Mental health essentials (mhGAP)
Most people with depression, psychosis, epilepsy, dementia or a drug use disorder in low- and middle-income countries never see a specialist. The WHO mhGAP Intervention Guide shows that nurses, clinical officers and doctors in general clinics can recognise these conditions, start effective care and follow people up. This course covers the essentials, updated for the 2023 mhGAP guideline, and includes psychological first aid and looking after yourself.
- Apply the mhGAP principles of respectful communication and essential care to every person with a mental, neurological or substance use condition.
- Offer psychological first aid after a crisis, and protect your own well-being and your colleagues'.
- Assess and manage depression with psychosocial care, psychological treatment and, where needed, antidepressants.
- Ask about self-harm and suicide, and act on imminent risk.
- Recognise psychosis and epilepsy, give first-line care safely and know when to consult a specialist.
- Recognise developmental, behavioural and emotional problems in children and adolescents and support their carers.
- Assess suspected dementia, support carers, and manage opioid overdose and other drug use at first-level care.
Essential care and practice, psychological first aid and caring for yourself
- Describe what mhGAP is and how the Intervention Guide is organised.
- Use core communication skills and the general steps of assessment and management.
- Give psychological first aid using the look, listen and link principles.
- Recognise stress in yourself and colleagues and take practical steps to manage it.
The WHO Mental Health Gap Action Programme (mhGAP) aims to close the gap between the number of people who need care for mental, neurological and substance use (MNS) conditions and the number who receive it. Its Intervention Guide version 2.0 (2016) turns WHO recommendations into simple flowcharts for health workers who are not mental health specialists. WHO updated the underlying guideline in 2023 (18 new and 30 updated recommendations alongside 90 existing ones).
The priority conditions
- Depression; psychoses (including bipolar disorder); epilepsy.
- Child and adolescent mental and behavioural disorders; dementia.
- Disorders due to substance use; self-harm and suicide.
- Other significant mental health complaints that affect daily life.
A master chart lists common presentations (for example low energy and sleep problems, marked behaviour change, convulsions, thoughts of self-harm) and points to the right module.
Communicate well
- Meet in a private space if possible; explain that what is said stays confidential.
- Include the person in every decision; with their consent, involve carers.
- Start by listening. Let the person speak without interruption; use simple language and open questions.
- Be friendly, respectful and non-judgemental. Respond with extra care when someone discloses violence, sexual assault or self-harm.
Assess the whole person
People with severe mental disorders are 2 to 3 times more likely to die of preventable physical illness such as infections and cardiovascular disease. Always take a physical history and examine. Then take the MNS history (presenting complaint, past episodes, general health and medicines, family history, current stressors and support), observe the person's appearance, mood, thinking, perceptions and cognition, and consider physical causes before deciding on an MNS condition.
Manage
- Agree a written treatment plan with the person (and carer).
- Always offer psychosocial interventions: psychoeducation, reducing stress and strengthening social support, and help to keep up daily activities.
- Use medicines when the module recommends them; start one at a time at the lowest dose.
- Refer or consult when needed: no response, serious side effects, complex comorbidity, risk of suicide.
- Plan follow-up and what happens if the person does not come back.
Psychological first aid (PFA)
After a crisis (an accident, violence, a disaster, sudden bad news) most people are distressed and most recover with ordinary support. Psychological first aid is humane, practical support for people in distress soon after such an event. It is not something only professionals can do, it is not counselling, and it does not involve pressing people to describe what happened. WHO and Sphere advise against psychological debriefing (asking people to recount the event and their feelings in detail), which has been found ineffective.
| Principle | What it means in practice |
|---|---|
| Look | Check for safety. Check for people with obvious urgent basic needs (injury, food, water, shelter, a lost child). Check for people with serious distress reactions |
| Listen | Approach people who may need support. Ask about their needs and concerns. Listen, and help them to feel calm; do not pressure them to talk |
| Link | Help people meet basic needs and reach services. Help them cope with problems. Give accurate information. Connect them with loved ones and social support |
In a humanitarian setting, WHO advises that all clinical staff should at least be able to give PFA; an orientation takes about half a day. People with severe distress, a mental disorder, or thoughts of self-harm need assessment with the mhGAP modules, not PFA alone.
