Mental Health Gap

1. 1
Base Course
Introduction

2. 2
Overview (Introduction)
A. Why train on mental, neurological and substance use
disorders? 5 minutes
B. What is mhGAP? 5 minutes
C. What is the mhGAP Intervention Guide (mhGAP-IG)? 5
minutes
D. Base course 5 minutes
E. Introduction to general principles of care 5 minutes
F. Key actions 35 min
1.Establish communication and build trust 5 min
2.Conduct assessment 10 min
3.Plan and start management 5 min
4.Link with other services and supports 5 min
5.Follow up 5 min

3. 3
True or False
• People with mental, neurological and substance use
disorders are not capable of making decisions about their
medical, financial, personal and social lives
• Many scientists, business people, artists, politicians, and
people from different backgrounds have mental,
neurological and substance use conditions and that do not
stop them from making decisions that lead to great success!
FALSE

4. 4
1 Unipolar depressive disorders 10.9%
2 Hearing loss, adult onset 4.6%
3 Refractory errors 4.6%
4 Alcohol use disorders 3.7%
5 Cataracts 3.0%
6 Schizophrenia 2.7%
7 Osteoarthritis 2.6%
8 Bipolar affective disorder 2.4%
9 Iron-deficiency anaemia 2.2%
10 Birth asphyxia and birth trauma 2.2%
(Both sexes, all ages)
Leading causes of years of life lived with disability

5. 5
Predictions for the leading causes of disability and
mortality in 2030
World 1 HIV/AIDS
2 Unipolar depressive disorder
3 Ischaemic heart dis.
High-income countries 1 Unipolar depressive disorder
2 Ischaemic heart disease
3 Alzheimer
Middle-income countries 1 HIV/AIDS
2 Unipolar depressive disorder
3 Cerebrovascular
Low-income countries 1 HIV/AIDS
2 Perinatal disorder
3 Unipolar depressive disorder

6. 6
In your community
• What are the daily challenges for persons with mental,
neurological and substance use disorders?
– Employment?
– Education?
– Marriage?
– Social life?
– Abuse?

7. 7
True or False
• Mental, neurological and substance use disorders respond
poorly to treatment
• Most common mental, neurological and substance use
disorders respond well to treatment.
• Up to 70% of persons with chronic psychosis can be stable
and live symptom free with adequate treatment
FALSE

8. 8
Mental Health Gap Action Programme (mhGAP)
• mhGAP is the WHO
programme to scale up care for
mental, neurological and
substance use disorders
• mhGAP was launched by the
WHO Director-General in 2008
• The initial focus is on increasing
non-specialist care, including
primary healthcare, to address
the unmet needs of people all
over the world

9. 9
mhGAP-IG conditions
1. Depression
2. Psychosis
3. Bipolar disorder
4. Epilepsy
5. Developmental disorders
6. Behavioral disorders
7. Dementia
8. Alcohol use and alcohol use disorders
9. Drug use and drug use disorders
10. Self-harm/suicide
11. Other significant emotional or medically unexplained
complaints

10. 11
What are the effects of stigma & discrimination
• Emotional state?
• Affects sense of self-worth
• Prognosis?
• Contributes to shortened life expectancy
• Slows recovery
• Access and quality of treatment?
• Limits access and quality of health care
• Human rights?
• Can lead to abuse
• Family?
• Disrupts relationships

11. 12
mhGAP General Principles of Care
• Communication
• Assessment
• Treatment and monitoring
• Provision of social support
• Protection of human rights
• Attention to overall well-being

12. 13
Establish communication and build trust
• Greet the person warmly and with respect
• Introduce yourself by name and position
• Maintain confidentiality and privacy
• Take time for the interview (especially the 1st interview)
• Show interest
• Explain your actions when examining a person
• Be honest - keep promises

13. 14
Use good communication skills
• Attitude
– Show respect
– Try not to judge
– Be genuine
• Listening and observing
– Listen carefully
– Notice non-verbal communication
• Communicating
– Summarize what the person says
– Show understanding of how the person feels and thinks
– Use simple and clear language

14. 15
Open and Closed Questions
Open Questions Closed Questions
1. "How are you feeling
today?"
1. "Are you sad?"
2. "How would you describe
your sleep?"
2. "Are you having problems
falling asleep?"
3. "Can you tell me how
your problem impacts
your life?“
3. "Are you still going to
work?"

