1. mhGAP-IG base course - field test version 1.00 – May 2012 1
Base Course
Introduction
Field test version-1.00 May 2012
DO NOT UPLOAD ON THE INTERNET
2. mhGAP-IG base course - field test version 1.00 – May 2012 2
Contents (Introduction)
A. Why train on mental, neurological and substance use
disorders? 35 minutes
B. What is mhGAP? 15 min
C. What is the mhGAP Intervention Guide (mhGAP-IG)? 5 min
D. Base course 10 min
E. Introduction to general principles of care 20 min
F. Key actions 2 hours 35 min
1.Establish communication and build trust 1 hour
2.Conduct assessment 1 hour
3.Plan and start management 10 min
4.Link with other services and supports 5 min
5.Follow up 20 min
Total time: 4 hours
3. mhGAP-IG base course - field test version 1.00 – May 2012 3
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
4. mhGAP-IG base course - field test version 1.00 – May 2012 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. mhGAP-IG base course - field test version 1.00 – May 2012 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. mhGAP-IG base course - field test version 1.00 – May 2012 6
Serious cases receiving no treatment during the last
12 months
Developed countries Developing countries
0
10
20
30
40
50
60
70
80
Lower range Upper range
Lower range Upper range
35%
50%
76%
85%
7. mhGAP-IG base course - field test version 1.00 – May 2012 7
Human resources for mental health care by income group
146
46
157
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
Psychiatrists Psychologists Nurses
n = 177 n = 147 n = 158
Low
Lower Middle
Upper Middle
High
World
per 100000
population
8. mhGAP-IG base course - field test version 1.00 – May 2012 8
In your community
• What are the daily challenges for persons with mental,
neurological and substance use disorders?
– Employment?
– Education?
– Marriage?
– Social life?
– Abuse?
9. mhGAP-IG base course - field test version 1.00 – May 2012 9
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
10. mhGAP-IG base course - field test version 1.00 – May 2012 10
True or False
• People with mental, neurological and substance use
disorders cannot understand information about their medical
treatment
• People with mental, neurological and substance use
disorders can understand information about their disorders
if it is given in an appropriate manner and time
• People with mental, neurological and substance use
disorders have the right to explanations of treatment plans
with risks and benefits explained
FALSE
11. mhGAP-IG base course - field test version 1.00 – May 2012 11
Stigma & Discrimination
• Many individuals with mental, neurological or substance use
disorders are perceived by the community as weak, inhuman,
dangerous or inferior because of their symptoms.
• As a result of stigma, these people are excluded or they
exclude themselves
• A father about his intellectually challenged daughter.
“Girls like her are only for house work, bringing her to
your clinic is a waste of my time”
• “I can’t come to see a doctor. If someone sees me I’ll
never get married”
12. mhGAP-IG base course - field test version 1.00 – May 2012 12
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
13. mhGAP-IG base course - field test version 1.00 – May 2012 13
Stigma and discrimination
in the health care system
• People with mental, neurological and substance use
disorders can experience stigma and discrimination from the
health system
– Can you think of any examples from your experience?
– What can you do to fight stigma and discrimination?
14. mhGAP-IG base course - field test version 1.00 – May 2012 14
As health providers we can
• Change our own perception and attitude towards people
with mental, neurological and substance use disorders
• Respect and advocate for the implementation of relevant
international conventions, such as the United Nations
Convention on the Rights of Persons with Disabilities
• Reaffirm that all persons with all types of disabilities must
enjoy all human rights and fundamental freedoms.
• Play a large part in fulfilling these rights
15. mhGAP-IG base course - field test version 1.00 – May 2012 15
Contents (Introduction)
A. Why train on mental, neurological and substance use
disorders?
B. What is mhGAP?
C. What is the mhGAP Intervention Guide (mhGAP-IG)?
D. Base course
E. Introduction to general principles of care
F. Key actions
1.Establish communication and build trust
2.Conduct assessment
3.Plan and start management
4.Link with other services and supports
5.Follow up
16. mhGAP-IG base course - field test version 1.00 – May 2012 16
Mental Health Gap Action Programme (mhGAP)
Play the video
• 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
17. mhGAP-IG base course - field test version 1.00 – May 2012 17
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
18. Mental Health and non-specialized healthcare
• Mental and physical health
are interwoven
• Primary care for mental
health
• Enhances access
• Promotes respect of
human rights
• Is affordable and cost-
effective
• Generates good health
outcomes
mhGAP-IG base course - field test version 1.00 – May 2012 18
19. mhGAP-IG base course - field test version 1.00 – May 2012 19
"We have the knowledge.
