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mhGAP-IG mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP). 1. Mental disorders – prevention and control. 2. Nervous system diseases. 3. Psychotic disorders. 4. Substance-related disorders. 5. Guidelines. I. World Health Organization. ISBN 978 92 4 154806 9 (NLM classification: WM 140) The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. © World Health Organization 2010 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for non-commercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. For more information, please contact: Department of Mental Health and Substance Abuse World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: mhgap-info@who.int Website: www.who.int/mental_health/mhgap Printed in Italy mhGAP-IG mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings Version 1.0 mental health Gap Action Programme mhGAP-Intervention Guide i ii Table of contents IV Modules Foreword iii 1. Moderate-Severe Depression 10 Acknowledgements iv 2. Psychosis 18 Abbreviations and Symbols vii 3. Bipolar Disorder 24 4. Epilepsy / Seizures 32 5. Developmental Disorders 40 6. Behavioural Disorders 44 7. Dementia 50 8. Alcohol Use and Alcohol Use Disorders 58 9. Drug Use and Drug Use Disorders 66 10. Self-harm / Suicide 74 11. Other Significant Emotional or Medically Unexplained Complaints 80 Advanced Psychosocial Interventions 82 I II Introduction General Principles of Care III Master Chart 1 6 8 V Foreword Health systems around the world face enormous challenges in delivering care and protecting the human rights of people with mental, neurological and substance use disorders. The resources available are insufficient, inequitably distributed and inefficiently used. As a result, a large majority of people with these disorders receive no care at all. mhGAP-IG » Foreword In 2008, WHO launched the mental health Gap Action Programme (mhGAP) to address the lack of care, especially in low- and middle-income countries, for people suffering from mental, neurological, and substance use disorders. Fourteen per cent of the global burden of disease is attributable to these disorders and almost three quarters of this burden occurs in low- and middle-income countries. The resources available in countries are insufficient – the vast majority of countries allocate less than 2% of their health budgets to mental health leading to a treatment gap of more than 75% in many low- and middleincome countries. It is against this background that I am pleased to present “mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings” as a technical tool for implementation of the mhGAP Programme. The Intervention Guide has been developed through a systematic review of evidence, followed by an international consultative and participatory process. It provides the full range of recommendations to facilitate high quality care at first- and second-level facilities by the non-specialist health-care providers in resource-poor settings. It presents integrated management of priority conditions using protocols for clinical decision-making. Taking action makes good economic sense. Mental, neurological and substance use disorders interfere, in substantial ways, with the ability of children to learn and the ability of adults to function in families, at work, and in society at large. Taking action is also a pro-poor strategy. These disorders are risk factors for, or consequences of, many other health problems, and are too often associated with poverty, marginalization and social disadvantage. I hope that the guide will be helpful for health-care providers, decision-makers, and programme managers in meeting the needs of people with mental, neurological and substance use disorders. There is a widely shared but mistaken idea that improvements in mental health require sophisticated and expensive technologies and highly specialized staff. The reality is that most of the mental, neurological and substance use conditions that result in high morbidity and mortality can be managed by non-specialist health-care providers. What is required is increasing the capacity of the primary health care system for delivery of an integrated package of care by training, support and supervision. iii We have the knowledge. Our major challenge now is to translate this into action and to reach those people who are most in need. Dr Margaret Chan Director-General World Health Organization iv Acknowledgements Vision and Conceptualization Ala Alwan, Assistant Director-General, Noncommunicable Diseases and Mental Health, WHO; Benedetto Saraceno, former Director, Department of Mental Health and Substance Abuse, WHO; Shekhar Saxena, Director, Department of Mental Health and Substance Abuse, WHO. Project Coordination and Editing