15. 16
Culture and communication
• Communicating with the opposite gender
• Eye contact
• Greeting
• Distance between two people
• How to address the person
• Communicating with a child or adolescent
• Communicating with a carer

16. 17
Communicating with children
• Model good interaction
• Carers can learn from you on how to interact with the
child
• Treat the child with dignity
• greet the child
• avoid any negative labels
• Use language that the child can understand
• Never forget that the child is in the room
• Child may listen and understand when adults talk about
them

17. 18
Communication with adolescents
• Try to see the adolescent alone
• Explain that you wish to help
• Explain that everything will be confidential
• Show respect
• Expect several appointments to establish trust

18. 19
Communicating with carers
• Carers (e.g. family) tend to be critical in the lives of people
with mental, neurological and substance use disorders
• Carers are usually key resources for support, but it is
important to remember that carers may need support as well
– In some situations carers are part of the problem (when
they abuse or discriminate)
• You must have the consent of the person before talking to a
carer
• Show understanding for the carer’s emotions
• Explain that they have a major role to play
• Explain that you wish to provide support

19. 20
Asking for further information
• History of presenting
complaint
• Other symptoms
• Medical history
• Medication
• Impact on function
• Family history
• Social stressors
• Available resources and
sources for social support
• Alcohol use
• Self harm/suicide

20. 21
General physical examination
• A proper general physical examination is necessary
• Need to rule out other medical conditions or an underlying
medical cause for the mental, neurological and substance use
disorder
• Need to assess for the physical effects of the condition, e.g.
• alcohol use
• suicide attempt
• self-neglect
• Do not forget that people with mental, neurological and
substance use disorders also need to be assessed for their
general physical health

21. 22
You also need to assess the person's carers
• Help carers cope because they ensure the well-being of the
person with the condition

22. 23
What is the impact on the carer?
• There are a number of potential strains on the carer
– Psychological
• Stress and feelings of hopelessness
• Depression – needs management as appropriate
– Physical
• Poorer physical health
• More visits to the doctor
– Social:
• Friends and families embarrassed
• Social isolation and exclusion
– Financial
• Loss of earning from time away from work
• Medical bills

23. 24
What do we communicate in psychoeducation?
I. Empowerment
– Focus on what the person and family can do now to
improve their situation
– Emphasize the importance of involving the person with the
disorder in all decisions
II. Facts
– Take time to explain the prognosis. Be realistic but
emphasize that with proper management, many people
improve

24. 25
What do we communicate in psychoeducation?
III. Coping strategies
– Recognize and encourage things people are doing well
– Discuss actions that have helped in the past
– Discuss local options for community resources
IV. Advice on overall wellbeing
– Encourage a healthy lifestyle including a good diet, regular
physical exercise and routine health checks at the doctor
– Advise the person and the carers to seek help when
needed

25. 26
Addressing stressors
• Offer an opportunity to talk, preferably in a private space
• Ask about current stressors
• Assess for any maltreatment or abuse
• Brain storm together for solutions or for ways of coping
• Identify and involve supportive family members
• Encourage involvement in self-help and family support
groups

26. 27
Link with other services and supports
• Other sectors and services have a role to play in the complete
care of the person, e.g.
• Housing
• Employment
• Education
• Child protection and social services
• In addition, there are people in the community who may be of
help, e.g.
• Community leaders
• Women's groups
• Self-help and family support groups

27. 28
Schedule follow up appointment
• Make a clear follow up plan (e.g. date, person)
• The frequency of follow up depends on the condition and
resources available
• In your context, what are the best methods for arranging
follow up?

28. 29
What would you do during a follow up visit
• Assess progress in a number of areas
– Symptoms and well-being of both the person and carer
– Check for new symptoms
– Ongoing stressors
– Medication effectiveness, adherence, side effects
– Links to community resources
• Make changes to the management plan as necessary.
• Refer to the mhGAP-IG if needed

29. 30
Key messages
• The burden of mental, neurological and substance abuse
disorders is large and growing
• Stigma and discrimination is common
• You can effectively manage these conditions in non-
specialized health care and reduce stigma and discrimination
• The base course provides the basic skills to identify and
manage these conditions (in consultation with specialists if
needed)