Caring for yourself and your colleagues
Long hours, heavy responsibility, unclear roles, poor communication, insecurity and hearing people's suffering every day all wear health workers down. You cannot care well for others if you are exhausted.
- Think about what has helped you cope before, and use it.
- Take time to eat, rest and relax, even briefly. Keep reasonable working hours; share the workload and take regular breaks.
- Remember that you are not responsible for solving all of a person's problems. Do what you can to help people help themselves.
- Keep alcohol, caffeine and nicotine low; avoid non-prescribed drugs.
- Check in with colleagues, and let them check in with you. Talk with people you trust.
- After a hard event, talk it through with a supervisor or colleague, acknowledge what you did well, and accept the limits of what was possible.
Second case: after the bus crash
A bus has crashed near your health centre. The injured have been treated or transferred. In the waiting area, a woman of about 40 who was on the bus is unhurt but sits shaking and crying. Her teenage son was taken to the district hospital. A colleague suggests asking her to describe the crash in detail 'so she can let it out'.
Psychological first aid. Look: she is safe and uninjured, but distressed and separated from her son. Listen: introduce yourself, offer water and a quiet seat, ask what she needs most, and listen without pressing her to describe the crash. Link: find out how her son is, help her get to him or contact family, and give clear information about what happens next.
2. What about your colleague's suggestion?
Asking her to recount the event in detail is psychological debriefing, which is not recommended. Let her talk if she wants to, but do not press her.
3. When would she need more than PFA?
If she cannot function, has thoughts of self-harm, or her distress does not settle over the following weeks: assess with the mhGAP modules.
A 34-year-old woman comes with headaches and poor sleep. The consulting room is shared with two other patients, and her husband answers most questions for her.
How could you make it easier for her to talk?
Find a more private space if possible, introduce yourself, explain confidentiality, and with her agreement ask to speak with her alone for part of the visit. Listen without interrupting and use open questions.
What must you check before deciding this is a mental health condition?
Her physical health: history, examination and basic tests to rule out causes such as anaemia, thyroid problems, medicine side effects or substance use. Then assess using the master chart, and ask about self-harm if a priority condition is suspected.
- mhGAP helps non-specialists care for depression, psychosis, epilepsy, self-harm, substance use, dementia and child mental health.
- Private space, confidentiality, listening, respect and involving the person in decisions come first.
- Always assess physical health and look for physical causes.
- Always ask about self-harm when a priority condition is suspected.
- Psychological first aid: look, listen, link. Not debriefing, not counselling; anyone can learn it.
- Look after yourself: rest, food, fair hours, peer support; seek help if distress lasts more than a month.
Recognising depression
- Apply the mhGAP criteria for depression.
- Rule out physical causes, bipolar disorder and normal grief.
Depression is common in every community and often presents as physical complaints: tiredness, aches, poor sleep or many symptoms without a clear cause. People may not use the word 'depression' at all.
Is it depression?
- Core symptom for at least 2 weeks: persistent depressed mood, or markedly reduced interest or pleasure in activities.
- Several other symptoms for at least 2 weeks: disturbed sleep or sleeping too much; change in appetite or weight; worthlessness or excessive guilt; tiredness or loss of energy; poor concentration; indecisiveness; agitation or restlessness; talking or moving more slowly; hopelessness; suicidal thoughts or acts.
- Considerable difficulty with daily functioning at home, at work or school, or socially.
If all three are present, consider depression. If not, use the module on other significant mental health complaints.
Other explanations to rule out
- Physical conditions that resemble or worsen depression: anaemia, malnutrition, hypothyroidism, substance use, medicine side effects (for example steroids). Treat these first, then reassess.
- A history of mania (several of: elevated or irritable mood, little need for sleep, more activity and talk, reckless behaviour, inflated self-esteem, lasting at least 1 week): this suggests bipolar disorder, which is treated differently. Consult a specialist.