Tarun Dua, Nicolas Clark, Edwige Faydi §, Alexandra Fleischmann, Vladimir Poznyak, Mark van Ommeren, M Taghi Yasamy, Shekhar Saxena. Contribution and Guidance Valuable material, help and advice was received from technical staff at WHO Headquarters, staff from WHO regional and country offices and many international experts. These contributions have been vital to the development of the Intervention Guide. WHO Geneva Meena Cabral de Mello, Venkatraman Chandra-Mouli, Natalie Drew, Daniela Fuhr, Michelle Funk, Sandra Gove, Suzanne Hill, Jodi Morris, Mwansa Nkowane, Geoffrey Reed, Dag Rekve, Robert Scherpbier, Rami Subhi, Isy Vromans, Silke Walleser. WHO Regional and Country Offices Zohra Abaakouk, WHO Haiti Country Office; Thérèse Agossou, WHO Regional Office for Africa; Victor Aparicio, WHO Panama Subregional Office; Andrea Bruni, WHO Sierra Leone Country Office; Vijay Chandra, WHO Regional Office for South-East Asia; Sebastiana Da Gama Nkomo, WHO Regional Office for Africa; Carina Ferreira-Borges, WHO Regional Office for Africa; Nargiza Khodjaeva, WHO West Bank and Gaza Office; Ledia Lazeri, WHO Albania Country Office; Haifa Madi, WHO Regional Office for Eastern Mediterranean; Albert Maramis, WHO Indonesia Country Office; Anita Marini, WHO Jordan Country Office; Rajesh Mehta, WHO Regional Office for South-East Asia; Linda Milan, WHO Regional Office for the Western Pacific; Lars Moller, WHO Regional Office for Europe; Maristela Monteiro, WHO Regional Office for the Americas; Matthijs Muijen, WHO Regional Office for Europe; Emmanuel Musa, WHO Nigeria Country Office; Neena Raina, WHO Regional Office for SouthEast Asia; Jorge Rodriguez, WHO Regional Office for the Americas; Khalid Saeed, WHO Regional Office for Eastern Mediterranean; Emmanuel Streel, WHO Regional Office for Eastern Mediterranean; Xiangdong Wang, WHO Regional Office for the Western Pacific. Administrative Support Frances Kaskoutas-Norgan, Adeline Loo, Grazia Motturi-Gerbail, Tess Narciso, Mylène Schreiber, Rosa Seminario, Rosemary Westermeyer. Interns Scott Baker, Christina Broussard, Lynn Gauthier, Nelly Huynh, Kushal Jain, Kelsey Klaver, Jessica Mears, Manasi Sharma, Aditi Singh, Stephen Tang, Keiko Wada, Aislinn Williams. International Experts Clive Adams, UK; Robert Ali, Australia; Alan Apter, Israel; Yael Apter, Israel; José Ayuso-Mateos *, Spain; Corrado Barbui *, Italy; Erin Barriball, Australia; Ettore Beghi, Italy; Gail Bell, UK; Gretchen Birbeck *, USA; Jonathan Bisson, UK; Philip Boyce, Australia; Vladimir Carli, Sweden; Erico Castro-Costa, Brazil; Andrew Mohanraj Chandrasekaran †, Indonesia; Sonia Chehil, Canada; Colin Coxhead, Switzerland; Jair de Jesus Mari, Brazil; Carlos de Mendonça Lima, Portugal; Diego DeLeo, Australia; Christopher Dowrick, UK; Colin Drummond, UK; Julian Eaton †, Nigeria; Eric Emerson, UK; Cleusa P Ferri, UK; Alan Flisher §*, South Africa; Eric Fombonne, Canada; Maria Lucia Formigoni †, Brazil; Melvyn Freeman *, South Africa; Linda Gask, UK; Panteleimon Giannakopoulos *, Switzerland; Richard P Hastings, UK; Allan Horwitz, USA; Takashi Izutsu, United Nations Population Fund; Lynne M Jones †, UK; Mario F Juruena, Brazil; Budi Anna Keliat †; Indonesia; Kairi Kolves, Australia; Shaji S Kunnukattil †, India; Stan Kutcher, Canada; Tuuli Lahti, Finland; Noeline Latt, Australia; Itzhak Levav *, Israel; Nicholas Lintzeris, Australia; Jouko Lonnqvist, Finland; Lars Mehlum, Norway; Nalaka Mendis, Sri Lanka; Ana-Claire Meyer, USA; Valerio Daisy Miguelina Acosta, Dominican Republic; Li Li Min, Brazil; Charles Newton †, Kenya; Isidore Obot *, Nigeria; Lubomir Okruhlica†, Slovakia; Olayinka Omigbodun *†, Nigeria; Timo Partonen, Finland; Vikram Patel *, India and UK; Michael Phillips *†, China; Pierre-Marie Preux, France; Martin Prince *†, UK; Atif Rahman *†, Pakistan and UK; Afarin Rahimi-Movaghar *, Iran; Janet Robertson, UK; Josemir W Sander *, UK; Sardarpour Gudarzi Shahrokh, Iran; John Saunders *, Australia; Chiara Servili †, Italy; Pratap Sharan †, India; Lorenzo Tarsitani, Italy; Rangaswamy Thara *†, India; Graham Thornicroft *†, UK; Jürgen Ünutzer *, USA; Mark Vakkur, Switzerland; Peter Ventevogel *†, Netherlands; Lakshmi Vijayakumar *†, India; Eugenio Vitelli, Italy; Wen-zhi Wang †, China. * Member of the WHO mhGAP Guideline Development Group † Participant in a meeting hosted by the Rockefeller Foundation on “Development of Essential Package for Mental, Neurological and Substance Use Disorders within WHO mental health Gap Action Programme” § Deceased Acknowledgements Technical Review In addition, further feedback and comments on the draft were provided by following international organizations and experts: Organizations ‡ Autistica (Eileen Hopkins, Jenny Longmore, UK); Autism Speaks (Geri Dawson, Andy Shih, Roberto