WHAT is mhGAP

◦ Mental Health GAP

◦ THE TREATMENT GAP - Mental, neurological, and substance use (MNS)
disorders are highly prevalent in all regions of the world, and they are major
contributors to disease, premature death, and disability worldwide. They are
also frequently associated with high levels of stigma and human rights
violations, particularly in low- and middle-income countries.
◦ WHO recognizes the need for action to reduce the burden, and to enhance the
capacity of Member States to respond to this growing challenge.
◦ mhGAP is WHO’s action plan to scale up services for mental, neurological and
substance use disorders for countries especially with low and lower middle
incomes (ex. African countries)
 WHY mhGAP?
◦ Because of the Treatment Gap of priority conditions that may cause premature
death, and disability addressed by mhGAP, priority conditions are:
1. depression,
2. schizophrenia ,psychotic disorders (Bipolar)
3. suicide,
4. epilepsy,
5. dementia,
6. disorders due to use of alcohol,
7. disorders due to use of illicit drugs,
8. mental disorders in children.
-NOTE- Persons with severe mental disorders are 2 to 3 times more likely to die of
preventable disease like infections and cardiovascular disorders. Focus on reducing risk
through education and monitoring.
 WHY mhGAP?
THE CASE FOR ACTION
1. The alarming burden of mental disorders -Leading contributors include
depression, substance abuse, schizophrenia, and dementia. This burden creates
an enormous toll in terms of suffering, disability, and economic.
2. Economic impact Lost wages, combined with the possibility of catastrophic
health care costs, can seriously affect patients and their families’ financial
situation, creating or worsening poverty.
3. Physical comorbidity
4. Stigma and discrimination
5. New Hope through Treatment Advances
 HOW mhGAP
◦ The mhGAP package consists of interventions for prevention and management
for each of these priority conditions.

Successful scaling up is the joint responsibility of governments, health

professionals, civil society, communities, and families, with support from the
international community.
The essence of mhGAP is building partnerships for collective action. A
commitment is needed from all partners to respond to this urgent public health
need.
How the Philippines responded to mhGap Program

◦ Government response (Law) - REPUBLIC ACT NO. 11036 "Mental

Health Act.“
◦ Department response (DOH) - DOH Mental Health Program
Mental Health Gap ActionProgram (mhGAP)
◦ First launched in 2008, to scale up care for MENTAL NEUROLOGICAL, SUBSTANCE USE
(MNS) disorders
◦ The program asserts that, with proper care, psychosocial assistance and medication,
tens of millions of people could be treated for depression, psychoses and epilepsy,
prevented from suicide and begin to lead normal lives – even where resources are scarce
◦ Its focus is to increase non-specialist care, including non-specialized health care, to
address the unmet needs of people with priority MNS conditions.
◦ Non-specialized health-care providers will be trained in basic mental health competencies
to identify and assess MNS conditions, provide basic care and refer complex cases to
specialist services. Mental health specialists (psychiatrist, psychologist) will be equipped to
work collaboratively with non-specialist health- care providers and offer supervision and
support. NON-SPECIALIZED HEALTH-CARE PROVIDERS
1. General physicians, family physicians, Nurses
2. First points of contact and outpatient care
3. First level referral centers
4. Community/barangay health workers
Mental Health Gap ActionProgram (mhGAP)
REASONS FOR INTEGRATING MENTAL HEALTH INTO NON-SPECIALIZED HEALTH CARE
The burden of mental disorders is great.
Mental and physical health problems are interwoven.
The treatment gap for mental disorders is enormous.
Enhance access to mental health care.
Promote respect of human rights.
It is affordable and cost-effective.
Generates good health outcomes.