- A major loss in the last 6 months, such as bereavement: do not treat as depression unless there are suicidal thoughts, beliefs of worthlessness, psychotic symptoms, marked slowing, or a past history of depression.
People with depression are at higher risk of most other priority conditions, especially substance use. Ask about alcohol and drugs.
Mr P has come three times in two months with back pain and 'no strength'. Tests were normal. He lost his job four months ago. He says he no longer enjoys anything, sleeps badly, feels he has failed his family and cannot concentrate. He has stopped going to the mosque and rarely leaves the house. He has never felt unusually high or energetic.
Does he meet the mhGAP criteria for depression?
Yes: a core symptom (loss of interest) for more than 2 weeks, several other symptoms (poor sleep, guilt or worthlessness, poor concentration), and difficulty with daily and social functioning. Physical causes have been looked for, and there is no history of mania.
What must you ask next?
About thoughts, plans or acts of self-harm or suicide, and about alcohol and other substance use.
- Depression: depressed mood or loss of interest for at least 2 weeks, plus several other symptoms, plus difficulty functioning.
- Look for physical causes first.
- A history of mania means bipolar disorder: consult; never give an antidepressant alone.
- After a recent major loss, do not treat grief as depression unless warning features are present.
Managing depression
- Deliver psychoeducation and psychosocial support.
- Decide with the person about psychological treatment and antidepressants, and plan follow-up.
For everyone with depression
- Psychoeducation: depression is common and can happen to anybody; it is not weakness or laziness; hopeless thoughts are part of the illness and usually improve with treatment; if thoughts of self-harm come, tell someone trusted and come back at once.
- Reduce stress and strengthen social support: address stressors where possible; reconnect with family, neighbours and community activities.
- Keep up daily activities: restart activities that used to be enjoyable, keep regular sleep and waking times, be physically active, eat regularly, spend time with trusted people.
- Do not use ineffective treatments such as vitamin injections.
Depression is an illness, like a fever of the mind. It is not your fault and it is not weakness. With treatment, most people get better.
Psychological treatment comes first
The 2023 mhGAP guideline makes a strong recommendation that adults with moderate to severe depression should be offered a structured psychological intervention, such as behavioural activation, problem-solving therapy, interpersonal therapy (IPT) or cognitive behavioural therapy (CBT). Trained and supervised non-specialists can deliver these, for example with WHO's Problem Management Plus (PM+), Group IPT or Thinking Healthy (for perinatal depression).
Antidepressants
The 2023 guideline suggests psychological treatment or combined treatment for adults with moderate to severe depression, and an antidepressant on its own only when psychological treatment is not available. Decide together with the person, and explain that antidepressants are not addictive, must be taken every day, may cause side effects in the first days, and take several weeks to work.
| Medicine | Starting and usual dose (mhGAP-IG 2.0) | Key cautions |
|---|---|---|
| Fluoxetine (SSRI) | 10 mg daily for 1 week, then 20 mg daily; if no response in 6 weeks, 40 mg (maximum 80 mg). Older or medically ill: maximum 40 mg | Preferred in older people, heart disease and suicide risk. Bleeding risk with aspirin or NSAIDs; avoid with warfarin |
| Amitriptyline (TCA) | 25 mg at bedtime, increasing by 25 to 50 mg a week to 100 to 150 mg daily | Do not use in heart disease, children or adolescents; avoid in older people. Overdose can be fatal |
- Continue for at least 9 to 12 months after symptoms have gone; then taper over at least 4 weeks.
- Stop the antidepressant immediately if mania develops, and consult.
- Suicide risk: prefer an SSRI and give small supplies (for example one week at a time), kept by a carer.
- Pregnancy and breastfeeding: avoid antidepressants if possible; if needed, use the lowest effective dose; avoid long-acting fluoxetine when breastfeeding; consult.
- Adolescents 12 and over: only fluoxetine, only if psychosocial care has not helped, with weekly review for 4 weeks. Children under 12: no antidepressants.