Feasible, affordable and cost-
effective measures for
preventing and treating mental
disorders exist, and are being
implemented, for example
through WHO's Mental Health
Gap Action Programme
(mhGAP)."
United Nations Secretary-General
Message on World Mental Health Day
10 October 2011
20. mhGAP-IG base course - field test version 1.00 – May 2012 20
Mental Health and Non-specialized Health Care
• 5 minute group discussion
• What is your current role and responsibility relating to the
management of people with mental, neurological, and
substance use disorders?
• Why should mental, neurological, and substance use
disorders be managed in non-specialized health care,
including primary health care?
21. mhGAP-IG base course - field test version 1.00 – May 2012 21
Contents (Introduction)
A. Why train on mental, neurological and substance use
disorders?
B. What is mhGAP?
C. What is the mhGAP Intervention Guide (mhGAP-IG)?
D. Base course
E. Introduction to general principles of care
F. Key actions
1.Establish communication and build trust
2.Conduct assessment
3.Plan and start management
4.Link with other services and supports
5.Follow up
22. mhGAP-IG base course - field test version 1.00 – May 2012 22
An evidence-based, clinical guide for the assessment and management of mental
neurological and substance use disorders in non-specialized health settings
23. mhGAP-IG base course - field test version 1.00 – May 2012 23
Who is the target audience for mhGAP-IG?
• Staff not specialized in mental health or neurology
• General physicians, family physicians, nurses
• First point of contact and outpatient care
• First level referral centers
26. mhGAP-IG base course - field test version 1.00 – May 2012 26
Contents (Introduction)
A. Why train on mental, neurological and substance use
disorders?
B. What is mhGAP?
C. What is the mhGAP Intervention Guide (mhGAP-IG)?
D. Base course
E. Introduction to general principles of care
F. Key actions
1.Establish communication and build trust
2.Conduct assessment
3.Plan and start management
4.Link with other services and supports
5.Follow up
27. mhGAP-IG base course - field test version 1.00 – May 2012 27
How will we learn to use the mhGAP-IG?
• Base course (30-35 hours)
– Covers core competencies relevant to all conditions
– Does not cover all advice that is in mhGAP-IG
• Standard training
– Only occurs after the base training
– Reviews core competencies learned during the base course
– Goes further to cover all advice in mhGAP-IG
• Supervision / consultation / specialist support starts after
base training
28. mhGAP-IG base course - field test version 1.00 – May 2012 28
Table 2 Key competencies in mhGAP Base course training
Key competencies Applicable to
Establish communication and build trust All conditions
Identifying the condition All conditions
Identification of underlying physical conditions All conditions
Protecting the user from harm All conditions
Basic psychosocial support (through psychoeducation / addressing
psychosocial stressors/ link with other services and supports)
All conditions
First-line medication treatment DEP, PSY, EPI
Brief (motivational )interventions ALC, DRU
Management of clinical emergencies PSY, EPI, SUI
Follow up and referral All conditions
Base Course: Competencies to be learned
29. Suggested schedule of Base Training course
(35hours)
mhGAP-IG base course - field test version 1.00 – May 2012 29
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6
Recap (15
min)
Recap (15
min)
Recap (15
min)
Recap (15
min)
Recap (15
min)
1
Opening and
pre-test 1.5h
DEP 3.5h
PSY 3h EPI 4h
General
framework for
working with
children and
adolescents
30min
ALC 3H
2
DEV 2h
Introduction
Session
(Introduction
to mhGAP,
Master
Chart,
General
Principles
of Care) 4h
3
DRU 1.5h
BEH 2.5h
4
SUI 2h
OTH 1.5h
5
DEM 1.5h Wrap up and
post test
1.5h
6
Daily
evaluation
Daily
evaluation
Daily
evaluation
Daily
evaluation
Daily
evaluation
30. • Would you like to share your experience related to the
material covered thus far?
• Is there anything we discussed that you do not agree
with?
• Is there anything we discussed that you do not fully
understand?
mhGAP-IG base course - field test version 1.00 – May 2012 30
Let's talk
31. mhGAP-IG base course - field test version 1.00 – May 2012 31
Contents (Introduction)
A. Why train on mental, neurological and substance use
disorders?