NON-SPECIALIZED HEALTH-CARE PROVIDERS

1. General physicians, family physicians, Nurses
2. First points of contact and outpatient care
3. First level referral centers
4. Community/barangay health workers
mhGAP
Intervention Guide
mhGAP Intervention Guide
▪ This presents the integrated management of priority MNS conditions
using algorithms for clinical decision-making that are aimed to aid
health-care providers to assess, manage and follow-up individuals
with priority MNS conditions
▪ The first version was developed in 2010 as a simple technical tool to
allow for integrated management of priority MNS conditions using
protocols for clinical decision-making.
▪ The mhGAP version 2.0, was launched in 2016 with updates
incorporating new evidence-based guidance, enhanced usability, and
new sections to expand its use by both health care providers as well
as program managers.
GENERAL PRINCIPLES OF CLINICAL CARE

▪ Use Effective Communication Skills

▪ Promote Respect and Dignity

ESSENTIALS OF MENTAL HEALTH CLINICAL PRACTICE

▪ Assess Physical Health

▪ Conduct a MNS Assessment
▪ Manage MNS Conditions
 Management of MNS conditions
(included in the Intervention Guide)

▪ Treatment Planning ▪ Referral to

specialist/hospital if needed
▪ Psychosocial Interventions
– Psychoeducation ▪ Follow-up
– Reduce stress and strengthen
social supports ▪ Involving Carers
– Promote functioning in daily ▪ Links with other sectors
activities
– Psychological Treatment ▪ Consider the needs of
Special Populations
▪ Pharmacological
Interventions
 mhGAP Master Chart
▪ This contains the overview of priority conditions and the
emergency presentations of each NMS conditions.
▪ This is where the common presentations of each MNS
conditions are shown that guides the assessment of the non-
specialized health-care provider.
NOTE!
▪ If the client present with features of more than one
condition, then all relevant conditions need to be assessed.
▪ All conditions apply to all ages, unless otherwise specified.
▪ For the emergency presentation, this must be assessed as the
presence of any of the given presentations require immediate
management and care
ASSESSMENT
CUES
Overview of
Priority MNS Conditions
1. These common presentations indicate the need for assessment.
2. If people present with features of more than one condition,
then all relevant conditions need to be assessed.
3. All conditions apply to all ages, unless otherwise specified.
4. For emergency presentations, please see the table on page 18.

COMMON PRESENTATION PRIORITY CONDITION

Multiple persistent physical symptoms with no

clear cause Low energy, fatigue, sleep problems
DEPRESSION (DEP)
Persistent sadness or depressed mood, anxiety
Loss of interest or pleasure in activities that are normally
pleasurable

Marked behavioural changes; neglecting usual responsibilities related to work,

school, domestic or social activities
Agitated, aggressive behavior, decreased or increased activity
Fixed false beliefs not shared by others in the person’s culture
PSYCHOSES (PSY)
Hearing voices or seeing things that are not there

Lack of realization that one is having mental health problems

Convulsive movement or fits/seizures

During the convulsion: loss of consciousness or impaired consciousness, stiffness,
rigidity, tongue bite, injury, incontinence of urine or faeces EPILEPSY (EPI)
After the convulsion: fatigue, drowsiness, sleepiness, confusion, abnormal behaviour,
headache, muscle aches, or weakness on one side of the body
 18

EMERGENCY Presentations of Priority MNS Conditions

EMERGENCY PRESENTATION CONDITION TO CONSIDER GO TO

Act of self-harm with signs of poisoning or intoxication,
bleeding from self-inflicted wound, loss of consciousness MEDICALLY SERIOUS ACT OF SELF-HARM
and/or extreme lethargy

Current thoughts, plan, or act of self-harm or suicide, or SUI

history of thoughts, plan, or act of self-harm or suicide in a IMMINENTRISK OF SELF-HARM/SUICIDE
person who is now extremely agitated, violent, distressed
or lacks communication
Acute convulsion with loss of consciousness or impaired
consciousness
EPILEPSY

Continuous convulsions STATUS EPILEPTICUS EPI, SUB

ALCOHOL OR OTHER SEDATIVE WITHDRAWAL
Agitated and/or aggressive behaviour
DEM, PSY, SUB
Smell of alcohol on the breath, slurred speech, uninhibited
behaviour; disturbance in the level of consciousness, cognition,
ACUTE ALCOHOL INTOXICATION
perception, affect or behaviour