Follow-up
See the person again within 1 week, then keep regular contact (for example monthly for the first 3 months, by visit, phone or home visit), then every 3 months as they improve. At each contact: mood, function, side effects, adherence and suicide risk.
Mr P (lesson 2) has moderate depression and no thoughts of self-harm. A trained community counsellor runs a group problem-solving programme at the clinic every week. He would prefer not to take tablets.
What would you offer?
Psychoeducation, support to reconnect with friends and the mosque and to keep active, and referral to the problem-solving group, which is a structured psychological intervention. With a psychological treatment available and his preference, an antidepressant alone is not the first choice.
Six weeks later he is no better despite attending. What now?
Review the diagnosis and suicide risk, then discuss adding an antidepressant (combined treatment), for example fluoxetine 10 mg daily for a week then 20 mg, and review in 1 to 2 weeks. Continue for 9 to 12 months after recovery.
- Everyone: psychoeducation, stress reduction, social support, daily activities.
- 2023 mhGAP: offer structured psychological treatment for moderate to severe depression; antidepressant alone only if psychological treatment is unavailable.
- Fluoxetine 10 mg then 20 mg; amitriptyline 25 mg at night rising to 100 to 150 mg; no amitriptyline in heart disease or young people.
- Continue 9 to 12 months after recovery; follow up within 1 week, then regularly.
Self-harm and suicide
- Ask about self-harm and decide whether there is a medically serious act, imminent risk, or ongoing risk.
- Make the person safe and organise support and follow-up.
Ask everyone over 10 years old who has a priority MNS condition, chronic pain or acute emotional distress about thoughts or plans of self-harm in the last month and acts of self-harm in the last year.
Three questions
| Question | If yes |
|---|---|
| Medically serious act? Poisoning, bleeding wound, loss of consciousness, extreme lethargy | Treat the injury or poisoning first. Do not leave the person alone. Keep them in a safe, supportive place at the facility. |
| Imminent risk? Current thoughts or plan; or recent thoughts or act in someone now very agitated, violent, distressed or not communicating | Remove means of self-harm. Do not leave the person alone; name a staff or family member to stay with them. Quiet, separate room if possible. Consult a mental health specialist if available. |
| Risk but not imminent? Thoughts or plan in the past month, or act in the past year | Offer and activate psychosocial support, treat any MNS condition, and keep regular contact. |
Pesticide poisoning
If the facility cannot resuscitate, manage the airway and give atropine and diazepam, transfer immediately. Do not make the person vomit and do not give oral fluids. Activated charcoal can be considered if the person is conscious, consents and comes within 1 hour.
Support
- Explore reasons and ways to stay alive; focus on strengths and how earlier problems were solved.
- Mobilise family, friends and community to watch over the person while risk persists.
- Advise the family to remove means: pesticides and other poisons, stored medicines, firearms.
- Prescribe the least dangerous medicines, in small supplies.
- Support carers, who are often very stressed; ask them to avoid hostility and harsh criticism.
Follow-up
Keep frequent contact for the first 2 months (for example daily or weekly), then every 2 to 4 weeks, and continue for 2 years with decreasing contact as the person improves. Ask about suicidal thoughts and plans at every contact.
Mr Q, 19, is brought in after swallowing a handful of his mother's tablets two hours ago. He is drowsy but rousable, with normal breathing and pulse. He says he still wants to die. His mother is shouting at him in the waiting area.
What category of risk is this, and what do you do now?
A medically serious act with imminent risk. Treat the poisoning following your emergency protocol (ABCDE, identify the tablets, transfer if needed). Do not leave him alone; name a staff member to stay with him; remove access to any means; keep him in a quiet, safe space.
How would you support his mother?
Speak with her calmly, acknowledge her fear, explain that asking about suicide helps, ask her to avoid criticism, and involve her in removing medicines and pesticides from the home and in watching over him.
- Ask about thoughts or plans in the last month and acts in the last year; asking does not provoke self-harm.
- Medically serious act: treat first. Imminent risk: remove means and never leave the person alone.