B. What is mhGAP?
C. What is the mhGAP Intervention Guide (mhGAP-IG)?
D. Base course
E. Introduction to general principles of care
F. Key actions
1.Establish communication and build trust
2.Conduct assessment
3.Plan and start management
4.Link with other services and supports
5.Follow up
32. mhGAP-IG base course - field test version 1.00 – May 2012 32
mhGAP General Principles of Care
• Communication
• Assessment
• Treatment and monitoring
• Provision of social support
• Protection of human rights
• Attention to overall well-being
33. mhGAP-IG base course - field test version 1.00 – May 2012 33
Contents (Introduction)
A. Why train on mental, neurological and substance use
disorders?
B. What is mhGAP?
C. What is the mhGAP Intervention Guide (mhGAP-IG)?
D. Base course
E. Introduction to general principles of care
F. Key actions
1.Establish communication and build trust
2.Conduct assessment
3.Plan and start management
4.Link with other services and supports
5.Follow up
34. mhGAP-IG base course - field test version 1.00 – May 2012 34
Contents (Introduction)
• Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Discuss and start management
4. Link with other services and supports
5. Follow up
We will discuss these points in general. We will later
revisit them for each condition throughout the base
course.
35. mhGAP-IG base course - field test version 1.00 – May 2012 35
Establish communication and build trust
• Discuss the following question in small groups
• What can a clinician do to make a person comfortable when
talking about private issues?
• Examples of private issues
– Feelings of depression
– Sexual health
36. mhGAP-IG base course - field test version 1.00 – May 2012 36
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 you actions when examining a person
• Be honest - keep promises
37. mhGAP-IG base course - field test version 1.00 – May 2012 37
Using good communication skills: Exercise
1. Pair up with another person. One person is "A" and the
other person is "B"
2. A describes a problem and B listens carefully for 2 minutes
3. Now repeat the problem but this time B shows little
interest
4. Now switch roles. B will describe a problem to A and
repeat both steps 2 and 3
38. mhGAP-IG base course - field test version 1.00 – May 2012 38
Afterwards…
• What made you feel that the person was listening and how
did it make you feel?
• How did you feel when the person was not listening to you?
39. mhGAP-IG base course - field test version 1.00 – May 2012 39
Good and bad communication
• We will watch two videos illustrating aspect of good and bad
communication
40. mhGAP-IG base course - field test version 1.00 – May 2012 40
Use good communication skills
• Attitude
– Show respect
– Try not 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
41. mhGAP-IG base course - field test version 1.00 – May 2012 41
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?"
42. mhGAP-IG base course - field test version 1.00 – May 2012 42
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
43. mhGAP-IG base course - field test version 1.00 – May 2012 43
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
44. mhGAP-IG base course - field test version 1.00 – May 2012 44
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
45. mhGAP-IG base course - field test version 1.00 – May 2012 45
Communicating with carers
• Carers (eg 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
46. mhGAP-IG base course - field test version 1.00 – May 2012 46
Group role play
• Let’s practice building trust and good communication
• Mary is a woman who has been really struggling at home. She
feels sad all the time and never leaves the house. She is usually
an active member of her community. She has three children with
her husband.
• How would you talk to Mary about her problem?
47. mhGAP-IG base course - field test version 1.00 – May 2012 47
Contents (Introduction)
• Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Discuss and start management
4. Link with other services and supports
5. Follow up
We will discuss these points in general. We will later revisit
them for each condition throughout the base course
48. mhGAP-IG base course - field test version 1.00 – May 2012 48
Using the master chart
• Open the mhGAP-IG on page 8
• For each condition you have common presentations (a
pattern of symptoms)
• If people present with features from more than one
condition, then the relevant condition(s) need to be assessed
50. mhGAP-IG base course - field test version 1.00 – May 2012 50
Process of assessment in mhGAP-IG
Does the presentation
suggest a priority condition
according to the master chart?
Conduct assessment according to the module
Go to relevant module(s)
Develop a management plan
NO
End assessment
If the person is presenting
with multiple possible
conditions, all must be
assessed.
