization become possible

Its place within clinical psychotherapy

This modification is a more complex application of the principles of clinical psychotherapy in psychogenic depression. Here — unlike in nocturnal enuresis — not a single intervention but a multilevel strategy is required:

In the first part, techniques from different schools are used consecutively — cognitive behavioral therapy (CBT), schema therapy, cognitive defusion from acceptance and commitment therapy (ACT), and religious-moral reasoning

In the second part, the practical component of the dynamic approach is presented in the form of 4 structured stages

For the patient, this is not “psychological counseling” but a structured, measurable, consistent clinical method — as in the nocturnal enuresis protocol.

The following chapter presents the system of global psychotherapeutic accreditation, international requirements, and the situation in Azerbaijan — that is, the institutional framework of quality psychotherapeutic care.

ACCREDITATION AND QUALITY CONTROL: INTERNATIONAL STANDARDS AND THE SITUATION IN AZERBAIJAN

Why is accreditation important?

Psychotherapy is an activity that intervenes deeply in the patient’s mental state. Incorrectly conducted therapy is not only ineffective but can also actively harm the patient: violations of client–therapist boundaries; the treatment of severe psychiatric cases by a specialist who lacks the capacity for clinical assessment — all of these can aggravate the patient’s condition and in some cases lead to catastrophic outcomes.

For this reason, strict, multilevel accreditation systems for psychotherapeutic activity exist throughout the world. Every psychotherapeutic school has formulated its own requirements, and these requirements constitute a minimum standard that is not open to discussion: they are either met or not met; there is no third option.

This chapter presents the accreditation requirements of the world’s leading psychotherapeutic schools with concrete figures, and then objectively assesses the situation in Azerbaijan.

International accreditation bodies and their requirements

Psychoanalysis: International Psychoanalytical Association (IPA)

The IPA — founded in 1910 by Sigmund Freud — is the world’s leading accreditation and regulatory organization. It comprises 12,000 psychoanalytic members and 70 organizations. In its mission statement the IPA defines itself as follows: “The principal accrediting and regulatory body of the psychoanalytic profession in the world.”

Requirements for admission to IPA membership (the Eitingon model — the most widespread model):

Table 10. IPA requirements for psychoanalytic training

Source: IPA Procedural Code, 2024 edition; British Psychoanalytic Association — a constituent society of the IPA, training requirements, 2024.

These requirements are ensured through a multi-network verification system: the training institute must be an IPA component society, the supervisor must be registered with the IPA, and every candidate must be entered in the register of the International Psychoanalytical Studies Organization (IPSO). Ordinary certification courses — even when conducted by recognized psychoanalysts — do not replace IPA membership.

Cognitive behavioral therapy: European Association for Behavioural and Cognitive Therapies (EABCT)

EABCT is a European organization founded in 1976; it currently unites 56 national associations from 43 countries. EABCT, in turn, accredits national associations, which then accredit individual specialists.

This system is a two-level accreditation chain:

EABCT accredits the national association of a specific country (the list of accredited national associations is published openly on the eabct.eu website)

The accredited national association accredits individual CBT therapists

EABCT accreditation requirements:

The national association must be a full member of EABCT

It must implement a defined accreditation scheme

It must meet the established training standards

A system of continuing professional development (CPD) must be in place

Table 11. The position of Azerbaijan and the region in EABCT

Source: European Association for Behavioural and Cognitive Therapies (EABCT) Accredited Associations List, eabct.eu, April 2025.

This table demonstrates an important fact: in Azerbaijan’s neighbors Turkey and Georgia, as well as in the region — Ukraine — there are national cognitive behavioral therapy (CBT) associations accredited by EABCT. Azerbaijan has none. This means that the only way for individual CBT therapists in Azerbaijan to obtain EABCT accreditation is through an accredited association of another country (for example, Turkey or Georgia).

Dialectical behavior therapy (DBT): DBT-Linehan Board of Certification (DBT-LBC)

DBT-LBC is a non-profit organization with 501(c)(3) status and the only certification body personally authorized by the founder of DBT, Dr. Marsha Linehan. This is an important point: many organizations issue “DBT certification”, but only DBT-LBC certification is recognized by the creator of the model.

Table 12. DBT-LBC certification requirements

Source: DBT-LBC.org, Individual Certification Requirements, 2024.

The rigor of these requirements is related to the nature of DBT: this method was developed for patients with chronic suicide risk and borderline personality disorder. Here, precise adherence to the model (model fidelity) is of vital importance — the mistakes that an inadequately trained specialist could make under the name of “DBT” are dangerous to the patient’s life.

Eye movement desensitization and reprocessing (EMDR): EMDR Europe

EMDR Europe is an organization uniting the national EMDR associations of European countries. EMDR has a three-level accreditation system:

Table 13. EMDR Europe accreditation levels

Source: EMDR Europe Accreditation Committee, 2024.

The situation of the European association, EMDR Europe, in Azerbaijan: Azerbaijan is not on this organization’s list of accredited national associations. Likewise, the only way to obtain individual EMDR accreditation in Azerbaijan is through an accredited organization in a neighboring country (for example, in Turkey).

