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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
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
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
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
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
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%
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
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?
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
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
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”
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
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?
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
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
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
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
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
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
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?
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
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
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
mhGAP-IG base course - field test version 1.00 – May 2012 24
mhGAP-IG base course - field test version 1.00 – May 2012 25
The Master Chart
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
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
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
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
• 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
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
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
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
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.
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
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
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
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?
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
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
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?"
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
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
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
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
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?
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
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
mhGAP-IG base course - field test version 1.00 – May 2012 49
The Master Chart
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
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
mhGAP-IG base course - field test version 1.00 – May 2012 52
mhGAP-IG: Assessment column
mhGAP-IG base course - field test version 1.00 – May 2012 53
mhGAP-IG: Decision column
mhGAP-IG base course - field test version 1.00 – May 2012 54
mhGAP-IG: Management column
mhGAP-IG base course - field test version 1.00 – May 2012 55
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
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
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
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
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.
mhGAP-IG base course - field test version 1.00 – May 2012 61
Is there imminent risk of suicide?
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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?
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
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?
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)

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Mh gap 01 base

  • 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
  • 24. mhGAP-IG base course - field test version 1.00 – May 2012 24
  • 25. mhGAP-IG base course - field test version 1.00 – May 2012 25 The Master Chart
  • 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
  • 49. mhGAP-IG base course - field test version 1.00 – May 2012 49 The Master Chart
  • 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
  • 55. mhGAP-IG base course - field test version 1.00 – May 2012 55
  • 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)