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Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies.
1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR.
ISBN 978 92 4 154892 2 (NLM classification: WM 30) World Health Organization 2015
All rights reserved. Publications of the World Health Organization are available on the WHO websit) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website ).
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All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner
for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management
of mental, neurological and substance use conditions in humanitarian emergencies.
Geneva: WHO, 2015.
Contact for feedback and communication: Department of Mental Health and Substance Abuse
at WHO () or the Public Health Section at UNHCR ()
Foreword
Today, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population's heightened mental health needs.
Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population's mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever.
This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO's mhGAP Intervention Guide (2010), a widely-used evidence-based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies.
This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings.
United Nations High Commissioner for Refugees World Health Organization Table of Contents
Conceptualization
Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO),
under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR)
Project Writing and Editorial Team
Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO)
WHO mhGAP Review Team
Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya,
Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy
Other Contributors/Reviewers
Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre
for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver),
Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School),
Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings),
Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission),
Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne),
Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University
of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul
(Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon),
Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers
for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King's College London),
Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan),
Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College
of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health),
Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa),
Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated
capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel),
Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan),
Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health
and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia),
Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor's
University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain),
Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO),
Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University),
Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision
International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove
(University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation),
Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF),
Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM),
Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross
and Red Crescent Societies) and William Yule (King's College London).
Funding
United Nations High Commissioner for Refugees (UNHCR)
This guide is an adaptation of th or use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG).
What is mhGAP?
Th is
These include general physicians, nurses, midwives and a WHO programme that seeks to address the lack of
clinical officers, as well as physicians specialized in areas care for people suffering from mental, neurological
other than psychiatry or neurology.
and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- In addition to clinical guidance, the mhGAP programme IG) was issued in 2010. mhGAP-IG is a clinical guide provides a range of tools to support programme on mental, neurological and substance use disorders implementation useful for situational analysis, for general health-care providers who work in non-
adaptations of clinical protocols to local contexts, specialized health-care settings, particularly in low- and
programme planning, training, supervision and monitoring.1 Why is there a need for adaptation to humanitarian emergency contexts?
Humanitarian emergencies include a broad range
Challenges include:
of acute and chronic emergency settings arising from
eightened urgency to prioritize and allocate scarce armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the » L imited time to train health-care providers
population's need for basic services overwhelms local » L imited access to specialists (for training, supervision,
capacity, as the local system may have been damaged by mentoring, referrals or consultations) the emergency. Resources vary depending on the extent and availability of local, national and international » L imited access to medications due to disruption of usual
humanitarian assistance. supply chain.
Humanitarian crises pose a set of challenges as well as The mhGAP Humanitarian Intervention Guide was unique opportunities for providers of health services. developed in order to address these specific challenges Opportunities include increased political will and of humanitarian emergency settings. resources to address and improve mental health services.2 Contents of this guide
The mhGAP Humanitarian Intervention Guide contains
Other changes include the following:
first-line management recommendations for MNS
uidance on conduct disorder was rewritten as conditions for non-specialist health-care providers in guidance on behavioural problems in adolescents, humanitarian emergencies where access to specialists
found in the module on other significant mental health and treatment options is limited.
complaints (OTH). This guide extracts essential information from the full » T he module
mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. (WHO, 2013) was separated This guide covers:
into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). » dvice for clinic managers;
glossary has been added. Terms marked with the » eneral principles of care applicable to humanitarian
asterisk symbol * are defined in Annex 2.
emergency settings, including: Provision of multi-sectoral support in accordance This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); (UNHCR, 2013) and other emergency- ttention deficit hyperactivity disorder (however, ◆ Instructions on stress reduction; adolescent behavioural problems are covered in this guide's module on other significant mental health » rief modules on the assessment and management of:
Acute stress (ACU) ◆◆ Grief (GRI) utism-spectrum disorders; Moderate-severe depressive disorder (DEP) ementia (however, support for carers of people with Post-traumatic stress disorder (PTSD) any MNS condition is covered in this guide's General Principles of Care); Epilepsy/seizures (EPI) on-imminent risk of self-harm; Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) » S econd-line treatments for most MNS conditions.
Guidance on these latter topics continues to be available Other significant mental health complaints (OTH).
in the full .
1 Email to obtain a copy of these tools.
2 See W WHO: Geneva, 2013.
Advice for Clinic Managers
The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (se). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points.
private space, preferably a separate
Consider having the room unmarked, in order to prevent room, to do consultations for MNS conditions. If a avoidance of MNS services out of fear of social stigma. separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Consider having at least one trained staf , consider holding a weekly or twice-weekly physically present at any given time on "MNS duty", i.e. "MNS clinic" within the general health facility, at a time a person who is assigned to assess and manage people of the day when the clinic is less busy. If people show up with MNS conditions. during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training
f about providing a supportive atmosphere
onsider assigning someone in the health-care team for people with MNS conditions. (e.g. a nurse, a psychosocial worker, a community » dentify staff members to be trained on MNS care.
social worker) to be trained and supervised to provide » nsure that resources are available not only for the
psychosocial support (e.g. providing brief psychological
training but also for supervision. Clinical supervision of
treatments, running self-help groups, teaching stress staff is an essential part of good MNS care. » f only a few staff can be trained on the contents of
rient all staff on local protection arrangements:
this guide, then ensure that the rest of the clinical staff Requirements for and limitations of consent, can offer psychological first aid (PFA)* at the least. including reporting around suspected child abuse, Orientation on PFA can be provided in approximately sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated facilitators can be found online.
children in particular must be protected and referred to appropriate temporary care arrangements, if » rient the receptionist (or person with similar role) on
how to deal with agitated people who may demand or require immediate attention. I f international mental health professionals are attached to the clinic to provide supervision, they » ain community workers and volunteers, if available,
should be briefed about the local culture and context.
on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek rient all staff on how to refer to available services. help at the clinic and (c) assist with follow-up care.
Referral
Ensure that the clinic has an updated contact list for » Ensure that the clinic has an updated contact list for
referrals for the care of MNS conditions.
other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). Raising awareness around available services
» Prepare messages for the community about available
» here appropriate, consider discussing the messages with
MNS care (e.g. purpose and importance of MNS care, local indigenous and traditional healing practitioners services available at the clinic, clinic location and hours).
who may be providing care for people with MNS iscuss the messages with community leaders.
conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. each out to marginalized groups who may not be aware of or have access to the clinic.
Medicines
» W
ork with relevant decision-makers to ensure a The following psychotropic medicines are included in constant supply of essential medicines.
» E nsure availability of:
▸ mitriptyline tablets: 25 mg tablet x 4000
at least one antipsychotic medicine (tablet and ▸ iperiden tablets: 2 mg tablet x 400
injectable forms) ▸ iazepam tablets: 5 mg tablet x 240
at least one anti-Parkinsonian m edicine (to deal ▸ iazepam injections: 5 mg/ml, 2 ml/ampoule x 200
with potential extrapyramidal side effects*) ▸ aloperidol tablets: 5 mg tablet x 1300
loperidol injections: 5 mg/ml; 1 ml/ampoule x 20
at least one anticonvulsant/antiepileptic medicine ▸ henobarbital tablets: 50 mg x 1000.
The quantity of medicines in the IEHK is not suf at least one antidepressant medicine (tablet form) for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional at least one anxiolytic medicine (tablet and injectable medicines will need to be ordered. Over the long term, the necessary quantities of medicines should be informed by actual use.
u may have access to the , a large box with » n addition to psychotropic medicines, atropine should be
medicines and medical supplies designed to meet the available for the clinical management of acute pesticide expected primary health-care needs of 10 000 people intoxication, a common form of self-harm. Atropine is exposed to major humanitarian emergencies for 3 contained in the IEHK (1mg/ml, 1 ml/ampoule x 50).
» E nsure that all medicines are stored securely.
Information management
» Ensur
e confidentiality. Health records should be stored
ollect and analyse the data and report the results to relevant public health decision-makers.
» I dentify data needed for input into the health
information system.
Consider using the UNHCR Health Information ◆ System's 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled "mental, neurological or substance use problem" should be added to the health information system. Over time this item should be replaced with a more detailed system. General Principles of Care GPC
for People with Mental,
Neurological and Substance Use
Conditions in Humanitarian Settings
1. Principles of Communication
In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to
see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and
focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will
help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions.
» eate an environment that facilitates open
and repeat key points. It can be helpful
to ask the person or carers to write down important Meet the person in a private space, if possible.
points. Alternatively, provide a written summary of Position yourself to be at the same eye level as the
the key points for the person.
person (e.g. if the person is sitting, sit down too).
◆ elcome the person; introduce yourself and your
» Respond with sensitivity when people disclose dif
position/role in a culturally appropriate way. experiences (e.g. sexual assault, violence or self-harm)
everyone present. Let the person know that you will respect the Ask the person whether he/she wants their carers or confidentiality of the information.
other people to stay. Never belittle the person' s feelings or preach or be ▸ nless the person is a young child, suggest that you
would like to talk to the person alone if possible. Acknowledge that it may have been dif If the person wants others to stay, respect this. person to share.
▸ f you see the person alone, seek permission to
If referral to other services is necessary , explain clearly ∙ sk the carers relevant assessment questions to
what the next steps will be. Seek the consent of the find out their perspective, and person to share information with other providers who ∙ nvolve the carers when the management plan is
may be able to help. For example: discussed and agreed. ▸ Y
ou have told me that your neighbour has done Let the person know that information discussed something very bad to you. I will not share this during the visit will be kept confidential and will not
with anyone else but I can think of some people be shared without their permission, except when you who may be able to help you. Is it OK if I discuss perceive a risk to the person or to others (note that your experience with my colleague from agency X? this message may need to be adapted according to » Do not judge people by their behaviours
national legal limits on confidentiality). People with severe MNS conditions may demonstrate Involve the person with the MNS condition as much
unusual behaviours. Understand that this may be as possible
because of their illness. Stay calm and patient. Never if the person's functioning is impaired, always try
laugh at the person. to involve them in the discussion. This is also true for
▸ I f the person behaves inappropriately (e.g.
children, youths and elderly people with MNS conditions. agitated, aggressive, threatening), look for the
Do not ignore them by talking only with their carers.
source of the problem and suggest solutions. explain to the person what you are
Involve their carers or other staff members in doing (e.g. during physical examination) and what creating a calm, quiet space. If they are extremely
you are going to do.
distressed or agitated, you may need to prioritize
their consultation and bring them into your Start by listening
consulting space at once. Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not » If needed, use appr
opriate interpreters
always give a clear history. When this happens, be If needed, try to work with trained interpreters, patient and ask for clarification. Try not to rush them.
preferably of the same gender as the person with not press the person to discuss or describe potentially the MNS condition. If a trained interpreter is not traumatic events* if they do not wish to open up. available, other health-care staff or carers may Simply let them know that you are there to listen. interpret, with the consent of the person. Children may need more time to feel comfortable. In situations where the carer interprets, be aware Use language that they can understand. Establishing that the person with the MNS condition may not fully a relationship with children may require talking disclose. In addition, conflict of interest between the about their interests (toys, friends, school, etc.).
person and the carer may influence communication. If this becomes an issue, arrange for an appropriate Be clear and concise
interpreter for future visits. Use language that the person is familiar with. A Instruct the interpreter to maintain confidentiality using technical terms.
and translate literally, without adding their own can impair people's ability to process information. thoughts and interpretations.