The general regulatory situation in the European Union

The official position of EABCT highlights an important point: “At the European level, there is no legislation regulating the practice of psychotherapy. At present, there is no official European body regulating or supervising psychotherapy in the European Union. This absence of regulation is one of EABCT’s main sources of concern.”

It follows that even within the European Union, professional regulation of psychotherapy is implemented at the national level. In some countries (Germany, the Netherlands, Austria) there is a strong state licensing system; in others, this system is weaker. In these circumstances, the only guarantors of professional standards are international professional accreditation bodies: the International Psychoanalytical Association (IPA), EABCT, DBT-LBC, and EMDR Europe.

The situation in Azerbaijan

The situation requires an objective assessment.

State regulation

In the Republic of Azerbaijan, there is no separate state licensing system for psychotherapeutic activity. State licensing in the field of medicine covers psychiatry, but psychotherapy and psychological counseling are not regulated separately. This means that, from a legislative standpoint, both a psychologist without specialized psychotherapeutic training and a licensed clinical psychiatrist can provide services as a “psychotherapist” with the same legal status. In the Azerbaijani context, this gap further increases the need for professional accreditation.

International accreditation status:

None of the international bodies listed above — IPA, EABCT, DBT-LBC, EMDR Europe — has an accredited national association of Azerbaijan. This is an objective fact and can be verified in open sources (eabct.eu, ipa.world, dbt-lbc.org, emdr-europe.org).

The situation with international psychiatric structures:

The only professional organization in Azerbaijan verified at the international level is the Azerbaijan Psychiatric Association (AZPA; psychiatry.az). AZPA is a full member of the World Psychiatric Association. This unambiguously confirms the legitimacy of AZPA in the international healthcare community.

The World Psychiatric Association (WPA) — according to wpanet.org, an international organization uniting more than 145 national psychiatric associations — has strict membership requirements: the national society must have official status, comply with transparent professional standards and submit periodic reports. The Azerbaijan Psychiatric Association (AZPA) meets these requirements.

The status of other organizations:

A number of non-profit organizations operate in the field of psychology and psychotherapy in Azerbaijan. Some of them use phrases such as “international cooperation”, “world congresses” and “international accreditation” on their own websites. Verification of these claims through international sources does not, in many cases, produce a positive result.

For this reason, the names of these organizations are not mentioned in this chapter — the aim is not controversy but the demonstration of a reliable framework for clinical practice. A specialist or patient wishing to investigate the legitimacy of any organization can consult the following objective sources:

eabct.eu/training-and-accreditation/accredited-association/ — accreditation in cognitive behavioral therapy (CBT)

ipa.world — the official source of information on psychoanalytic accreditation

dbt-lbc.org — the DBT-Linehan Board of Certification (DBT-LBC)

emdr-europe.org — EMDR accreditation

wpanet.org — the official website of the WPA

How to distinguish a specialist

When a patient or a young specialist encounters a claim of an “international certificate”, the following questions are of key importance:

1. Which body issued the certificate?

The first step of verification is to check whether the organization that issued the certificate has an official relationship with one of the international bodies listed above. The expression “international certificate” conveys no meaning in itself; what matters is which international body issued the certificate.

2. How long did the training last?

See the information presented above. A one-week or one-month “international certificate” does not meet the requirements of any recognized accreditation. Membership in the International Psychoanalytical Association (IPA) requires at least 4 years, individual accreditation by the European Association for Behavioural and Cognitive Therapies (EABCT) 3–4 years and the DBT-LBC certificate 12 months of continuous practice — these are the shortest periods that leave no doubt.

3. Is supervision provided?

Supervision occupies a central place in all serious accreditation systems. It should be established how many hours of supervised clinical work the certificate holder has completed. A certificate issued without supervised work is an academic certificate (such as the completion of a course) and not a certificate of clinical competence.

4. Is continuing professional development (CPD) required?

Accreditations must be renewed after a certain period. EABCT and EMDR Europe require renewal every 5 years and DBT-LBC every 4 years. A “lifelong certificate obtained once” is a sign of the absence of serious professional standards.

5. Can local mental health organizations serve as proof of international recognition?

Membership in a club or association of a local psychologist or psychotherapist is not in itself international recognition. Is such an organization itself a member of an internationally accredited body? That is the key question.

The place of this book in this context

This book is not a substitute for international accreditation — it is intended as a tool for preparing for accreditation. It offers the specialist a reliable framework for clinical diagnosis, evidence-based interventions, structured protocols and clinical reasoning.

After a specialist has built their practice on the basis of the protocols and discussion in this book, they acquire a solid foundation for formal professional training (through accredited organizations in Turkey, Georgia, Germany or other countries). In addition, this book can play an initial guiding role for patients — for assessing the quality of the care they receive, asking the right questions and demanding evidence-based treatment.

In the following sections, the disorders of Chapter 6 of ICD-11 are presented sequentially.