- Pesticides: no induced vomiting, no oral fluids; transfer if you cannot manage the airway.
- Follow up frequently for 2 months and continue for 2 years.
Psychosis and epilepsy: recognise, act safely, follow up
- Recognise psychosis and start first-line care with specialist support.
- Manage a convulsion safely, diagnose epilepsy and start treatment.
Psychosis
Suspect psychosis when a person has at least two of: delusions (fixed false beliefs not shared by others in their culture), hallucinations (hearing voices or seeing things that are not there), and disorganised speech or behaviour. First look for a physical cause of delirium: infection, cerebral malaria, dehydration, hypoglycaemia or low sodium, or medicines such as some antimalarials or steroids.
- Psychoeducation for the person and carers; keep the person and others safe; support daily activities and community life.
- Antipsychotic medicine: start low and increase slowly to the lowest effective dose (for example haloperidol starting at 1.5 to 3 mg daily, per mhGAP-IG 2.0; follow your national formulary).
- Consider stopping only 12 months after symptoms have resolved (longer if symptoms had lasted more than 3 months), slowly and with specialist advice; review side effects and physical health.
- Manic episode with bipolar disorder: stop any antidepressant; consult a specialist about a mood stabiliser or antipsychotic.
- Pregnancy: avoid valproate, lithium and carbamazepine; consult.
A convulsion in front of you
- Keep the person safe; turn them on their side; loosen tight clothing; something soft under the head. Do not put anything in the mouth and do not restrain them.
- Check ABC, glucose, blood pressure and temperature. Time the convulsion.
- Convulsing for 5 minutes or more is an emergency: give a benzodiazepine (for example diazepam 10 mg IV in adults, or the rectal or buccal route if no IV access, per national protocol). If not stopped after 10 minutes, give a second dose. Never more than 2 doses: refer urgently.
- Second half of pregnancy or up to 1 week after birth, without known epilepsy: suspect eclampsia and give magnesium sulfate.
Is it epilepsy?
Epilepsy is likely if the person has had at least two unprovoked seizures on two different days in the past year. Look for a cause (birth injury, head injury, brain infection, family history). A simple febrile seizure in a child needs the cause treated, not antiepileptic medicine.
- Choose one antiepileptic that will be consistently available; start low and increase until seizures are controlled.
- Common choices in mhGAP are carbamazepine, phenobarbital, phenytoin and valproate; for women who could become pregnant follow the valproate addendum above.
- Advise: no swimming alone or cooking on open fires; regular sleep; avoid alcohol; follow local driving rules.
- Consider stopping slowly only after 2 seizure-free years, in discussion with the person.
Ms R, 28, is brought by her sister. For three months she has believed neighbours are poisoning her food, hears them talking about her when no one is there, and has stopped washing or working. She has no fever, glucose is normal, she takes no medicines and does not drink. She is not pregnant and does not want to be.
Is psychosis likely?
Yes. She has delusions, hallucinations and disorganised behaviour (self-neglect), and no physical cause has been found. Ask about self-harm and check for mania.
What is your plan?
Psychoeducation for her and her sister; start a low-dose antipsychotic per national formulary and increase slowly; consult a specialist if available; ensure safety; follow up regularly and support a return to daily activities. Consider stopping only 12 months after symptoms resolve.
- Psychosis: two of delusions, hallucinations, disorganised speech or behaviour, after ruling out delirium.
- Start antipsychotics low and go slow; consider stopping only 12 months after symptoms resolve.
- Convulsion: side position, nothing in the mouth; a benzodiazepine if it lasts 5 minutes; no more than 2 doses.
- Epilepsy: two seizures on two different days in a year. No valproate for women and girls who could become pregnant.
Child and adolescent mental and behavioural problems
- Recognise developmental, behavioural and emotional problems at different ages, and signs of maltreatment.
- Give carers practical guidance and support, and know when medicines have a place and when they do not.