Provide one point at a time to help the person understand what is being said before moving on to 2. Principles of Assessment
Clinical assessment involves identifying the MNS condition as well as the person's own understanding of the problem(s).
It is important also to assess the person's strengths and resources (e.g. social supports). This additional information will
help health-care providers offer better care.
It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. » Explor
e the presenting complaint
» Explor
e possible alcohol and drug use
What brings you here today? When and how did the Questions regarding alcohol and drugs can be perceived problem start? How did it change over time? as sensitive and even offensive. However, this is an How do you feel about this problem? Where do you essential component of MNS assessment. Explain to the think it came from? person that this is part of the assessment and try to ask How does this problem impact on your daily life? questions in a non-judgemental and culturally How does the problem affect you at school/work or in daily community life? I need to ask you a few routine questions as part of What kind of things did you try to solve this problem? the assessment. Do you take alcohol (or any other Did you try any medication? If so, what kind (e.g. substance known to be a problem in the area)? [If prescribed, non-prescribed, herbal)? What effect did yes] How much per day/week? Do you take any tablets when you feel stressed, upset » Explor
e possible family history of MNS conditions
or afraid? Is there anything you use when you have Do you know of anyone in your family who has had pain? Do you take sleeping tablets? [If yes] How a similar problem? much/many do you take per day/week? Since when? e the person's general health history
Explore possible suicidal thoughts and suicide attempts
Ask about any previous physical health problem: Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an ▸ ave you had any serious health problem
in the past? MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. ▸ o you have any health problem for which you are
currently receiving care? You may start with: What are your hopes for the Ask if the person is taking any medication: future? If the person expresses hopelessness, ask further questions ( module), such as ▸ as a health-care provider prescribed any
medication you are supposed to be taking Do you feel that life is worth living? Do you think right now? about hurting yourself? or Have you made any plans to end your life? )
▸ hat is the name of that medication? Did you
bring it with you? How often do you take it? » Conduct a targeted physical examination
Ask if the person has ever had an allergic reaction should be a focused physical examination, guided to a medication.
by the information found during the MNS assessment. » Explor
e current stressors, coping strategies and social
If any physical condition is found at this stage, either manage or refer to appropriate resources.
How has your life changed since the … [state the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? How is it affecting you?What are your most serious problems right now? ◆ How do you deal/cope with these problems day by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? If an MNS condition is suspected, go to the r
elevant module for assessment.
If the person pr
esents with features relevant to more than one MNS condition,
then all relevant modules need to be considered.
3. Principles of Management
Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however,
continuity of care may be difficult because mental health care is not consistently available or people have been or are
about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable
resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include
anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or
other trusted people. Increasing the person's and the carer's understanding of the MNS condition, management plan
and follow-up plan will enhance adherence.
» anage both mental and physical conditions in people
e the person leaves:
with MNS conditions
Confirm that the person and the carer understand Provide information about the condition to the and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). ▸ f the person agrees, also provide the information
Encourage self-monitoring of the symptoms and educate the person and carer on when to seek Discuss and determine achievable goals, and develop urgent care.
and agree on a management plan with the person Arrange a follow-up visit. ▸ f the person agrees, also involve the carer in this
reate a follow-up plan, taking into consideration the current humanitarian situation (e.g. fleeing/ ▸ or the proposed management plan, provide
moving population and disruptions in services).
▸ I f the person is unlikely to be able to access the
∙ xpected benefits of treatment;
∙ uration of treatment;
∙ rovide a brief written management plan and
∙ mportance of adhering to treatment,
encourage the person to take this to any future including practising any relevant psychological clinical visits.
interventions (e.g. relaxation training) at home ∙ rovide contact information for other health-
and how carers could help; care facilities nearby.
∙ otential side-effects of any medication being
Initial follow-up visits should be more frequent until the symptoms begin to respond to treatment.
∙ otential involvement of social workers, case
Once the symptoms start improving, less frequent but managers, community health workers or other regular appointments are recommended.
trusted members in the community Explain that the person can return to the clinic at any time in between follow-up visits if needed (e.g. when experiencing side-effects of medications).
∙ rognosis. Maintain a hopeful tone, but be
At each follow-up meeting, assess for:
realistic about recovery.
Response to treatment, medication side-ef Provide information about the financial aspects of and adherence to medications and psychosocial the management plan, if relevant.
interventions. Acknowledge all progress towards the » ddress the person's and the carer's questions and
goals and reinforce adherence.
concerns about the management plan
General health status. Monitor physical health ◆ regularly.
Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person's own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management.
s and the carer's understanding and expectations of the treatment. Correct any misconceptions.
If the person is pregnant or breastfeeding:
Always check the latest contact information, as it can ◆ change frequently. » void prescribing medications that may have
potential risks to the fetus, and facilitate During the entir
e follow-up period:
access to antenatal care.
Maintain regular contact with the person and their » void prescribing medications that may
carer. If available, assign a community worker or have potential risks to the infant/toddler of another trusted person in the community to keep a breastfeeding woman. Monitor the baby in touch with the person. This person may be a family of a breastfeeding woman who is on any medication. Consider facilitating access to Have a plan of action for when the person does not ry to find out why the person did not return. A community worker or another trusted person can help locate the person (e.g. home visits).
▸ I f possible, try to address the issue so that the
person can return to the clinic. Consult a specialist if the person does not improve.
4. Principles of Reducing Stress and Strengthening Social Support
Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where
people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection) and overall well-
being of the population affected by humanitarian crises .
» Explor
e possible stressors and the availability of social
provide the person with a short referral note. ◆ each stress management: What is your biggest worry these days? ▸ dentify and develop positive ways to relax
How do you deal with this worry? (e.g. listening to music, playing sports, etc.).
What are some of the things that give you comfort, ▸ each the person and the carers specific stress
strength and energy? management techniques (e.g. breathing exercises Who do you feel most comfortable sharing your problems with? When you are not feeling well, who ∙ I n some settings, you can refer to a health worker
do you turn to for help or advice? (e.g. nurse or psychosocial worker) who can teach How is your relationship with your family? In what these techniques. way do your family and friends support you and in what way do you feel stressed by them? ess stress of the carers
Ask the carer(s) about: e of signs of abuse or neglect
▸ orries and anxiety around caring for the person
Be attentive to potential signs of sexual or physical with MNS conditions in the current humanitarian abuse (including domestic violence) in women, emergency situation; children and older people (e.g. unexplained bruises or ▸ ractical challenges (e.g. burden on the carers'
injuries, excessive fear, reluctance to discuss matters time, freedom, money); when a family member is present).
▸ bility to carry out other daily activities, such as
Be attentive to potential signs of neglect, particularly work or participation in community events; in children, people living with disability and older people (e.g. malnourishment in a family with access ▸ hysical fatigue;
to sufficient food, a child who is overly withdrawn).
▸ ocial support available to the carers:
When signs of abuse or neglect are present, interview ∙ A
re there other people who can help you when the person in a private space to ask if anything you are not able to care for the person (for hurtful is going on. example, when you are sick or very tired)?; If you suspect abuse or neglect: ▸ sychological well-being. If carers seem distressed
▸ alk immediately with your supervisor to discuss
or unstable, assess them for MNS conditions the plan of action.
▸ ith the person's consent, identify community
After the assessment, try to address the carers' needs resources (e.g. trusted legal services and protection and concerns. This may involve: networks) for protection. ▸ iving information;
▸ inking the carer with relevant community services
Based on information gather
ed, consider the following
▸ iscussing respite care. Another family member
Problem-solving: or a suitable person can take over the care of the ▸ se problem-solving techniques* to help the person
person temporarily while the main carer takes a address major stressors. When stressors cannot be rest or carries out other important activities; solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. ▸ erforming problem-solving counselling* and
In general, do not give direct advice. Try to teaching stress management; encourage the person to develop their own ▸ anaging any MNS conditions identified in the carer.
Acknowledge that it is stressful to care for people ▸ hen working with children and adolescents, it is
with MNS conditions, but tell the carer that it is essential to assess and address the carer's sources important that they continue to do so. Even when of stress as well. this is difficult, carers need to respect the dignity of Strengthen social support: the people they care for and involve them in making ▸ elp the person to identify supportive and trusted
decisions about their own lives as much as possible.
family members, friends and community members and to think through how each one can be involved in helping.
▸ ith the person's consent, refer them to other
community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: ∙ ocial or protection services
∙ helter, food and non-food items
∙ ommunity centres, self-help and support groups
∙ ncome-generating activities and other
vocational activities f ∙ ormal/informal education
∙ hild-friendly spaces or other structured activities
for children and adolescents.
When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and Box GPC 1: Strengthening community supports
In addition to clinical management, encourage activities that enhance family and community support for
everyone, especially marginalized community members. For further guidance, see (UNHCR, 2013) and Action Sheet 5.2 of the
Box GPC 2: Relaxation exercise: instructions for slow breathing technique
I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some
practice before you feel the full benefits of this breathing technique.
The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That's great. Now when you practise on your own, don't be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 5. Principles of Protection of Human Rights
People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often
experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas
of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience
abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some
people with severe MNS conditions may not be aware that they have a problem that requires care and support.
People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support;D » enial of the right to exercise legal capacity;
Lack of access to services for their specific needs; Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; Abandonment or separation from family during displacement; Abandonment and neglect in institutional settings.
Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings.
» Engage the key stakeholders
» rotect the rights of people with severe MNS conditions
Identify key stakeholders who should be made aware in health-care settings
of the protection issues surrounding people with MNS treat people with MNS conditions with respect conditions. These key stakeholders include: ▸ eople with MNS conditions and their carers;
Ensure that people with MNS conditions have the ▸ ommunity leaders (e.g. elected community
same access to physical health care as people without representatives, community elders, teachers, MNS conditions.
religious leaders, traditional and spiritual healers); Respect a person' s right to refuse health care unless ▸ anagers of various services (e.g. protection/
they lack the capacity to make that decision (cf. security, health, shelter, water and sanitation, signed international conventions). nutrition, education, livelihood programmes); Discourage institutionalization. If the person is ▸ anagers of disability services (many disability
already institutionalized, advocate for their rights in services inadvertently overlook disability due to the institutional setting.
» romote the integration of people with severe MNS
▸ epresentatives of community groups (youth or
conditions in the community
women's groups) and human rights organizations; Advocate for the inclusion of people with MNS police and legal authorities.
conditions in livelihood supports, protection Organize awareness-raising activities for the key programmes and other community activities.