Identify the condition and treatment
51. mhGAP-IG base course - field test version 1.00 – May 2012 51
Assess, Decide and Manage
• The assess column guides clinical assessment of the person
• The decide column specifies different clinical scenarios
• The manage column describes how to manage the problem
52. mhGAP-IG base course - field test version 1.00 – May 2012 52
mhGAP-IG: Assessment column
53. mhGAP-IG base course - field test version 1.00 – May 2012 53
mhGAP-IG: Decision column
54. mhGAP-IG base course - field test version 1.00 – May 2012 54
mhGAP-IG: Management column
56. mhGAP-IG base course - field test version 1.00 – May 2012 56
Case 1: What do you suspect
• A young woman says her husband is agitated and behaving
oddly
– Abnormal or disorganized behaviour
• He is convinced that somebody is following him
– Delusions
• He has refused to go to work in the last few days
– Neglecting usual responsibilities
• He has been sleeping only few hours per night
– Manic symptoms
• She thinks he hears voices which are not there
– Hallucinations
57. mhGAP-IG base course - field test version 1.00 – May 2012 57
Case 2: What do you suspect
• A father is concerned about his 16 year old son’s behaviour
• He has stolen money from home
– Repeated and continued behaviour that disturbs others
• The boy's teachers say he never finishes his work
– Excessive inattention and absent-mindedness
• The teachers have recently punished him for maltreating a cat
and for aggressive behaviour towards classmates
– Repeated and continued behaviour that disturbs others
• He is very impulsive
– Excessive impulsivity
• Father is sure that the son is not taking drugs or alcohol
58. mhGAP-IG base course - field test version 1.00 – May 2012 58
Assess the person
Once you suspect a condition on the master chart you need to
identify the condition(s) and decide on treatment scenario with
use of the module assessment and management guide(s)
Your assessment may require gathering more information
including physical examination and further investigations
59. mhGAP-IG base course - field test version 1.00 – May 2012 59
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
60. mhGAP-IG base course - field test version 1.00 – May 2012 60
Assess for alcohol use in anybody
• Ask at least one question about alcohol use!
• “Do you drink alcohol?”
• If yes, ask more questions :
You will learn about this in the alcohol module session.
61. mhGAP-IG base course - field test version 1.00 – May 2012 61
Is there imminent risk of suicide?
62. mhGAP-IG base course - field test version 1.00 – May 2012 62
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
63. mhGAP-IG base course - field test version 1.00 – May 2012 63
You also need to assess the person's carers
• Help carers cope because they ensure the well-being of the
person with the condition
64. mhGAP-IG base course - field test version 1.00 – May 2012 64
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
65. Game: Looking for the right person
Symptoms for
depression
Symptoms for
dementia
Symptoms for
psychosis
Symptoms for
behavioural
disorders
Symptoms for
self-harm/suicide
Symptoms for
epilepsy
66. mhGAP-IG base course - field test version 1.00 – May 2012 66
Contents (Introduction)
• Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
We will discuss these points in general. We will later
revisit them for each condition throughout the base
course
67. mhGAP-IG base course - field test version 1.00 – May 2012 67
Plan and start management
• Explain results and likely diagnosis while keeping a realistic
and positive outlook
• Explain and discuss all treatment options including benefits
and risks
• Provide psychoeducation and other psychosocial support
• Explain any possible medications before prescribing
• Make sure that everyone understands the plan
68. mhGAP-IG base course - field test version 1.00 – May 2012 68
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
69. mhGAP-IG base course - field test version 1.00 – May 2012 69
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
70. mhGAP-IG base course - field test version 1.00 – May 2012 70
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
71. mhGAP-IG base course - field test version 1.00 – May 2012 71
Prescribing principles
• Medication treatment depends on the condition.
– Worldwide more than 50% of all medicines are
prescribed, dispensed, or sold inappropriately, while 50%
of patients fail to take them correctly (WHO, 2002)
• Safe prescribing
– Explain effects, time of onset, side effects
– Obtain consent
– Start low, go slow
– Follow up on a regular basis with thorough assessment
72. mhGAP-IG base course - field test version 1.00 – May 2012 72
Contents (Introduction)
• Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
We will discuss these points in general. We will later
revisit them for each condition throughout the base
course
73. mhGAP-IG base course - field test version 1.00 – May 2012 73
Link with other services and supports
• Many people with mental, neurological and substance use
disorders have many, serious needs
• Some of these needs may be non-medical, but you have a
crucial role to play in improving these people's lives by linking
them to relevant services and supports
74. mhGAP-IG base course - field test version 1.00 – May 2012 74
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
75. mhGAP-IG base course - field test version 1.00 – May 2012 75
Contents (Introduction)
• Key actions
1. Establish communication and build trust
2. Assess the person
3. Discuss and start management
4. Link with other services and supports
5. Follow up
We will discuss these points in general. We will later
revisit them for each condition throughout the base
course
76. mhGAP-IG base course - field test version 1.00 – May 2012 76
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?
77. mhGAP-IG base course - field test version 1.00 – May 2012 77
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
78. mhGAP-IG base course - field test version 1.00 – May 2012 78
Let’s talk…
• Would you like to share your experience related to the
material covered thus far?
• Is there anything we discussed that you do not agree with?
• Is there anything we discussed that you do not fully
understand?
79. mhGAP-IG base course - field test version 1.00 – May 2012 79
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)