Tremor in hands, sweating, vomiting, increased pulse and ALCOHOL WITHDRAWAL

blood pressure, agitation, headache, nausea, anxiety; seizure
and confusion in severe cases
ALCOHOL WITHDRAWAL DELIRIUM SUB
Unresponsive or minimally responsive, slow respiratory rate,
SEDATIVE OVERDOSE OR INTOXICATION
pinpoint pupils

Dilated pupils, excited, racing thoughts, disordered thinking,

strange behaviour, recent use of cocaine or other stimulants, ACUTE STIMULANTINTOXICATION OR OVERDOSE
increased pulse and blood pressure, aggressive, erratic or
violent behaviour
DEP
depression
• This is primarily characterized by persistent depressed mood
with markedly diminished interest in, or pleasure from,
activities.
• symptoms must be present for at least two weeks.
DEP COMMON PRESENTATION

▪ Multiple persistent physical symptoms with

no clear cause
▪ Low energy, fatigue, sleep problems
▪ Persistent sadness or depressed mood,
anxiety
▪ Loss of interest or pleasure in activities that
are normally pleasurable
DEP ASSESSMENT
▪ Consider physical conditions such as anemia, malnutrition and
hypothyroidism as this can resemble some manifestations of
depression such as low energy, fatigue, low mood, lack of focus,
etc.
▪ Assess for possible substance use or medication side-effects as
it may also cause mood changes.
▪ Ask for history of mania, this can be a depressive episode in
bipolar and would require different form of management.
▪ Major losses can also bring about grieving that can normally
result to depressed mood
▪ Assess for self-harm/suicide
DEP MANAGEMENT
▪ Psychoeducation.
▪ Reducing stress and strengthening social supports.
▪ Promoting functioning in daily activities.
▪ Referral. Consider a referral to a hospital due to non-responsive to treatment, shows serious
side-effects to meds, needs further treatment for any comorbid physical condition, risk of
self-harm/suicide
▪ Linkages - return to their studies and/or start a livelihood activity
▪ Brief psychological treatments -Group interpersonal therapy, Multi-component behavioral
treatment, Cognitive behavioral therapy
▪ Psychopharmacologic management. (Meds)
DEP FOLLOW UP

▪ Observe if the client shows improvement or

remains the same or deteriorating.
▪ Monitor clients on antidepressants.
Pharmacologic responses that will require
action:
– symptoms of mania
– inadequate response
– no response.
PSY
psychoses
• includes psychosis and bipolar disorder.
PSY OVERVIEW
▪ This is the most common NMS condition that causes stigma,
discrimination, and human rights violation.
▪ The nurse must also play a proactive role on decreasing stigma,
discrimination, and human rights abuses
▪ Psychosis is characterized by: disturbed perception, disturbed
thinking and/or disturbed behaviors and emotions
▪ Bipolar disorder is often characterized by significant disturbance in
mood and activity levels with manic episodes (in which the
person’s mood is elevated and their activity levels increase) and
depressive episodes (in which the person’s mood is lowered
(depressive) and their energy levels decrease).
PSY COMMON PRESENTATION
▪ Marked behavioral changes; neglecting usual responsibilities
related to work, school, domestic or social activities
▪ Agitated, aggressive behavior, decreased or increased
activity
▪ Fixed false beliefs not shared by others in the person's culture
▪ Hearing voices or seeing things that are not there
▪ Lack of realization that one is having mental health problems
PSY ASSESSMENT
▪ Establish communication and build trust
▪ Evaluate for medical conditions such as delirium,
medications, and metabolic abnormalities
▪ Evaluate for other relevant MNS condition
PSY MANAGEMENT
▪ Psychoeducation
– Not to try and convince the person that their beliefs or
experiences are false and not real.
– Explain that instead carers should be open to listening to
the person talk about their experience but should not
have a judgement or opinion about the experiences.
Instead stay neutral.
– Remind carers to stay calm and patient and not to get
angry with the person.
PSY MANAGEMENT