Advocate for the inclusion of children with epilepsy ▸ onsider offering orientation workshops on MNS
and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ▸ onsult people with MNS conditions, their carers
children and adults with intellectual disabilities/ and the disability and social service sectors in the developmental delay in community disability support design and implementation of awareness-raising Advocate for maintaining, as far as possible, ▸ uring the awareness raising activities:
autonomy and independence for people with MNS ∙ ducate and dispel misconceptions about people
with MNS conditions. E ∙ ducate on the rights of people with
MNS conditions, including equal access to humanitarian aid and protection.
D ∙ ispel discrimination against people with MNS
∙ dvocate for support for the carers of people
with MNS conditions.
General principles of protection in humanitarian action are described in the 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 (IASC, 2007).
6. Principles of Attention to Overall Well-being
In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being.
This is especially true in humanitarian settings where basic services, social structures, family life and security are often
disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of
health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions
across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1).
Support people with MNS conditions to safely access
» Arrange priority access to r
elevant activities for people
services necessary for survival and for a dignified
with MNS conditions, such as helping children with
way of living (e.g. water, sanitation, food aid, shelter,
such conditions to access child-friendly spaces.
livelihoods support). This may involve:
» Support the general physical health of people with
advising about the availability and location of such Arrange regular health assessments and vaccinations.
actively referring and working with the social sector Advise about basic self-care (nutrition, physical to connect people to social services (e.g. social work- activity, safe sex, family planning, etc.).
type case management);advising about security issues when the person is not ◆ sufficiently aware of threats to security.
Clinical mental health care (whether by
PHC staff or mental health professionals)
Focused psychosocial
Basic emotional and practical support
to selected individuals or families
Activating social networks
Strengthening community
and family supports
Supportive child-friendly spaces
Advocacy for good humanitarian practice:
Social considerations in
basic services that are safe, socially
basic services and security
appropriate and that protect dignity
Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies
(adapted with permission)
cute Stress
In humanitarian emergencies, adults, adolescents and children are often exposed
to potentially traumatic events*. Such events trigger a wide range of emotional,
cognitive, behavioural and somatic reactions. Although most reactions are self-limiting
and do not become a mental disorder, people with severe reactions are likely to present
to health facilities for help.
In many humanitarian emergencies people suffer various combinations of potentially
traumatic events and losses; thus they may suffer from both acute stress and grief.
The symptoms, assessment and management of acute stress and grief have much
in common. However, grief is covered in a separate module .
After a recent potentially traumatic event, clinicians need to be able to identify
the following:
» Significant symptoms of acute str
ess (ACU).
People with these symptoms may present with a wide range of non-specific psychological and medically
unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the
last month, for which people seek help or which causes considerable difficulty with daily functioning, and which
does not meet the criteria for other conditions covered in this guide. The present module covers assessment and
management of significant symptoms of acute stress.
» Post-traumatic str
When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. oblems and disorders that are more likely to occur after exposure
to stressors (e.g. potentially traumatic events) but that could also occur
in the absence of such exposure.
These include: moderate-severe depressive disorder (), psychosis (, harmful use of alcohol and drugs
(, suicide ( and other significant mental health complaints .
» Reactions that ar
e not clinically significant and that do not require clinical
management.
Of all reactions, these are the most common. They include transient reactions for which people do not seek help
and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help
address the person's needs and concerns and monitor whether expected natural recovery occurs.
Assessment question 1: Has the person recently experienced a potentially
traumatic event?
» Ask if the person has experienced a
potentially
how much time has passed since the event(s).
traumatic event. A potentially traumatic event is any
to assessment question 2 if a potentially traumatic threatening or horrific event such as physical or sexual event has occurred within the last month.
violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: a major loss (e.g. the death of a loved one) has What major stress have you experienced? Has your occurred, also assess for grief . life been in danger? Have you experienced something a potentially traumatic event has occurred more than that was very frightening or horrific or has made you 1 month ago, then consider other conditions covered in feel very bad? Do you feel safe at home? this guide , , .
Assessment question 2: If a potentially traumatic event has occurred within the
last month, does the person have significant symptoms of acute stress?
» C
» S ignificant symptoms of acute stress stress are likely if
anxiety about threats related to the traumatic the person meets all of the following criteria:
a potentially traumatic event has occurred approximately 1 month
concentration problems the symptoms started after the event
recurring frightening dreams, flashbacks* or intrusive ficulty with daily functioning because memories* of the events, accompanied by intense of the symptoms or seeking help for the symptoms.
fear or horrordeliberate avoidance of thoughts, memories, activities or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being "jumpy" or "on edge"; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements ◆ f eeling shocked, dazed or numb, or inability to feel anythingany disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ a ▸ggression
▸ ocial isolation and withdrawal
▸ isk-taking behaviours in adolescents
▸ egressive behaviour* such as bedwetting,
clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of medically unexplained physical complaints, such as: ◆ p ▸alpitations, dizziness
▸ eadaches, generalized aches and pains
▸ issociative symptoms relating to the body (e.g.
medically unexplained paralysis*, inability to speak or see, "pseudoseizures"*).
Assessment question 3: Is there a concurrent condition?
» Check for any
physical conditions that may explain the
» Check for any other
mental, neurological and substance
symptoms, and manage accordingly if found.
use (MNS) condition (including depression) covered in
this guide that may explain the symptoms and manage
accordingly if found.
Basic Management Plan
DO NOT prescribe medications to manage symptoms of acute stress
(unless otherwise noted below).
1. In ALL cases:
Provide basic psychosocial support fer additional psychosocial support as described in carefully. DO NOT pressure the person to talk.
the Principles of Reducing Stress and Strengthening the person about his/her needs and concerns. Social Support : the person to address basic needs, access services current psychosocial stressors.
and connect with family and other social supports.
Strengthen social support. ◆ otect the person from (further) harm.
◆ each stress management. » E ducate the person about normal reactions to grief and
acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. anage concurrent conditions.
2. In case of sleep problems as a symptom of acute stress,
offer the following additional management:
Explain that people commonly develop sleep problems » E xceptionally, in extremely severe cases where
(insomnia) after experiencing extreme stress.
psychologically oriented interventions (e.g. relaxation and address any environmental causes of techniques) are not feasible or not effective, and insomnia (e.g. noise). insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with » xplore and address any physical cause of insomnia (e.g.
benzodiazepines may be considered. » dvise on sleep hygiene, including regular sleep
or adults, prescribe 2–5 mg of diazepam at routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late or older people, prescribe 1–2.5 mg of diazepam in the day or before going to bed. Emphasize that alcohol disturbs sleep.
heck for drug-drug interactions before ommon side-effects of benzodiazepines include drowsiness and muscle weakness. aution: benzodiazepines can slow down breathing. Regular monitoring may be necessary. aution: benzodiazepines may cause dependence*. Use only for short-term treatment.
◆ ▸T his treatment is for adults only.
o not prescribe benzodiazepines to children or void this medication in women who are pregnant or breastfeeding. onitor for side-effects frequently when using this medication in older people.
his is a temporary solution for an extremely severe sleep problem.
enzodiazepines should not be used for insomnia caused by bereavement in adults or children. enzodiazepines should not be used for any other symptoms of acute stress or PTSD.
3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event .
3. In the case of bedwetting in children as a symptom of acute stress, offer
the following additional management:
» Obtain the history of bedwetting to confirm that it
» Consider training carers on the use of simple
started after experiencing a stressful event. Rule out
behavioural interventions (e.g. rewarding avoidance of and manage other possible causes (e.g. urinary tract
excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be » Explain
anything the child likes, such as extra playtime, stars on common, harmless reaction in
a chart or local equivalent. children who experience stress. Children should not be punished for bedwetting
because punishment adds to the child's stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive.
4. In the case of hyperventilation (breathing extremely fast and
uncontrollably) as a symptom of acute stress, offer the following additional
management:
» Rule out and manage
other possible causes, even if
e calm and remove potential sources of anxiety if hyperventilation started immediately after a stressful possible. Help the person regain normal breathing by event. Always conduct necessary medical investigations practising slow breathing ( to identify possible physical causes such as lung disease.
no physical cause is identified, reassure the Principles of Care) (do not recommend breathing into
person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. 5. In the case of a dissociative symptom relating to the body (e.g.
medically unexplained paralysis, inability to speak or see, "pseudoseizures")
as a symptom of acute stress, offer the following additional management:
» Rule out and manage
other possible causes, even if the
k for the person's own explanation of the symptoms
symptoms started immediately after a stressful event. and apply the general guidance on the management of Always conduct necessary medical investigations to medically unexplained somatic symptoms ().
identify possible physical causes. See epilepsy module eassure the person that these symptoms sometimes for guidance on medical investigations relevant to develop after experiencing extreme stress and that it is unlikely to be a serious medical problem.
the person's suffering and maintain a nsider the use of culturally specific interventions that respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms.
6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or
at any time if the symptoms get worse.
In humanitarian emergencies, adults, adolescents and children are often exposed to
major losses. Grief is the emotional suffering people feel after a loss. Although most
reactions to loss are self-limiting without becoming a mental disorder, people with
significant symptoms of grief are more likely to present to health facilities for help.
After a loss, clinicians need to be able to identify the following:
» Significant symptoms of grief (GRI).
As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific
psychological and medically unexplained physical complaints. People have significant symptoms of grief after
a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected)
or if people seek help for the symptoms. The present module covers assessment and management of significant
symptoms of grief.
olonged grief disorder.
When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person's culture). In these cases, health providers need to consult a specialist.
oblems and disorders that are more likely to occur after exposure
to stressors (e.g. bereavement) but that also occur in the absence
of such exposure.
These include: moderate-severe depressive disorder (), psychosis (, harmful use of alcohol and drugs
(, self-harm/suicide and other significant mental health complaints
Reactions that ar
e not clinically significant and that do not require clinical
management.
Of all reactions, these are the most common. They include transient reactions for which people do not seek
help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health
providers need to be supportive, help address the person's needs and concerns and monitor whether expected
natural recovery occurs; however, such reactions do not require clinical management.
Assessment question 1: Has the person recently experienced a major loss?
» Ask if the person has experienced a
major loss.
how much time has passed since the event(s).
o to assessment question 2 if a major loss has occurred How has the disaster/conflict af fected you? within the last 6 months.
Have you lost family or friends? Y our house? Your money? Your job or livelihood? Your community? a major loss has occurred more than 6 months ago How has the loss af fected you? or if a potentially traumatic event has occurred more Are any family members or friends missing? than 1 month ago, then consider other conditions
covered in this guide , or
prolonged grief disorder.
Assessment question 2: If a major loss has occurred within the last 6 months,4
does the person have significant symptoms of grief?