Children and adolescents rarely come saying they have a mental health problem. They come with poor feeding, tantrums, school refusal, stomach aches or a worried parent. Always look at the home and school as well as the child, and always check for maltreatment.
Common presentations
| Age | Developmental | Behavioural | Emotional |
|---|---|---|---|
| Under 5 | Poor feeding, failure to thrive, floppy, late smiling, sitting, walking, talking or toilet training | Very frequent severe tantrums | Excessive crying, clinging, freezing, new wetting or thumb sucking, sleep and eating problems |
| 6 to 12 | Delay in reading, writing or self-care | Over-activity, inattention, not finishing tasks, impulsivity | Repeated unexplained stomach aches or headaches, refusing to go to school |
| 13 to 18 | Poor school performance, difficulty with instructions and social interaction | Persistent disobedience, cruelty, stealing, sudden change in friends or behaviour | Irritable or low mood, anxiety, emotional outbursts, wanting to be alone, poor concentration |
Assess
- Ask the carer and, separately where possible, the child or adolescent. Ask about home, school, friends, bullying and violence.
- Look for physical causes: hearing or vision problems, malnutrition, anaemia, thyroid problems, epilepsy (always check in a child with developmental delay), and medicines.
- Adolescents: ask about mood, self-harm, alcohol and drugs (lessons 2, 4 and 7).
Manage
- For every child: guidance on well-being (play, routines for eating and sleeping, praise for good behaviour), psychoeducation for carers, and protection from maltreatment and bullying.
- Guidance on behaviour: give attention and praise for good behaviour, set clear simple rules, avoid harsh punishment and shouting, and use consistent consequences.
- Support carers: their stress matters; link them with community resources and, where available, parent skills training.
- Talk with the school (with consent) about practical adjustments.
- Developmental delay or disorder: refer for specialist assessment; link with community-based rehabilitation; follow up every 3 months. No medicines for the delay itself.
- Conduct problems: psychosocial measures only; no medicines.
- ADHD: environmental and behavioural measures first. The 2023 mhGAP guideline allows methylphenidate for children 6 and older only if impairment persists after these measures, after careful assessment, and prescribed by or with a specialist.
- Emotional problems or depression: psychological interventions first. No medicines under 12. From 12, fluoxetine only (no other antidepressant), only if psychological treatment has not helped, and with a specialist (lesson 3).
- Follow up every 3 months, or monthly for an adolescent with depression; sooner if needed.
Your child is not being naughty on purpose, and you are not a bad parent. Children do best with calm routines, lots of praise for what they do well, and clear, gentle rules.
Second case: a boy who will not sit still
Master U, 7, is brought by his mother because his teacher says he cannot stay in his seat, interrupts all the time and never finishes his work. This has been so since he started school two years ago, and it happens at home too. He is beaten at home 'to make him behave'. His hearing and vision seem normal.
ADHD is possible: over-activity and inattention in more than one setting for a long time. Rule out physical conditions that can look like ADHD (thyroid disease, acute or chronic infection including HIV, uncontrolled pain), check hearing, vision and development, and ask about sleep. The beatings are harsh discipline: address them as a protection concern.
2. What is your plan?
Psychoeducation for the mother; guidance on behaviour (praise, routines, clear rules, no beating); with consent, talk with the teacher about seating him near the front and breaking tasks into short steps; parent skills training if available; follow up in 3 months. Methylphenidate only if he still has significant impairment after these measures, through a specialist.
Miss V has come four times in two months with stomach aches; examinations and tests have been normal. Her mother says she has stopped seeing friends and often refuses to go to school. Speaking alone with you, she says she has felt sad and tired for two months, cannot concentrate, and a group of girls at school send her cruel messages every day. She says she sometimes wishes she would not wake up.
What is your first priority?
Her wish not to wake up: ask directly about thoughts, plans and acts of self-harm (lesson 4). If there is a plan or imminent risk, act on that first: do not leave her alone, remove means, involve a trusted adult and consult a specialist.
If there is no imminent risk, what is the plan?