▪ Promoting functioning in ADLs help a person cope

with and manage their symptoms
▪ Pharmacological interventions
– Oral medication can be more dignified than using
intramuscular treatment. It is also empowering as it
means the person must take responsibility in their own
recovery by taking medication every day. Only use
intramuscular treatment if oral routes are not possible.
PSY FOLLOW UP
▪ Follow up with a person with psychosis.
▪ Focus on re-assessment of the symptoms.
▪ Assessment of side-effects of medication.
▪ Assessment of psychosocial interventions
specifically strengthening social support, reducing
stress and life skills.
EPI
epilepsy
• Seizures are brief disturbances in the electrical functions of the brain.
• There are potentially many different causes of epilepsy but it is not always
easy to identify one.
EPI OVERVIEW
▪ There are two types of epilepsy: convulsive
and non-convulsive.
– Convulsive epilepsy has features such as sudden
abnormal movements including stiffening and
shaking the body (due to a convulsive seizure).
– Non-convulsive epilepsy has features such as
changes in mental status (due to non-convulsive
seizures).
EPI OVERVIEW
▪ Seizures are considered as emergency due to the
following reasons:
– Treatment can end seizures or shorten seizure duration,
which limits the damage they can cause.
– Prolonged or repeated seizures can result in brain injury.
– Prolonged or repeated seizures can result in death if not
treated immediately.
– Seizures can be a symptom of a life threatening problem,
like meningitis.
EPI COMMON PRESENTATION
▪ Convulsive movement or fits/seizures
▪ During the convulsion: loss of consciousness or
impaired consciousness, stiffness, rigidity, tongue
bite, injury, incontinence of urine or feces
▪ After the convulsion: fatigue, drowsiness, sleepiness,
confusion, abnormal behavior, headache, muscle
aches, or weakness on one side of the body
EPI ASSESSMENT
▪ In order to receive a diagnosis of epilepsy, there
needs to have been two or more recurrent
unprovoked seizures (in the past 12 months):
– Recurrent = usually separated by days, weeks or months.
– Unprovoked = there is no evidence of an acute cause of
the seizure (e.g. febrile seizure in a young child).
▪ Seizures are brief disturbances of the electrical
function of the brain.
EPI ASSESSMENT
▪ Assess for the following:
– Signs of head and/or spinal trauma.
– Pupils: Dilated? Pinpoint? Unequal? Unreactive?
– Signs of meningitis: stiff neck, vomiting.
– Weakness on one side of body or in one limb.
▪ In unconscious people who are unresponsive to pain, you may notice that one
limb or side of the body is “floppy” compared with the other.
– Are they diabetic? Are they on any medications?
▪ Could this be low blood sugar?
– Are they HIV positive? Are they on any medications?
▪ Could this be an infection (e.g. meningitis)?
– Is there any chance of poisoning?
– Is this person a drug user or a heavy drinker?
▪ If yes, in addition to managing their acute seizures, you will need to do an
assessment according to the drug and alcohol use sections of the mhGAP-IG.
EPI MANAGEMENT
▪ During an actual seizure:
–Check ABCs AIRWAY - BREATHING - CIRCULATION
–If the person is still unconscious, use the
recovery position Sims position w/ hand under chin to keep mouth
open and other arm bent to prevent rolling over
–Measure and document vital signs
–Administer rectal diazepam
EPI MANAGEMENT
▪ if you suspect a brain infection:
–Manage the seizure
–Initiate treatment for the underlying brain
infection (such as i.v. antibiotic for
meningitis).
–Refer to hospital as this is an emergency.
EPI MANAGEMENT
▪ if you suspect trauma:
–Manage the seizure.
–Stabilize the neck:
▪ DO NOT move the neck.
▪ There could be a cervical spine injury.
▪ Log roll the person when moving.
–Assess for other evidence of trauma.
–Refer to the hospital as this is an emergency.
EPI MANAGEMENT
▪ if the person is a child with fever:
– It could be a febrile seizure.
– Febrile seizures are events occurring in children
(three months to five years of age), who are
suffering from fever and don't have any
neurological illness or brain infection.
– There are two types of febrile seizure:
▪ Complex (these need to be ruled out).
▪ Simple febrile seizures.
CHM
child & adolescent mental
and behavioral disorders
• children/adolescents with mental and behavioral disorders face
major challenges with stigma, isolation, and discrimination as well as
lack of access to health care and educational facilities
CMH COMMON PRESENTATION