» C
» S ignificant symptoms of grief are likely if the person
meets all of the following criteria:
yearning and preoccupation with loss one or more losses within approximately 6 months intrusive memories*, images and thoughts of the any of the above symptoms that started after the loss ficulty with daily functioning because loss of appetite of the symptoms (beyond what is culturally expected) or seeking help for the symptoms.
◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the voice of the deceased person, being visited by the deceased person in dreams).
Assessment question 3: Is there a concurrent condition?
» Check for any
physical conditions that may explain
» Check for any
other mental, neurological and substance
the symptoms, and manage accordingly if found.
use (MNS) condition (including depression) covered in
this guide that may explain the symptoms and manage
accordingly if found.
4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months.
Basic Management Plan
DO NOT prescribe medications to manage symptoms of grief.
1. Provide basic psychosocial support5
carefully. DO NOT pressure the person to talk.
the person to address basic needs, access services and connect with family and other social supports.
the person about his/her needs and concerns. otect the person from (further) harm.
2. Offer additional psychosocial support as described in the Principles
of Reducing Stress and Strengthening Social Support ()
current psychosocial stressors.
» T each stress management.
social support. 3. Educate the person about common reactions to losses, e.g.:
People may react in dif ferent ways after major losses. s a person may feel fine for a while, then Some people show strong emotions while others do not. something reminds them of the loss and they may feel does not mean you are weak. as bad as they did at first. This is normal and again these experiences become less intense and less frequent who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. over time. is no right or wrong way to feel grief. Sometimes » ou may think that the sadness and pain you feel will
you might feel very sad, and at other times you might never go away, but in most cases, these feelings lessen over time. be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions.
5. Discuss and support culturally appropriate adjustment/mourning* processes
Ask if appropriate mourning ceremonies/rituals have » If the body cannot be found, discuss alternative ways to
occurred or have been planned. If this is not the case, preserve memories, such as memorials.
discuss the obstacles and how they can be alleviated.
Find out what has happened to the body . If the body is missing, help trace or identify the remains.
6. If feasible and culturally appropriate, encourage early return to previous,
normal activities (e.g. at school or work, at home or socially).
7. For the specific management of sleep problems, bedwetting,
hyperventilation and dissociative symptoms after recent loss, see the
relevant sections in the module on acute stress .
5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event .
8. If the person is a young child:
» Answer the child'
s questions by providing clear and » Check for and correct "magical thinking" common in
honest explanations that are appropriate to the child's young children ( e.g. children may think that they are level of development. Do not lie when asked about responsible for the loss; for example, they may think a loss (e.g. Where is my mother?). This will create that their loved one died because they were naughty or confusion and may damage the person's trust in the because they were upset with them).
health provider.
9. For children, adolescents and other vulnerable persons who have
lost parents or other carers, address the need for protection and ensure
consistent, supportive caregiving, including socio-emotional support.
» If needed, connect the person to trusted protection
agencies/networks.
10. If prolonged grief disorder is suspected, consult a specialist for further
assessment and management.
» The person may have prolonged grief disorder
if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve
or at any time if the symptoms get worse.
6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months.
Moderate-severe depressive disorder may develop in adults, adolescents and children
who have not been exposed to any particular stressor. In any community there will be
people suffering from moderate-severe depressive disorder. However, the significant
losses and stress experienced during humanitarian emergencies may result in grief,
fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe
depressive disorder. Nevertheless, these emotions may also be normal reactions to
recently experienced adversity.
Management for moderate-severe depressive disorder should only be considered
if the person has persistent symptoms over a number of weeks and as a result has
considerable difficulties carrying out daily activities.
Typical presenting complaints of moderate-severe depressive disorder:
Low energy, fatigue, sleep problems
Multiple persistent physical symptoms with no clear cause (e.g. aches and pains)
Persistent sadness or depressed mood, anxiety
Little interest in or pleasure from activities.
Assessment
Assessment question 1: Does the person have moderate-severe depressive disorder?
» Assess for the following:
The person has had at least one of the following cor
ability to concentrate and sustain attention on tasks
symptoms of depressive disorder for at least 2 weeks:
essed mood
agitation or physical restlessness
▸ or children and adolescents: either irritability or
◆ alking or moving more slowly than normal
about the future Markedly diminished inter
est in or pleasure from
thoughts or acts.
activities, including those that were previously
C. The individual has considerable difficulty with daily
functioning in personal, family, social, educational,
▸ he latter may include reduced sexual desire.
occupational or other important domains.
The person has had at least several of the following
additional symptoms of depressive disorder to
A, B and C – all 3 – are present for at least 2 weeks,
a marked degree (or many of the listed symptoms
then moderate-severe depressive disorder is likely.
to a lesser degree) for at least 2 weeks:
Delusions* or hallucinations* may be present. or sleeping too much
Check for these. If present, treatment for depressive change in appetite or weight (decrease
disorder needs to be adapted. Consult a specialist.
the person's symptoms do not meet the criteria for worthlessness or excessive guilt
moderate-severe depressive disorder, go to or loss of energy module for assessment and management of the presenting complaint.
Assessment question 2: Are there other possible explanations for the symptoms
(other than moderate-severe depressive disorder)?
» Rule out concurr
ent physical conditions that can
If a manic episode has ever occurred, then the resemble depressive disorder.
depression is likely to be part of another disorder Rule out and manage anaemia, malnutrition, called bipolar disorder* and requires different
hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*).
out a history of manic episode(s).
ule out normal reactions to major loss (e.g.
Assess if there has been a period in the past bereavement, displacement) (.
when several of the following symptoms occurred The reaction is more likely to be a normal reaction to major loss if: ▸ ecreased need for sleep
▸ here is marked improvement over time without
▸ uphoric, expansive or irritable mood
▸ acing thoughts; being easily distracted
▸ one of the following symptoms is present:
▸ ncreased activity, feeling of increased energy
eliefs of worthlessness uicidal ideation ▸ mpulsive or reckless behaviours such as excessive
alking or moving more slowly than normal gambling or spending, making important decisions ∙psychotic symptoms (delusions or hallucinations);
without adequate planning ▸ here is no previous history of depressive disorder
▸ nrealistically inflated self-esteem.
or manic episode; and
Assess to what extent the symptoms impaired ▸ ymptoms do not cause considerable difficulty
functioning or were a danger to the person or to with daily functioning.
others. For example: xception: impaired functioning can be part of ▸ as your excessive activity a problem for you
a normal response after bereavement when it is or your family? Did anybody try to hospitalize within cultural norms. or confine you during that time because of your ule out prolonged grief disorder: symptoms include
severe preoccupation with or intense longing for the There is a history of manic episode(s) if both deceased person accompanied by intense emotional the following occurred: pain and considerable difficulty with daily functioning ▸ everal of the above 6 symptoms were present
for at least 6 months (and for a period that is much for longer than 1 week. longer than what is expected in that person's culture). ▸ he symptoms caused significant difficulty with
Consult a specialist if this disorder is suspected.
daily functioning or were a danger to the person or to others. Assessment question 3: Is there a concurrent mental, neurological and substance
use (MNS) condition requiring management?
» Assess for
thoughts or plans of self-harm or suicide
» If a concurrent MNS condition is found, manage the
condition and moderate-severe depressive disorder at » Assess
for harmful alcohol or drug use .
the same time.
7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. Basic Management Plan
1. Offer psychoeducation
» ey messages to the person and the carers:
Even if it is dif ficult, the person should try to do Depression is a very common condition that can as many of the following as possible, as they can all happen to anybody.
help to improve mood: The occurrence of depression does not mean that the ry to start again (or continue) activities that were person is weak or lazy.
previously pleasurable. The negative attitudes of others (e.g. "Y ry to maintain regular sleeping and waking times.
stronger", "Pull yourself together") may relate to the ry to be as physically active as possible.
fact that depression is not a visible condition (unlike ry to eat regularly despite changes in appetite.
a fracture or a wound) and the false idea that people ry to spend time with trusted friends and family. can easily control their depression by sheer force of ry to participate in community and other social activities as much as possible.
People with depression tend to have unrealistically The person should be aware of thoughts of self-harm negative opinions about themselves, their life or suicide. If they notice these thoughts, they should and their future. Their current situation may be not act on them, but should tell a trusted person and very difficult, but depression can cause unjustified come back for help immediately. thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves.
2. Offer psychosocial support as described in the Principles of Reducing
Stress and Strengthening Social Support )
Address current psychosocial stressors. » T each stress management.
social supports.
◆ ry to reactivate the person's previous social networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities).
3. If trained and supervised therapists are available, consider encouraging
people with moderate-severe depression to use one of the following brief
psychological treatments whenever they are available:
problem-solving counselling* » cognitive behavioural therapy (CBT)*
interpersonal therapy (IPT)* » behavioural acti
There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. 1. Consider antidepressants
» In
children younger than 12:
Discuss with the person and decide together whether prescribe antidepressants.
to prescribe antidepressants. Explain: adolescents 12–18 years of age:
▸ ntidepressants are not addictive.
consider antidepressants as first-line ▸ t is very important to take the medication every
treatment. Offer psychosocial interventions first.
day as prescribed.
▸ ome side-effects () may be
experienced within the first few days but they If the person has a concurrent physical condition that
usually resolve.
can resemble depressive disorder ▸ t usually takes several weeks before improvements
, always manage that condition first. in mood, interest or energy can be noticed.
Consider prescribing antidepressants if the depressive ◆ ntidepressant medication usually needs to be continued disorder does not improve after managing the for at least 9–12 months after the person feels well. concurrent physical conditions.
Medications should not be stopped just because If you suspect the symptoms are normal reactions
the person has experienced some improvement to a major loss (), do not
(it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication.
2. If it is decided to prescribe antidepressants, choose an appropriate
antidepressant (» Choose the antidepressant based on the person'
elderly people:
concurrent medical conditions and drug side-effect ◆ void amitriptyline if possible.
» In people with
adolescents 12 years and older:
Do not prescribe amitriptyline.
fluoxetine (but no other selective serotonin
» In adults with
thoughts or plans of suicide:
reuptake inhibitors (SSRI) or tricyclic antidepressants is the first choice. If there is an imminent (TCAs)) only if symptoms persist or worsen despite risk of self-harm or suicide (, only give
psychosocial interventions. a limited supply of antidepressants (e.g. one week pregnant or breastfeeding women:
of supply at a time). Ask the person's carers to keep ◆ void antidepressants if possible. Consider and monitor medications and to follow up frequently antidepressants at the lowest effective dose if there to prevent medication overdose.
is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available.