This sounds like depression in an adolescent, made worse by bullying. Offer psychoeducation to her and her mother, address the bullying (with her consent, with the school), support her to keep up activities and friendships, and refer for a psychological intervention if available. Follow up at least monthly and keep asking about self-harm.
Would you start an antidepressant?
Not as first line. She is over 12, so if psychological treatment does not help, fluoxetine (and no other antidepressant) can be considered with a specialist, with close review.
- Children present with physical complaints, behaviour and school problems: look at home, school and maltreatment.
- Guidance on well-being and behaviour, carer support, school liaison and parent skills training are the core treatments.
- No medicines for developmental delay or conduct problems; methylphenidate for ADHD only from 6 years, after other measures, with a specialist.
- No antidepressants under 12; from 12, fluoxetine only, after psychological treatment, with a specialist.
Dementia, and drug use beyond alcohol
- Assess suspected dementia, rule out delirium and depression, and support the person and carers.
- Recognise and manage opioid overdose, stimulant intoxication and benzodiazepine dependence, and give a brief intervention for drug use.
Dementia
Dementia is a long-term, usually progressive decline in memory, thinking, behaviour and the ability to manage daily life. It is common in older people but it is not a normal part of ageing.
- Suspect it when there are problems with memory and orientation (forgetting what happened yesterday, getting lost) and difficulty with usual work, household or social tasks. Interview someone who knows the person well: when did it start, and is it getting worse?
- Dementia develops slowly over at least 6 months. Sudden onset, a short history (days to weeks), worse at night, or fluctuating consciousness suggests delirium: look for infection (check the urine), medicines (especially those with anticholinergic effects), pain, dehydration, low sodium, low glucose.
- Depression can mimic dementia: treat moderate to severe depression first, then reassess.
- Refer unusual presentations: onset before 60, after a head injury or stroke, or with signs of hypothyroidism or a history of HIV or other sexually transmitted infection.
- Manage cardiovascular risk factors (hypertension, diabetes, smoking, obesity).
Care for the person and the carers
- Ask whether the person wants to know the diagnosis and with whom to share it. Give simple information: it is an illness of the brain, it usually gets worse over time, there is no cure, but a lot can be done.
- Keep the person oriented (day, date, names), keep routines simple, make the home safe (clear floors, rails, signs to the toilet), encourage activity, and manage poor hearing or vision.
- Behaviour that challenges (wandering, agitation, aggression): look first for pain, infection or another physical cause, and identify and change triggers. Antipsychotics only if there is imminent risk of harm and psychological measures have failed: start low, go slow, review at least monthly. Avoid diazepam.
- Do not use cholinesterase inhibitors or memantine routinely; only where a specific diagnosis can be made with specialist support.
- Carers carry a heavy load. The 2023 mhGAP guideline says carers should be offered psychosocial support (psychoeducation, counselling and other approaches), and respite care should be considered. Ask about their own mood, money and help.
- Follow up at least every 3 months, monthly if on medicines.
Drug use beyond alcohol
Ask everyone with a priority mental health condition about alcohol and other drugs, in a non-judgemental way. Many people use more than one substance. Alcohol is covered in the protocol Alcohol use.
| Emergency | Signs | Action |
|---|---|---|
| Opioid overdose | Unresponsive or barely responsive, slow breathing, pinpoint pupils | Airway, breathing support and oxygen. Naloxone 0.4 to 2 mg IV, IM, intranasal or subcutaneous; if no response within 2 minutes, give a second dose. Observe for 1 to 2 hours and repeat as needed, as drowsiness can return |
| Sedative overdose (alcohol, benzodiazepines) | Drowsy, slow breathing, normal pupils | Airway and breathing support, recovery position, no oral fluids while sedated; look for head injury, infection or low glucose; observe until recovered or transferred |
| Stimulant intoxication (cocaine, amphetamines) | Dilated pupils, excited, racing thoughts, raised pulse and BP, aggressive or erratic | Calm, safe space; diazepam in titrated doses until calm and lightly sedated, per protocol; if psychotic symptoms do not settle, consider an antipsychotic and go to the psychosis module |
| Opioid withdrawal | Dilated pupils, muscle aches, abdominal cramps, nausea, vomiting, diarrhoea, runny eyes and nose, anxiety, restlessness | Methadone or buprenorphine where available (any opioid in the acute setting if not); consider clonidine; consult. Doses per protocol |
| Benzodiazepine withdrawal | Anxiety, tremor, sweating; seizures and confusion if severe | Do not stop suddenly. Switch to a long-acting benzodiazepine and taper over 8 to 12 weeks with psychosocial support; severe withdrawal needs hospital |
Brief intervention
The 2023 mhGAP guideline recommends that adults using cannabis or psychostimulants be offered screening and a brief intervention: at least one session with personal feedback and advice on cutting down or stopping, and an offer of follow-up. Refer for specialist help if this does not work. Methylphenidate, dexamphetamine and modafinil are not recommended for stimulant use disorders.