▪ Child/adolescent being seen for physical

complaints or a general health assessment who
has:
– Problem with development, emotions or behaviour
(e.g. inattention, over-activity, or repeated defiant,
disobedient and aggressive behaviour)
– Risk factors such as malnutrition, abuse and/or
neglect, frequent illness, chronic diseases (e.g.
HIV/AIDS or history of difficult birth)
CMH COMMON PRESENTATION

▪ Carer with concerns about the

child/adolescent's:
– Difficulty keeping up with peers or carrying out daily
activities considered normal for age
– Behaviour (e.g. too active, aggressive, having
frequent and/or severe tantrums, wanting to be
alone too much, refusing to do regular activities or
go to school)
CMH COMMON PRESENTATION

▪ Teacher with concerns about a child/adolescent

– e.g. easily distracted, disruptive in class, often
getting into trouble, difficulty completing school
work
▪ Community health or social services worker
with concerns about a child/adolescent
– e.g. rule- or law-breaking behaviour, physical
aggression at home or in the community
CMH ASSESSMENT

▪ whenever we assess children’s development

and psychological well-being, we also need to
assess:
– The carers’ capacity to provide a caring
environment.
– The availability of other people who can support
the child and carers.
CMH ASSESSMENT

▪ DEVELOPMENTAL DISORDERS are

only suspected when there is a
substantial delay in learning skills in more
than one domain. Two common types of
developmental disorder are:
–intellectual disability
–autism and other pervasive developmental
disorders.
CMH ASSESSMENT

▪ PROBLEM BEHAVIORS can be defined as:

–excessive over-activity
–excessive inattention
–excessive impulsivity
–repeated and continued behavior that disturbs
others
–sudden changes in behavior or peer relations.
CMH ASSESSMENT

▪ behavioral disorder characterized by

dissocial, aggressive and disobedient
behavior is also called “conduct
disorder”.
CMH MANAGEMENT
▪ Psychosocial interventions for treatment of behavioral disorders
– Behavioral interventions for children and adolescents, and caregiver skills
training.
▪ Psychosocial interventions, treatment of emotional disorders
– Psychological interventions, such as CBT, IPT for children and adolescents
with emotional disorders, and caregiver skills training focused on their
caregivers
▪ Caregiver skills training for the management of developmental
disorders
▪ Antidepressants among adolescents with moderate-severe
depressive disorder for whom psychosocial interventions have
proven ineffective
DEM
dementia
• Dementia is a term used to describe a large group of conditions
affecting the brain which cause a progressive decline in a person’s
ability to function.
DEM OVERVIEW
▪ It is not a normal part of ageing.
▪ People with dementia can present with problems
in:
– Cognitive function: Confusion, memory, problems
planning.
– Emotion control: Mood swings, personality changes.
– Behavior:Wandering, aggression.
– Physical health: Incontinence, weight loss
– Difficulties in performing daily activities:Ability to
cook, clean dishes.
DEM COMMON PRESENTATION
▪ Decline or problems with memory (severe
forgetfulness) and orientation (awareness of time,
place and person)
▪ Mood or behavioral problems such as apathy
(appearing uninterested) or irritability
▪ Loss of emotional control (easily upset, irritable or
tearful)
▪ Difficulties in carrying out usual work, domestic or
social activities
DEM ASSESSMENT