Table DEP 1: Antidepressants
Amitriptylinea (a TCAb)
Fluoxetine (an SSRIc)
Starting dose for adults
25–50 mg at bedtime 10 mg once per day. Increase to 20 mg Starting dose for adolescents
Not applicable (do not prescribe TCAs 10 mg once per day Starting dose for elderly and medically ill
10 mg once per day Dose increment for adults
Increase by 25–50 mg per week If no response in 6 weeks, increase to 40 mg once per day Typical effective dose in adults
100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents,
50–75 mg (max. dose 100 mg) elderly and medically ill
Do not prescribe in adolescents 20 mg (max. dose 40 mg) Prolonged akathisia* Bleeding abnormalities in those Serious and rare side effects
Cardiac arrhythmia who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Orthostatic hypotension (risk of fall), dry Headache, restlessness, nervousness, mouth, constipation, difficulty urinating, gastrointestinal disturbances, reversible dizziness, blurred vision and sedation sexual dysfunction Stop immediately if the person develops Stop immediately if the person develops a Available in the Interagency Emergency Health Kit (WHO, 2011)b TCA indicates tricyclic antidepressantc SSRI indicates selective serotonin reuptake inhibitord Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses).
3. Follow-up
» fer regular follow-up.
» Monitor response to antidepressants.
Schedule and conduct regular follow-up sessions It may take a few weeks for antidepressants to according to the Principles of Management show effect. Monitor the response carefully before increasing the dose.
Schedule the second appointment within 1 week and If symptoms of a manic episode develop
subsequent appointments depending on the course , stop the medication
of the disorder. immediately and go to management of the manic episode.
Consider tapering of f the medication 9–12 months after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder
In people with bipolar disorder, never prescribe antidepressants alone without a mood
stabilizer, because antidepressants can lead to a manic episode.
If the person has a history of manic episode:
» Consult
a specialist.
a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate ().
Start the medicine at a low dose. Incr
ease slowly over the following weeks.
▸ f possible, avoid carbamazepine and valproate in women who are pregnant or who are
planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder » T ell the person and the carers to stop the antidepressant immediately and return for help if symptoms
of manic episode develop.
Table DEP 2: Mood stabilizers in bipolar disorder
Starting dose
Typical effective dose
400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day (max. dose 2500 mg/day) Twice daily, oral Twice daily, oral Severe skin rash (Stevens-Johnson syndrome*, Rare but serious side-effects
toxic epidermal necrolysis*) Bone marrow depression* Nausea, diarrhoea ◆ roubling walking ◆ ransient hair loss (re-growth normally begins within 6 months)Impaired hepatic function As mentioned in the Acute Stress (and children to develop a wide range of psychological reactions or symptoms after
experiencing extreme stress during humanitarian emergencies.
For most people, these symptoms are transient.
When a specific, characteristic set of symptoms (re-experiencing, avoidance
and heightened sense of current threat) persists for more than a month after
a potentially traumatic event*, the person may have developed post-traumatic
stress disorder (PTSD).
Despite its name, PTSD is not necessarily the only or the main condition that occurs
after exposure to potentially traumatic events. Such events can also trigger many
of the other mental, neurological and substance use (MNS) conditions described
in this guide.
Typical presenting complaints of PTSD
People with PTSD may be hard to distinguish from those suffering from other
problems because they may initially present with non-specific symptoms, such as:
» sleep problems (e.g. lack of sleep)
» irritability, persistent anxious or depressed mood
» multiple persistent physical symptoms with no clear physical cause
(e.g. headaches, pounding heart).
However, on further questioning they may reveal that they are suffering from
characteristic PTSD symptoms.
Assessment question 1: Has the person experienced a potentially traumatic
event more than 1 month ago?
» Ask if the person has experienced a potentially
» If the person has experienced a potentially traumatic
traumatic event. This is any threatening or horrific
event, ask when this occurred. event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person's house, or major accidents or injuries. Consider asking: How have you been af fected by the disaster/conflict? Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? Assessment question 2: If a potentially traumatic event occurred more than
1 month ago, does the person have PTSD?8
» Assess for:
» If all of the above are present approximately 1 month
These are repeated after the event, then PTSD is likely.
and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). ▸ n children this may involve replaying or drawing
the events repeatedly. Younger children may have frightening dreams without a clear content.
◆ voidance symptoms. These involve deliberate
avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a heightened sense of current
threat (often called "hyperarousal symptoms"). These
involve excessive concern and alertness to danger
or reacting strongly to loud noises or unexpected
movements (e.g. being "jumpy" or "on edge").
Considerable
difficulty with daily functioning.
Assessment question 3: Is there a concurrent condition?
» Assess for and manage any
concurrent physical
» Assess for and manage
all other MNS conditions that
conditions that may explain the symptoms.
are covered in this guide.
8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation.
Basic Management Plan
1. Educate on PTSD
» Advise the person to:
Many people recover from PTSD over time without Continue their normal daily r
outine as much as
treatment while others need treatment.
People with PTSD repeatedly experience unwanted ◆ alk to trusted people about what happened and
recollections of the traumatic event. When this how they feel, but only when they are ready to do so. happens, they may experience emotions such as fear Engage in r
elaxing activities to reduce anxiety and
and horror similar to the feelings they experienced when the event was actually happening. They may ◆ void using alcohol or drugs to cope with PTSD
also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled ("jumpy") or constantly on the watch for danger.
People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood.
2. Offer psychosocial support as described in the Principles of Reducing
Stress and Strengthening Social Support
Address current psychosocial stressors. » Strengthen social supports.
When the person is a victim of severe human rights » T each stress management.
violations, discuss with them possible referral to a trusted protection or human rights agency.
3. If trained and supervised therapists are available, consider referring for:
Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing
4. In adults, consider antidepressants (selective serotonin reuptake inhibitors
or tricyclic antidepressants) when cognitive behavioural therapy, EMDR
or stress management do not work or are unavailable
Go to the module on moderate-severe depression for » DO NOT of
fer antidepressants to manage PTSD in more detailed guidance on prescribing antidepressants children and adolescents.
5. Follow-up
Schedule and conduct regular follow-up sessions » Schedule the second appointment within 2–4 weeks and
according to the Principles of Management subsequent appointments depending on the course of the disorder.
Adults and adolescents with psychosis may firmly believe or experience things
that are not real. Their beliefs and experiences are generally considered abnormal
by their communities. People with psychosis are frequently unaware that they have
a mental health condition. They are often unable to function normally in many areas
of their lives.
During humanitarian emergencies, extreme stress and fear, breakdown of social
supports and disruption of health-care services and medication supply can occur.
These changes can lead to acute psychosis or can exacerbate existing symptoms
of psychosis. During emergencies, people with psychosis are extremely vulnerable
to various human rights violations such as neglect, abandonment, homelessness,
abuse and social stigma.
Typical presenting complaints of psychosis
Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech,
wandering aimlessly, mumbling or laughing to self) Hearing voices or seeing things that are not there
Extreme suspicion
Lack of desire to be with or talk with others; lack of motivation to do daily chores
and work.
Assessment question 1: Does the person have psychosis?
» Note that while people with psychosis may have
» Psychosis
is likely if multiple symptoms are present. abnormal thoughts, beliefs or speech, this does not Always assess for imminent risk of suicide (
mean that everything they say is wrong or imaginary. and harm to and from others.
Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information.
(fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) ▸ ip: Probe further by asking what the person
means, and listen carefully.
(hearing, seeing or feeling things that ▸ o you hear or see things that others cannot?
that switch between topics without logical connection; speech that is difficult to followUnusual experiences such as believing that place thoughts in one's mind, that others withdraw
thoughts from one's mind or that one's thoughts are
being broadcast to others
Abnormal behaviour
such as odd, eccentric, aimless and agitated activity or maintaining an abnormal
body posture or not moving at all
Chr
onic symptoms that involve a loss of normal
▸ ack of energy or motivation to do daily chores
▸ pathy and social withdrawal
▸ oor personal care or neglect
▸ ack of emotional experience and expressiveness.
Assessment question 2: Are there acute physical causes of psychotic
symptoms that can be managed?
» Rule out
delirium* from acute physical causes such as
» Rule out
alcohol or drug intoxication/withdrawal
head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities Ask about alcohol, sedative or other drug use. (e.g. hypoglycaemia*, hyponatraemia*).
Smell for alcohol.
out medication side-effects (e.g. from certain
Assessment question 3: Is this a manic episode?
» Rule out mania. Assess for:
» Manic episode
is likely if several of these symptoms are decreased need for sleep present for more than 1 week, and either the symptoms euphoric, expansive or irritable mood cause considerable difficulty with daily functioning or racing thoughts; being easily distracted the person cannot be managed safely at home. increased activity , feeling of increased energy or rapid speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planningunrealistically inflated self-esteem.
Basic Management Plan
A. Pharmacological interventions
1. For psychosis without acute physical causes
oral antipsychotic medication. Consider
intramuscular (i.m.) treatment only if oral treatment ▸ I n case of significant acute extrapyramidal
is not feasible. Check if the person has used an side-effects* such as Parkinsonism (combination antipsychotic medication in the past that helped control of tremors*, muscular rigidity and decreased body the symptoms. If yes, resume the medication at the movements) or akathisia* (inability to sit still): same dose. If the medication is not available, start a ∙ educe the dose of antipsychotic medication.
new medication. The involvement of a carer or health ∙ f extrapyramidal side effects persist despite
worker in keeping and giving out the medication will reducing the dose, consider short-term use of be essential at the start of treatment to ensure safe anticholinergics (e.g. biperiden for 4-8 weeks
one antipsychotic at a time
▸ I n case of acute dystonia (acute spasm of muscles,
(e.g. haloperidol ).
typically of neck, tongue and jaw): "Start low
, go up slow": start with the lowest
∙ op antipsychotic medication temporarily and
therapeutic dose and increase slowly to achieve provide anticholinergics (e.g. biperiden
the desired effect at the lowest effective dose.
. If these are not available, diazepam may ◆ ry the medication for an adequate amount of time be given to induce muscle relaxation.
at a typical effective dose before considering it If possible, consult a specialist about the duration ineffective (i.e. for at least 4–6 weeks) of treatment and when to discontinue antipsychotic ▸ se the lowest effective oral dose in women who
▸ I n general, continue the antipsychotic medication
are planning pregnancy, are pregnant or are
for at least 12 months after the symptoms resolve.
aper down slowly when discontinuing the If agitation cannot be adequately managed by an medication over several months.
antipsychotic alone, give a dose of benzodiazepine
ever stop the medication abruptly.
(e.g. diazepam, maximum 5 mg orally) and consult
a specialist immediately.
2. For psychotic symptoms from acute physical causes (e.g. alcohol
withdrawal or delirium)
» Manage the acute cause.
In case of acute physical causes other than alcohol
For management of alcohol withdrawal, see
withdrawal, prescribe an oral antipsychotic
medication as needed (e.g. haloperidol, initially 0.5
mg per dose up to 2.5–5 mg 3 times a day). Only
prescribe antipsychotic medication at a moment
when there is a need to control agitation, psychotic
symptoms or aggression. Stop the medication as soon
as these symptoms resolve. Consider intramuscular
treatment only if oral treatment is not feasible.
3. For manic episode
» Initiate an oral antipsychotic medication
» A manic episode is part of bipolar disorder*.
Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with » When the person is extremely agitated despite
a mood stabilizer such as valproate or carbamazepine.
antipsychotic treatment, consider adding a dose of Consult a specialist for management and/or follow benzodiazepine (e.g. diazepam, maximum 5 mg orally)
instructions on bipolar disorder in the full
and consult a specialist immediately.
Table PSY 1: Antipsychotic medications
Typical effective dose
4–10 mg/day (max. dose 20 mg) (max. dose 1000 mg) (max. dose 10 mg) Oral/intramuscular Significant side-effects:
Extrapyramidal side-effects*
Sedation (especially in elderly) Urinary hesitancy Orthostatic hypotension* Neuroleptic malignant syndrome* a Available in the Interagency Emergency Health Kit (WHO, 2011)b Up to 1 g may be necessary in severe cases.
c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid.
Table PSY 2: Anticholinergic medications
Biperidena
1 mg daily5–15 mg daily Typical effective dose
3–6 mg/day (max. dose 12 mg) (max. dose 20 mg) Significant side-effects:
Confusion, memory disturbance (especially in elderly)
Sedation (especially in elderly) Urinary hesitancy a Available in the Interagency Emergency Health Kit (WHO, 2011) B. Psychosocial interventions
For all cases:
1. Offer psychoeducation
Key messages to the person and the carer(s):
Messages to the carer(s):
» P sychosis can be treated and the person can recover.
not try to convince the person that his or her beliefs » S tress can worsen psychotic symptoms.
or experiences are false or not real. » T ry to continue regular social, educational and
» T ry to be neutral and supportive even when the person
occupational activities as much as possible, even if that shows unusual or aggressive behaviour. may be difficult in the emergency setting.
void getting into arguments or being hostile towards » o not use alcohol, cannabis or other non-prescribed drugs,
because they can make the psychotic symptoms worse.
» T ry to give the person freedom to move about. Avoid
» P eople with psychosis need to take the prescribed
restraining the person while ensuring that their basic medications and return for follow up regularly.
security and that of others is met. ecognize if the psychotic symptoms return or worsen. » P sychosis is not caused by witchcraft or spirits.
Return to the clinic as management may need to be o not blame the person or others in the family or accuse them of being the cause of the psychosis. » I f the person has recently given birth, do not leave her
alone with the baby, in order to ensure the baby's safety. 2. Facilitate rehabilitation back into the community
» T alk with community leaders to increase community
» Connect with community resources such as community-
acceptance and tolerance of the person.
based health workers, protection service workers, social » F acilitate the inclusion of the person in community-
workers and disability service workers. Ask for their based economic and social activities. help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and

C. Follow-up
» Schedule and conduct
regular follow-up sessions
» Continue the antipsychotic treatment for
according to the Principles of Management 12 months after complete resolution of symptoms.
If possible, consult a specialist regarding the decision » chedule the second visit within 1 week and subsequent
to continue or discontinue the medication.
visits depending on the course of the condition.
on page 40 for assessment and management of a person
who is convulsing or is unconscious following a seizure*.
Epilepsy is the most frequently treated condition of all mental, neurological and
substance use (MNS) conditions in humanitarian settings in low- and middle-income
countries. Epilepsy affects all age groups including young children.
Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures
caused by abnormal electrical activity in the brain. There are various types of epilepsy
and this module covers only the most prevalent type, convulsive epilepsy.
Convulsive epilepsy is characterized by seizures that cause sudden involuntary
muscle contractions alternating with muscle relaxation, causing the body and limbs
to shake or become rigid. Seizures are often associated with impaired consciousness.
A convulsing person may fall and suffer injuries.
The supply of antiepileptic medications is often disrupted during humanitarian
emergencies. Without continuous access to these medications, people with epilepsy
may begin experiencing seizures again, which can be life-threatening.
Typical presenting complaints of convulsive epilepsy
A history of convulsive movements or seizures.
Assessment question 1: Does the person meet the criteria for convulsive seizure?
» Ask the person, and carer
, if the person has had any of » The person meets the criteria for a
convulsive seizure
the following symptoms: if there are convulsive movements and at least 2 other
convulsive
movements lasting longer than 1–2 minutes
symptoms from the above list.
loss of or impaired consciousness » S uspect non-convulsive seizures or other medical
◆ fness or rigidity of the body or limbs lasting longer conditions if only 1 or 2 of the above criteria are
than 1–2 minutes bitten or bruised tongue or bodily injury Consult a specialist if the person has had more than loss of bladder or bowel control during the episode.
one non-convulsive seizure. After the abnormal movements, the person may Manage accordingly if other medical conditions are demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain Follow up after 3 months to re-assess.
of fatigue, headache, or muscle ache.
Assessment question 2: In the case of convulsive seizure, is there an acute cause?
» Check for signs and symptoms of
» Refer to a hospital immediately
if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a child (aged 6 months to 6
meningeal irritation* (e.g. stif years) with a fever if any of the following criteria for
heck for other possible causes of convulsions:
complex febrile seizures is present:
▸ ocal seizure – seizure starts in one part of the body
metabolic abnormality* (e.g. hypoglycaemia*, ▸ rolonged seizure – seizure lasts more than
alcohol or drug intoxication or withdrawal ▸ epetitive seizure – more than 1 seizure during
( on page 48).
the current illness.
If none of the above 3 criteria are present in a febrile there is an identifiable acute cause of convulsive
child, suspect simple febrile seizure. Manage the seizure, treat the cause.
Maintenance treatment with antiepileptic guidelines. Observe the child for 24 hours.
medications is not required in these cases.
» Follow
up in 3 months to re-assess.
Assessment question 3: In the case of convulsive seizure without an identified
acute cause, is this epilepsy?
» It is considered
epilepsy if the person has had 2 or more
» If there was only 1 convulsive seizure in the last 12
unprovoked, convulsive seizures on 2 different days in months without an acute cause, then antiepileptic the last 12 months.
treatment is not required. Follow up in 3 months.
Basic Management Plan
1. Educate the person and carers about epilepsy
» What epilepsy is and
what causes it:
eople with epilepsy should avoid:
▸ pilepsy is a chronic condition, but with medication
∙jobs that require working near heavy machinery or fire
three out of every four people can be seizure-free.
∙ ooking over open fires
▸ pilepsy involves recurrent seizures.
∙ wimming alone
A seizure is a problem related to abnormal ∙ lcohol and recreational drugs
electrical activity in the brain.
∙ ooking at flashing lights.
▸ pilepsy is not caused by witchcraft or spirits.
∙ hanging sleep patterns (e.g. sleeping much less
▸ pilepsy is not contagious. Saliva does not transmit
than usual).
What to do at home
when seizures occur What the relevant lifestyle issues are:
(message to carers): ▸ eople with epilepsy can lead normal lives:
▸ I f a seizure starts while the person is standing
∙ hey can marry and have healthy children.
or sitting, help to prevent a fall injury by gently ∙ hey can work productively and safely at most jobs.
assisting them to sit or lie on the ground.
∙ hildren with epilepsy can go to school.
ake sure that the person is breathing properly. Loosen the clothes around the neck. lace the person in the recovery position (see Figures A–D below).
Figures A–D: The recovery position
A. Kneel on the floor on one side of the person.
D. The person's top arm should be supporting the head
Place the arm closest to you at a right angle to their and the bottom arm will stop the person from rolling body with the person's hand upwards towards the too far (see Figure D above). Open the person's airway
head (see Figure A above).
by gently tilting his or her head back and lifting the
B. Place the other hand under the side of the person's
chin, and check that nothing is blocking the airway.
head, so that the back of the hand is touching the This manoeuvre moves the tongue out of the airway cheek (see Figure B above).
and helps the person breathe better and prevents C. Bend the knee furthest from you to a right angle.
choking from secretions and vomit.
Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above).
o not try to restrain or hold the person to the floor. o not put anything in the person's mouth.
ove any hard or sharp objects away from the person to prevent injury.
tay with the person until the seizure stops and the person regains consciousness.
2. Initiate or resume antiepileptic drugs
» Check if the person has ever used an antiepileptic
» Explain
to the person and carers:
medication that controlled the seizures. If yes, then Medication dosing schedule resume the same medication at the same dose.
Potential side-ef fects ().
the medication is not available, start a new Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical only one antiepileptic drug (see Table EPI 1).
Consider potential side-ef fects, drug-disease Importance of medication adherence. Missed doses
interactions* or drug-drug interactions*. Consult or abrupt discontinuation can cause seizures to recur. the National or WHO Formulary, as necessary.
The medications should be taken at the same time
lowest dose and increase gradually
each day.
until complete seizure control is obtained.
◆ ime for the medication to start working. It usually takes a few weeks before the effect becomes clear.
Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years.
Importance of regular follow-up.
Table EPI 1: Antiepileptic medications
Starting dose
in children
15–20 mg/kg/day Typical effective
dose in children
10–30 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose
in adults
Typical effective
dose in adults
400–1400 mg/day 400–2000 mg/day In children, give twice Once daily at bedtime daily; in adults, it can be Usually 2 or 3 times daily Anaemia and other Severe skin rash (Stevens- Severe skin rash (Stevens-Johnson Rare but serious
Johnson syndrome*) syndrome*, toxic Hypersensitivity reactions including epidermal necrolysis*) severe skin rash (Stevens-Johnson Nausea, vomiting, Nausea, diarrhoea Hyperactivity in children Ataxia and slurred Transient hair loss (regrowth normally begins within 6 months) Impaired hepatic void phenobarbital in Precautions
children with intellectual disability or behavioural in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 3. Follow-up
» nsure regular follow-up:
stopping the antiepileptic medication if
For the first 3 months or until seizures are controlled, no seizure has occurred in the last 2 years.
schedule follow-up appointments at least once a hen stopping the medication, the dose should be tapered down slowly over several months to avoid Meet every 3 months if seizures are controlled.
seizures from medication withdrawal.
Principles of Management Involve carers in monitoring for seizure control.
) for more detailed
Review lifestyle issues and provide further advice on follow-up.
psychoeducation/support to the person and the carers » each follow-up:
described above).
Monitor for seizure control: ◆ R ▸efer to the seizure diary to see how well seizures
are controlled.
Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled.
▸ f seizures are still not controlled at the maximum
therapeutic dose of one medication or the side-effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. I ▸ f seizures are very infrequent and a further
increase in the dose may produce severe side-effects, then the current dose may be acceptable. C ▸ onsult a specialist if 2 medications were tried
one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Box EPI 1: Special management considerations for women with epilepsy
» the woman is of childbearing age:
» The decision to start an antiepileptic medication in a
Give folate 5 mg/day to prevent possible birth pregnant woman should be made together with the defects if she becomes pregnant.
woman. The severity and frequency of the seizures » she is pregnant:
as well as the potential harm to the fetus from either Consult with a specialist for management.
the seizures or the medication should be considered. Advise more frequent antenatal visits and delivery in If the decision is made to start medication, then either phenobarbital or carbamazepine can be used.