- Ask permission to talk about it; stay non-judgemental and avoid arguing.
- Give personal feedback on the risks you see (to health, family, money, work).
- Ask what the person likes and dislikes about their use, and what their own goals are.
- Agree realistic options and next steps; say you are confident they can change.
- Signs of dependence: strong craving, difficulty controlling use, tolerance and withdrawal; for example cannabis 1 g or more a day, or taking more prescribed pills than prescribed.
For people dependent on opioids, opioid agonist maintenance treatment with methadone or buprenorphine reduces illicit drug use, HIV spread and deaths. It needs a regulated national framework and supervised dosing; find out where your nearest programme is and refer.
Second case: found unconscious
A young man is carried in by friends. He is barely rousable, breathing 6 times a minute, with pinpoint pupils. A friend says he 'took something' an hour ago.
Opioid overdose. Open the airway, support breathing with a bag-valve-mask and oxygen, and give naloxone 0.4 to 2 mg (IV, IM, intranasal or subcutaneous). If he has not responded within 2 minutes, give a second dose.
2. He wakes up. Can he go home?
No. Observe for 1 to 2 hours at least and repeat naloxone if he becomes drowsy again. Before he leaves, talk with him about his drug use, offer referral to an opioid treatment programme, and ask about self-harm.
Mrs X's daughter says her mother has become forgetful over the past two years: she repeats questions, has got lost twice in the market and can no longer manage her money. For the past three days she has been much worse, is awake and agitated at night, and does not know where she is. She has been passing urine often.
What explains the last three days?
A sudden change over days, worse at night, with disorientation, suggests delirium on top of a probable dementia. Look for a physical cause: check the urine for infection, review her medicines, look for pain, dehydration and low glucose, and treat the cause.
Once the delirium has settled, how do you support her and her daughter?
Explain the probable diagnosis (asking Mrs X what she wants to know), give simple orientation and safety advice, check BP and other cardiovascular risks, avoid unnecessary sedatives, and assess the daughter's strain, mood and needs: offer psychoeducation, support and, where possible, respite. Follow up at least every 3 months.
- Dementia develops over 6 months or more; sudden confusion over days is delirium until proven otherwise.
- Support the person and carers: orientation, safety, activity, carer support and respite. No routine cholinesterase inhibitors; antipsychotics only for imminent risk; avoid diazepam.
- Opioid overdose: support breathing, naloxone 0.4 to 2 mg, second dose after 2 minutes if needed, observe 1 to 2 hours.
- Cannabis and stimulants: screening and a brief intervention; never stop benzodiazepines suddenly in dependence.
Quiz and CPD certificate
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Sources
- World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016 (ISBN 9789241549790).
- World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023 (ISBN 9789240084278).
- World Health Organization. mhGAP-IG 2.0 addendum on the use of valproic acid (sodium valproate) in women and girls of childbearing potential. 2023.
- World Health Organization. mhGAP evidence centre: depression recommendations (2023 update). 2023.
- World Health Organization, War Trauma Foundation and World Vision International. Psychological first aid: guide for field workers. 2011 (ISBN 9789241548205).
- World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 2015 (ISBN 9789241548922).