Tuchman, USA); CBM (Julian Eaton, Nigeria; Allen Foster, Birgit Radtke, Germany); Cittadinanza (Andrea Melella, Raffaella Meregalli, Italy); Fondation d’Harcourt (Maddalena Occhetta, Switzerland); Fondazione St. Camille de Lellis (Chiara Ciriminna, Switzerland); International Committee of the Red Cross (Renato Souza, Brazil); International Federation of the Red Cross and Red Crescent Societies (Nana Wiedemann, Denmark); International Medical Corps (Neerja Chowdary, Allen Dyer, Peter Hughes, Lynne Jones, Nick Rose, UK); Karolinska Institutet (Danuta Wasserman, Sweden); Médecins Sans Frontières (Frédérique Drogoul, France; Barbara Laumont, Belgium; Carmen Martinez, Spain; Hans Stolk, Netherlands); ‡ Mental Health Users Network of Zambia (Sylvester Katontoka, Zambia); National Institute of Mental Health (Pamela Collins, USA); ‡ Schizophrenia Awareness Association (Gurudatt Kundapurkar, India); Terre des Hommes, (Sabine Rakatomalala, Switzerland); United Nations High Commissioner for Refugees (Marian Schilperoord); United Nations Population Fund (Takashi Izutsu); World Association for Psychosocial Rehabilitation (Stelios Stylianidis, Greece); World Federation of Neurology (Johan Aarli, Norway); World Psychiatric Association (Dimitris Anagnastopoulos, Greece; Vincent Camus, France; Wolfgang Gaebel, Germany; Tarek A Gawad, Egypt; Helen Herrman, Australia; Miguel Jorge, Brazil; Levent Kuey, Turkey; Mario Maj, Italy; Eugenia Soumaki, Greece, Allan Tasman, USA). ‡ Civil society / user organization mhGAP-IG » Acknowledgements Expert Reviewers Gretel Acevedo de Pinzón, Panama; Atalay Alem, Ethiopia; Deifallah Allouzi, Jordan; Michael Anibueze, Nigeria; Joseph Asare, Ghana; Mohammad Asfour, Jordan; Sawitri Assanangkornchai, Thailand; Fahmy Bahgat, Egypt; Pierre Bastin, Belgium; Myron Belfer, USA; Vivek Benegal, India; José Bertolote, Brazil; Arvin Bhana, South Africa; Thomas Bornemann, USA; Yarida Boyd, Panama; Boris Budosan, Croatia; Odille Chang, Fiji; Sudipto Chatterjee, India; Hilary J Dennis, Lesotho; M Parameshvara Deva, Malaysia; Hervita Diatri, Indonesia; Ivan Doci, Slovakia; Joseph Edem-Hotah, Sierra Leone; Rabih El Chammay, Lebanon; Hashim Ali El Mousaad, Jordan; Eric Emerson, UK; Saeed Farooq, Pakistan; Abebu Fekadu, Ethiopia; Sally Field, South Africa; Amadou Gallo Diop, Senegal; Pol Gerits, Belgium; Tsehaysina Getahun, Ethiopia; Rita Giacaman, West Bank and Gaza Strip; Melissa Gladstone, UK; Margaret Grigg, Australia; Oye Gureje, Nigeria; Simone Honikman, South Africa; Asma Humayun, Pakistan; Martsenkovsky Igor, Ukraine; Begoñe Ariño Jackson, Spain; Rachel Jenkins, UK; Olubunmi Johnson, South Africa; Rajesh Kalaria, UK; Angelina Kakooza, Uganda; Devora Kestel, Argentina; Sharon Kleintjes, South Africa; Vijay Kumar, India; Hannah Kuper, UK; Ledia Lazëri, Albania; Antonio Lora, Italy; Lena Lundgren, USA; Ana Cecilia Marques Petta Roselli, Brazil; Tony Marson, UK; Edward Mbewe, Zambia; Driss Moussaoui, Morocco; Malik Hussain Mubbashar, Pakistan; Julius Muron, Uganda; Hideyuki Nakane, Japan; Juliet Nakku, Uganda; Friday Nsalamo, Zambia; Emilio Ovuga, Uganda; Fredrick Owiti, Kenya; Em Perera, Nepal; Inge Petersen, South Africa; Moh’d Bassam Qasem, Jordan; Shobha Raja, India; Rajat Ray, India; Telmo M Ronzani, Brazil; SP Sashidharan, UK; Sarah Skeen, South Africa; Jean-Pierre Soubrier, France; Abang Bennett Abang Taha, Brunei Darussalam; Ambros Uchtenhagen, Switzerland; Kristian Wahlbeck, Finland; Lawrence Wissow, USA; Lyudmyla Yur`yeva, Ukraine; Douglas Zatzick, USA; Anthony Zimba, Zambia. v Production Team Editing: Philip Jenkins, France Graphic design and layout: Erica Lefstad and Christian Bäuerle, Germany Printing Coordination: Pascale Broisin, WHO, Geneva Financial support The following organizations contributed financially to the development and production of the Intervention Guide: American Psychiatric Association, USA; Association of Aichi Psychiatric Hospitals, Japan; Autism Speaks, USA; CBM; Government of Italy; Government of Japan; Government of The Netherlands; International Bureau for Epilepsy; International League Against Epilepsy; Medical Research Council, UK; National Institute of Mental Health, USA; Public Health Agency of Canada, Canada; Rockefeller Foundation, USA; Shirley Foundation, UK; Syngenta, Switzerland; United Nations Population Fund; World Psychiatric Association. vi Abbreviations and Symbols Abbreviations Symbols AIDS acquired immune deficiency syndrome CBT cognitive behavioural therapy HIV human immunodeficiency virus i.m. intramuscular IMCI Integrated Management of Childhood Illness IPT interpersonal psychotherapy i.v. intravenous mhGAP mental health Gap Action Programme mhGAP-IG mental health Gap Action Programme Intervention Guide OST opioid-substitution therapy Attention / Problem SSRI selective serotonin reuptake inhibitor Go to / look at / Skip out of this module STI sexually transmitted infection TCA tricyclic antidepressant Babies / small children Refer to hospital Children / adolescents Medication Women Psychosocial intervention Pregnant women Consult specialist Adult Terminate assessment Older person mhGAP-IG » Abbreviations and Symbols vii Do not If YES Further information If NO 1 Introduction Mental Health Gap Action Programme (mhGAP) – background Development of the mhGAP Intervention Guide (mhGAP-IG) Purpose of the mhGAP Intervention Guide About four out of five people in low- and middle-income countries who need services for mental, neurological and substance use conditions do not receive them. Even when available, the interventions often are neither evidence-based nor of high quality. WHO recently launched the mental health Gap Action Programme (mhGAP) for low- and middle-income countries with the objective of scaling up care for mental, neurological and substance use disorders. This mhGAP Intervention Guide (mhGAP-IG) has been developed to facilitate mhGAP-related delivery of evidence-based interventions in non-specialized health-care settings. The mhGAP-IG has been developed through an intensive process of evidence review. Systematic reviews were conducted to develop evidence-based recommendations. The process involved a WHO Guideline Development Group of international experts, who collaborated closely with the WHO Secretariat. The recommendations were then converted into clearly presented stepwise interventions, again with the collaboration of an international group of experts. The mhGAP-IG was then circulated among a wider range of reviewers across the world to include all the diverse contributions. The mhGAP-IG has been developed for use in non-specialized health-care settings. It is aimed at health-care providers working at first- and second-level facilities. These health-care providers may be working in a health centre or as part of the clinical team at a district-level hospital or clinic. They include general physicians, family physicians, nurses and clinical officers. Other non-specialist health-care providers can use the mhGAP-IG with necessary adaptation. The first-level facilities include the health-care centres that serve as first point of contact with a health professional and provide outpatient medical and nursing care. Services are provided by general practitioners or physicians, dentists, clinical officers, community nurses, pharmacists and midwives, among others. Second-level facilities include the hospital at the first referral level responsible for a district or a defined geographical area containing a defined population and governed by a politico-administrative organization, such as a district health management team. The district clinician or mental health specialist supports the firstlevel health-care team for mentoring and referral. There is a widely shared but mistaken idea that all mental health interventions are sophisticated and can only be delivered by highly specialized staff. Research in recent years has demonstrated the feasibility of delivery of pharmacological and psychosocial interventions in non-specialized health-care settings. The present model guide is based on a review of all the science available in this area and presents the interventions recommended for use in low- and middle-income countries. The mhGAP-IG includes guidance on evidence-based interventions to identify and manage a number of priority conditions. The priority conditions included are depression, psychosis, bipolar disorders, epilepsy, developmental and behavioural disorders in children and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm / suicide and other significant emotional or medically unexplained complaints. These priority conditions were selected because they represent a large burden in terms of mortality, morbidity or disability, have high economic costs, and are associated with violations of human rights. The mhGAP-IG is based on the mhGAP Guidelines on interventions for mental, neurological and substance use disorders (http:// www.who.int/mental_health/mhgap/evidence/en/). The mhGAP Guidelines and the mhGAP-IG will be reviewed and updated in 5 years. Any revision and update before that will be made to the online version of the document. The mhGAP-IG is brief so as to facilitate interventions by busy non-specialists in low- and middle-income countries. It describes in detail what to do but does not go into descriptions of how to do. It is important that the non-specialist health-care providers are trained and then supervised and supported in using the mhGAP-IG in assessing and managing people with mental, neurological and substance use disorders.