▪ Assess for signs of dementia

– Test orientation, memory and language
▪ Rule out delirium and depression
▪ Evaluate for other medical issues
▪ Assess for behavioral or psychological symptoms
▪ Rule out other MNS conditions
▪ Evaluate the need of carers
DEM MANAGEMENT
▪ Carer support
– Empathize: Acknowledge how difficult and frustrating it is to
care for someone with dementia
– Encourage carer to seek help and support.
– Provide information to carers about dementia and the
symptoms.
– Train the carers and support them to learn to tackle difficult
behaviours like wandering and aggression (use role plays).
– If possible, offer respite care for the carer.
– Explore any financial support or benefits the carer and person
may be entitled to.
SUB
disorders due to
substance use
SUB COMMON PRESENTATION
▪ Appearing affected by alcohol or other substance
(e.g. smell of alcohol, slurred speech, sedated, erratic
behavior)
▪ Signs and symptoms of acute behavioral effects,
withdrawal features or effects of prolonged use
▪ Deterioration of social functioning (i.e. difficulties at
work or home, unkempt appearance)
SUB COMMON PRESENTATION
▪ Signs of chronic liver disease (abnormal liver
enzymes), jaundiced (yellow) skin and eyes, palpable
and tender liver edge (in early liver disease), ascites
(distended abdomen is filled with fluid), spider naevi
(spider-like blood vessels visible on the surface of the
skin), and altered mental status (hepatic
encephalopathy)
▪ Problems with balance, walking, coordinated
movements, and nystagmus
SUB COMMON PRESENTATION

▪ Persons with disorders due to substance use

may not report any problems with substance
use. Look for:
– Recurrent requests for psychoactive medications
including analgesics
– Injuries
– Infections associated with intravenous drug use
(HIV/AIDS, HepatitisC)
SUB ASSESSMENT
▪ Assess for substance-specific signs and symptoms
SUB MANAGEMENT

▪ motivational interviewing empowers and

motivates individuals to take
responsibility and change their substance
use behavior.
▪ Mutual help groups
SUI
self-harm/suicide
• ingestion of pesticides, hanging and firearms are the most common
methods of suicide globally
SUI COMMON PRESENTATION
▪ Extreme hopelessness and despair
▪ Current thoughts, plan or act of self-
harm/suicide, or history thereof
▪ Any of the other priority conditions, chronic
pain, or extreme emotional distress
SUI ASSESSMENT
▪ in an emergency assessment of self-
harm/suicide attempts look for:
–Signs of poisoning.
–Bleeding, loss of consciousness and
–extreme lethargy.
SUI ASSESSMENT
▪ while assessing for suicide, it is essential to
assess for:
– Other concurrent MNS conditions.
– Chronic pain such as pain due to HIV/AIDS, cancer
etc.
– Emotional distress – this can be due to the loss of a
loved one, loss of employment, intense family
conflict, problems at school, intimate partner
violence, physical or sexual abuse or uncertainty
about gender and sexual orientation etc.
SUI MANAGEMENT
▪ key to the management of self-harm/suicide is to:
– Ensure the person does not have access to means.
– Support the carers.
– Mobilize family and friends to support and make the
person feel safe.
– Focus on protective factors.
– Offer psychoeducation to ensure the person understands
how useful it is to talk about negative feelings and how
important it is to identify people to turn to when feeling
this way
SUI MANAGEMENT
▪ It is important to treat any underlying MNS
condition, chronic pain and emotional
distress.
▪ As self-harm/suicide is always serious, refer
the person to a mental health specialist when
available and consult them regarding next
steps.
References:
World Health Organization. (2017). mhGAP training manuals for the mhGAP
intervention guide for mental, neurological and substance use disorders
in non-specialized health settings, version 2.0 (for field testing). World
Health Organization. https://apps.who.int/iris/handle/10665/259161
License: CC BY-NC-SA 3.0 IGO

World Health Organization. (2016). mhGAP intervention guide for mental,

neurological and substance use disorders in non-specialized health
settings: mental health Gap Action Programme (mhGAP), version 2.0.
World Health Organization.
https://apps.who.int/iris/handle/10665/250239

Adapted ppt JJ. Nicolas

REPUBLIC ACT No. 11036"Mental Health Act.“
Described as:
An Act Establishing a National Mental Health Policy for the Purpose of
Enhancing the Delivery of Integrated Mental Health Services, Promoting and
Protecting the Rights of Persons Utilizing Psychosocial Health Services,
Appropriating Funds Therefor and Other Purposes

Principal Author: Akbayan Senator Risa Hontiveros

Pls see RA 11036