, give 1 mg vitamin K intramuscularly
Valproate and polytherapy* should be avoided. (i.m.) to the newborn. can be used by women who are Figure EPI 1: Example seizure diary
When the seizure occurred
Description of seizure (including body
Medications that were taken
parts affected and duration of seizure)
Box EPI 2: Assessment and management of a person who is convulsing or is unconscious
following a seizure
Assessment and management of acute seizures should proceed simultaneously.
Assessment of seizur
anagement of seizures
Put the person on their side in the recovery position
Most seizures will stop after a few minutes. airway, breathing and circulation, including
blood pressure, respiratory rate and temperature. If the seizure does not spontaneously stop after signs of head or spinal injury (e.g. dilated
1–2 minutes, insert an intravenous (i.v.) line pupils may be a sign of serious head injury). as quickly as possible and give glucose and
stiff neck or fever (signs of meningitis).
benzodiazepines slowly (30 drops/minute).
the carer:
▸ f an i.v. line is difficult to establish, give the
When did this seizure start? benzodiazepines through the rectum. Is there a past history of seizures? ▸ aution: benzodiazepines can slow down
Is there is a history of head or neck injury? breathing. Give oxygen if available and monitor
Are there other medical problems? the person's respiratory status frequently.
Did the person take any medication, poison, alcohol ▸ hild glucose dose: 2–5 ml/kg of 50% glucose
▸ hild benzodiazepines dose:
◆ female: Is she in the second half of pregnancy or
iazepam rectally 0.2–0.5 mg/kg or first week after delivery? iazepam i.v. 0.1–0.3 mg/kg or ∙ l orazepam i.v. 0.1 mg/kg.
urgently to a hospital:
▸ dult glucose dose: 5 ml of 50% glucose
If there is any sign of major injury, shock* or
▸ dult benzodiazepines dose:
iazepam rectally 10–20 mg or If the person may have had a serious head or neck
iazepam i.v. 10–20 mg slowly or ∙ l orazepam i.v. 4 mg.
▸ o not move the person's neck.
▸ o not give benzodiazepines intramuscularly
▸ og-roll* the person when transferring them.
If the person is a woman in the second half of
second dose of benzodiazepines if the
pregnancy or less than 1 week after delivery
seizure continues for 5–10 minutes after the first ◆ neuroinfection is suspected
more than 5 minutes since
Use the same dose as the first dose.
the seizure started.
Do not give mor
e than 2 doses of benzodiazepines.
If the person needs more than 2 doses, they should
be sent to a hospital.
Suspect
status epilepticus if:
▸ eizures occur frequently and the person does
not recover in between episodes, or S ▸ eizures are not responsive to 2 doses of
benzodiazepines, or S ▸ eizures last for more than 5 minutes.
efer urgently to a hospital:
If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines If the person is having breathing problems after ◆ receiving benzodiazepines.
Intellectual disability9 is characterized by limitations across multiple areas of expected
intellectual development (i.e. cognitive*, language, motor and social skills)
that are not reversible. The limitations have existed from birth or started during
childhood. Intellectual disability interferes with learning, daily functioning and
adaptation to a new environment.
People with intellectual disability often have substantial care needs. They often
experience challenges in accessing health care and education. They are extremely
vulnerable to abuse, neglect and exposure to hazardous situations in chaotic
emergency environments. For example, people with intellectual disability are more
likely to walk into dangerous areas unknowingly. Moreover, they can be perceived
as burdensome by their families and communities and may be abandoned during
displacement. Therefore, people with intellectual disability require extra attention
during humanitarian emergencies.
This module covers moderate, severe and profound intellectual disability in children,
adolescents and adults.
Typical presenting complaints
» In infants: poor feeding, failure to thrive, poor motor tone, delay in meeting
expected developmental milestones for appropriate age and stage such as
smiling, sitting, standing.
» In children: delay in meeting expected developmental milestones for appropriate
age such as walking, toilet training, talking, reading and writing.
» In adults: reduced ability to live independently or look after oneself
» In all ages: difficulty carrying out daily activities considered normal for the
person's age; difficulty understanding instructions; difficulty meeting demands
of daily life.
9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development.
Assessment question 1: Does the person have intellectual disability?
» Review
the person's skills and functioning:
Rule out hearing impairment:
young children and toddlers, assess whether
▸ or a child >6 months, ask the carer if the child can
the child has fully reached age-appropriate
do the following, while directly observing the child milestones across all developmental areas
∙ i f the child turns his/her head to see who is
questions to carers of children: speaking from behind ▸ s your child behaving like others of the same age?
∙ i f the child reacts to loud noises
▸ hat kinds of things can your child do alone
∙ i f the child makes various vocal sounds (tata,
(sitting, walking, eating, dressing or toileting)? dada, baba).
▸ ow does your child communicate with you?
▸ f any of the answers is No, inform the carer that
Does the child smile at you? Does the child react the child may have impaired hearing and consult a to his/her name? How does the child talk to you? specialist, if available.
Is the child able to ask for what he/she wants? out problems in the environment:
▸ ow does your child play? Is your child able to play
▸ oderate-severe depressive disorder in the mother
well with other children of the same age? or main carer )
older children and adolescents, ask whether
▸ ack of stimulation (stimulation is essential for
they go to school and, if so, how they are managing brain development in young children). schoolwork (learning, reading and writing) and ∙ W
ho regularly interacts and plays with the child? everyday household activities.
∙ H
ow do you/they play with your child? ▸ re you going to school? How are you doing in
How often? school? Are you able to finish your schoolwork? ∙ H
ow do you/they communicate with your child? Do you often have difficulties in school because How often? you cannot understand or follow instructions? out malnutrition and other nutritional
adults, ask whether they work and, if so, how or hormonal deficiencies including iodine deficiency*
they are managing their work and other daily out epilepsy (), which can mimic or occur
▸ o you work? What kind of work do you do?
together with intellectual disability. Do you often get into trouble at work because you » Manage
the identified treatable problems and follow cannot understand or follow instructions? up to reassess whether the person has intellectual older children, adolescents and adults, ask how
much help the person is currently receiving to do For confirmed cases of hearing and visual daily activities (e.g. at home, school, work).
impairments, provide or advocate for necessary aids there is delay in reaching expected developmental (glasses, hearing aid).
milestones, rule out treatable or reversible conditions Manage depressive disorder in the carer , if applicable.
that can mimic intellectual disability.
◆ each the carer how to provide a more stimulating out visual impairment:
environment for young children. See ▸ or a child >6 months, ask the carer if the child can
do the following, while directly observing the child (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ∙ f the child can follow a moving object with
(ECD) programmes, if appropriate.
disability is likely if a) there is a significant
∙ f the child can recognize familiar people
delay in reaching expected developmental milestones ∙ f the child can grab an object with their hands.
and difficulty meeting demands of daily life and b) ▸ f any of the answers is No, inform the carer that
treatable or reversible conditions have been ruled out the child may have impaired vision and consult or addressed.
a specialist, if available.
Assessment question 2: Are there associated behavioural problems?
» Not listening to carers
» Eating non-organic materials
» T emper tantrums. Aggression and self-harming
» Reckless
sexual or other problematic behaviour.
behaviour when upset Basic Management Plan
1. Offer psychoeducation
Explain the disability
to the person and their carers. ers should reward the person when the behaviour
People with intellectual disability should not be blamed is good and withhold rewards when the behaviour is for the disability. The aim is for the carers to have problematic. Use a balanced discipline: realistic expectations and to be kind and supportive. ive clear, simple and short instructions on what parenting skills training. The aim should be to the person should do rather than what the person improve positive interactions between parent/carer
should not do. Break complex activities into smaller and child. Teach the carers skills that can help reduce
steps so that the person can learn and be rewarded behaviour problems. one step at a time (e.g. learning to put trousers on Carers should understand the importance of training before buttoning them up).
the person to perform self-care and hygiene (e.g. hen the person does something good, offer a toilet training, brushing teeth).
reward. Distract the person from the things they Carers should have very good knowledge of the should not do. However, such distraction should person. Carers should know what stresses the person not be pleasurable and rewarding for the person. and what makes them happy, what causes behaviour O NOT use threats or physical punishments when problems and what prevents them, what the person's the behaviour is problematic.
strengths and weaknesses are and how the person » Educate
the carers that the person is more vulnerable learns best.
to physical and sexual abuse in general, requiring extra Carers should keep the person' s daily activities such attention and protection.
as eating, playing, learning, working and sleeping as » E ducate carers to avoid institutionalization.
regular as possible. 2. Promote community-based protection
Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental
agencies or international agencies) and ask for relevant support for the person.
3. Advocate for inclusion in community activities
If the person is a child, keep them in normal schools » Encourage participation in enjoyable social activities in
as much as possible. the community.
Liaise with the child' s school to explore possibilities » Assess
availability of community-based rehabilitation of adapting the learning environment to the child. (CBR*) programmes and advocate to have the person Simple tips are available in with intellectual disability included in such programmes.
4. Care for the carers according to the Principles of Reducing Stress
and Strengthening Social Support (
5. If possible, refer to a specialist for further assessment and management
of possible concurrent developmental conditions
Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes
(e.g. Down syndrome*).
6. Follow-up
Schedule and conduct follow-up sessions according to the Principles of Management .
Box ID 1: Developmental milestones: warning signs to watch for
Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs By the age of 1 MONTH Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ omiting and diarrhoea, which can lead to dehydration fness or difficulty moving limbs Constant moving of the head (this might indicate an ear infection, which could By the age of 6 MONTHS lead to deafness if not treated)Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods Does not make sounds in response to others ◆ Does not look at objects that move By the age of 12 MONTHS Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food Lack of response to others ◆ ficulty keeping balance while walking By the age of 2 YEARS Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Loss of interest in playing ◆ Frequent falling ◆ ficulty manipulating small objects By the age of 3 YEARS Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food , anger or violence when playing with other children, which could be signs By the age of 5 YEARS of emotional problems or abuse ◆ ficulties making and keeping friends and participating in group activities ◆ voiding a task or challenge without trying, or showing signs of helplessness By the age of 8 YEARS ◆ rouble communicating needs, thoughts and emotions ◆ rouble focusing on tasks, understanding and completing schoolwork Excessive aggression or shyness with friends and family Harmful Use of SUB
Alcohol and Drugs
of life-threatening alcohol withdrawal.
Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*,
diverse prescribed medications such as benzodiazepines* and tramadol*)
can lead to various problems. These include withdrawal (physical and mental
symptoms that occur upon cessation or significant reduction of use), dependence*
and harmful use (damage to physical or mental health and/or general well-being).
Use of alcohol or drugs is harmful when it leads to physical or mental disorders,
risky health behaviours, family/relationship problems, sexual and physical violence,
accidents, child abuse and neglect, financial difficulties and other protection issues.
The prevalence of harmful alcohol or drug use may increase during humanitarian
emergencies as adults and adolescents may try to cope with stress, loss or pain
by self-medicating*.
Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life-
threatening withdrawal symptoms in individuals who were using substances over a
prolonged period of time at relatively high doses. This is particularly true for alcohol.
This module focuses on harmful use of alcohol or drugs and includes a box on
life-threatening alcohol withdrawal

Typical presenting complaints
» Appearing to be under the influence of alcohol or drugs
(e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) » Recent injury
» Signs of intravenous (i.v.) drug use (injection marks, skin infection)
» Requests for sleeping tablets or painkillers.
Assessment question 1: Is there harm to physical or mental health and/or
general well-being from alcohol or drug use?
» Explor
e the use of alcohol or drugs, without sounding
» Perform
a quick general physical examination to look
for the signs of chronic alcohol or drug use and pattern of use
▸ bdominal pain
▸ o you drink alcohol? If so, in what form?
▸ lood in vomit
How many drinks per day/week? ▸ lood in stool or black stool
▸ o you use prescribed sleeping tablets/anxiety
pills/painkillers? What kind? How many per day/ ▸ evere: jaundice, ascites*, enlarged and hardened
liver and spleen, hepatic encephalopathy* ▸ o you use illegal drugs? What kind?
Malnutrition, severe weight loss How do you take them – by mouth, injection, ◆ Evidence of infections associated with drug use snorting? How much/how often per day/week? (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis).
◆ riggers to alcohol or drug use
▸ hat makes you want to take alcohol or drugs?
» Assess
for both harmful alcohol and drug use in the
to self or others
same person as they often occur together.
▸ edical problems or injuries as a result of alcohol
∙ ave you experienced health problems since you
started drinking alcohol or using drugs?H ∙ ave you ever been injured while you were
under the influence of alcohol or drugs? ▸ ontinued use of alcohol or drugs despite advice
∙ hen the person was pregnant or breastfeeding
∙ hen the person was told there is a problem
with their stomach or liver because of drinking or ∙ hen the person was on medications that have
harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications ▸ ocial problems as a result of alcohol or drug use:
∙ inancial or legal problems
∙ ave you ever been in trouble with money or
broken the law because of alcohol or drug use? ∙ ccupational problems
∙ ave you ever lost a job or done badly at work
because of your alcohol or drug use? ∙ ifficulty caring for children or other dependants
∙ ave you ever found it hard to take care of your
child/family because of alcohol or drug use? ∙ iolence towards others
∙ ave you ever hurt someone while taking
alcohol or drugs? ∙ elationship/marital problems
∙ as your alcohol or drug use ever caused
a problem with your partner? Basic Management Plan
1. Manage the harmful effects of alcohol or drug use
Provide necessary medical care for physical
» Address
urgent social consequences (e.g. liaise with
consequences of harmful alcohol or drug use. protection services in case of abuse, such as gender- any concurrent mental conditions, such
based violence).
as moderate-severe depressive disorder, PTSD and
psychosis ).
2. Assess the person's motivation to stop or reduce the use of alcohol or drugs
Assess whether the person sees alcohol or drug use as
Have you thought about stopping or reducing your a problem and if the person is ready to do something
alcohol or drug use? about it.
Have you tried stopping or reducing alcohol or drug Do you think you may have a problem with alcohol use in the past? or drugs? 3. Motivate the person to either stop or reduce the use of alcohol or drugs
brief motivational conversation about
◆ ovide additional information on the harmful effects
of alcohol and drugs, both short-term and long-term.
perceived benefits and harms
▸ A
lcohol or drugs may result in serious medical of alcohol or drug use. Do not be judgemental, and mental health problems, including injuries but try to understand what motivates the person and addiction. to use alcohol or drugs. that stopping alcohol or drug use ▸ hat kind of pleasure do you get when taking
is difficult. Let the person know you are willing alcohol or drugs? to support them. Encourage people to decide ▸ o you see any negative aspects of taking alcohol
for themselves if it is a good idea to stop alcohol or drugs? ▸ id you ever regret using alcohol or drugs?
◆ the person is not ready to stop or reduce alcohol any exaggerated sense of benefit from or drugs, respect the decision. Ask the person alcohol or drug use. For example, if the person uses to come back another time to talk further.
alcohol or drugs to try to forget life problems, say: » Repeat
the brief motivational conversations described ▸ s forgetting the problem really a good thing?
Does that make the problem go away? above over several sessions.
some of the negative aspects of alcohol and drug use that may have been underestimated by the person. ▸ ow much money do you spend buying alcohol
or drugs? Per week? Per month? Per year? What else could you be doing with that money? 4. Discuss various ways to reduce or stop harmful use
Discuss the following strategies: » Consider referral to a self-help group for alcohol
Do not store alcohol or drugs at home.
or drug use, if available.
Do not go near places where people may use alcohol the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient Ask for support from carers and friends.
withdrawal symptoms (i.e. <1 week). carers to accompany the person to follow-up visits.
Describe the symptoms (e.g. anxiety and agitation after Encourage social activities without alcohol or drugs.
withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms.
5. Offer psychosocial support as described in the Principles of Reducing Stress
Address current psychosocial stressors. » T each stress management.
social support. 6. Offer regular follow-up
fer support, discuss and work together Schedule and conduct regular follow-up sessions with the person and the carers about reducing in General Principles
or stopping alcohol or drug use. Box SUB 1 Assessment and management of life-threatening alcohol withdrawal
Typical presenting complaints of person with life-threatening alcohol withdrawal
» gitation, severe anxiety
or hallucinations* (seeing, hearing » Increased
blood pressure (e.g. >180/100 mm Hg) or feeling things that are not there) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal
Assessment question 1: Is this alcohol withdrawal?
Assessment question 2: If the person has alcohol
Rule out and manage other causes
that can explain the withdrawal, is this life-threatening alcohol withdrawal?
symptoms, including: » Assess for
Malaria, HIV/AIDS, other infections, head injury Convulsions/seizures (typically within 48 hours) metabolic abnormality* (e.g. hypoglycemia*, Features of delirium* (typically within 96 hours) hyponatraemia*), hepatic encephalopathy, ▸ cute confusion, disorientation
hyperthyroidism*, stroke, drug use ▸ allucinations.
(e.g. amphetamines), known history of psychosis » Assess
whether the person is at high risk of developing
and known history of epilepsy.
life-threatening features (convulsions or delirium) in the
» the above causes are ruled out, take an alcohol history
next 1–2 days: by asking the person and carers: Previous life-threatening features (convulsions or Does the person drink alcohol? When was the last drink? Current and severe withdrawal symptoms: How much does the person usually drink? ▸ evere agitation, severe irritability, severe anxiety
withdrawal is likely if the symptoms develop ▸ xcessive sweating, tremor of hands
after the cessation of regular/heavy alcohol use. This ▸ ncreased blood pressure (e.g. >180/100 mm Hg)
happens typically 1–2 days after the last drink. and/or heart rate (e.g. >100 bpm).
If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy () or psychosis ().
If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life-
threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital.
Emergency management plan for life-threatening alcohol withdrawal
1. Treat alcohol withdrawal immediately
» If possible, provide a quiet, non-stimulating and well-lit
with diazepam (>> Table SUB 1)
environment. Try to provide some light even at night to » he dose of diazepam treatment depends on the
prevent falls if the person decides to get up in the middle person's tolerance* for diazepam, the severity of the of the night. Consider putting the person on a mattress withdrawal symptoms and the presence of concurrent on the floor to prevent injury. If possible, ask a carer to physical disorders. stay with the person and monitor. Avoid restraints if at Adjust the dose to the observed ef fect. The right dose all possible.
is the one that gives slight sedation. ▸ oo high a dose can cause over-sedation and depress
2. Address malnutrition
respiration. Monitor the person's respiratory rate ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. and level of sedation (e.g. sleepiness) frequently.
ssess for and address malnourishment. oo low a dose risks seizures/delirium. the withdrawal symptoms frequently (every 3–4 3. Maintain hydration
hours). Continue to use diazepam until symptoms resolve » S tart i.v. hydration if possible.
(typically 3–4 days but no longer than 7 days).
» E ncourage oral fluid intake (at least 2–3 litres/day).
» the case of a withdrawal seizure, DO NOT use
antiepileptic drugs. Continue using diazepam.
4. When the life-threatening withdrawal is over,
» ymptoms of delirium such as confusion, agitation
proceed to assessment and management
or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, of harmful alcohol or drug use
consider using antipsychotics such as haloperidol 2.5–5
(see main text of this module)
mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not Table SUB 1: Diazepam for life-threatening alcohol withdrawal
Initial dose
10–20 mg up to 4 times/day for 3–7 days Gradually decrease the dose and/or frequency as soon as the symptoms improve.
Monitor frequently, as people respond differently to this medication Severe side-effects (rare)
Respiratory depression*, severely impaired consciousness Caution: monitor respiratory rate and level of sedation frequently Drowsiness, amnesia, altered consciousness, muscle weakness Caution: do not give another dose if the person is drowsy Precautions in special groups
Use one quarter to half of the suggested dose in older people Do not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) Mental disorder, acute emotional distress and hopelessness are common
in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*.
Some health-care workers mistakenly fear that asking about suicide will provoke
the person to attempt suicide. On the contrary, talking about suicide often reduces
the person's anxiety around suicidal thoughts, helps the person feel understood and
opens opportunities to discuss the problem further.
Adults and adolescents with any of the mental, neurological or substance use (MNS)
conditions covered in this guide are at risk of suicide or self-harm.
Typical presenting complaints of a person at risk of suicide
or self-harm
Feeling extremely upset or distressed
Profound hopelessness or sadness
Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose,
self-inflicted wounds). Assessment question 1: Has the person recently attempted suicide or self-harm?
» Assess for:
Poisoning
, alcohol/drug intoxication, medication overdose or other self-harm
Signs r
equiring urgent medical treatment
▸ eeding from self-inflicted wound
▸ oss of consciousness
▸ xtreme lethargy.
Assessment question 2: Is there an imminent risk of suicide or self-harm?
» Ask the person and/or carers about:
» The person is considered at
imminent risk of suicide
Thoughts or plans of suicide or self-harm if either of the following is present: (currently or in past month) ent thoughts, plans or acts of suicide
Acts of self-harm in the past year History of thoughts or plans
of self-harm in the Access to means of suicide (e.g. pesticides, rope, past month or acts of self-harm in the past year in weapons, knives, prescribed medications and drugs). a person who is now extremely agitated, violent, » Look for:
Severely emotional distress or hopelessness or uncommunicative.
Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate.
Assessment question 3: Are there concurrent conditions associated
with suicide or self-harm?
» Assess and manage possible concurrent conditions:
Chronic pain or disability (e.g. due to recent injuries Harmful alcohol or drug use incurred during the humanitarian emergency) Post-traumatic stress disorder Moderate-severe depressive disorder Acute emotional distress Box SUI 1: How to talk about suicide or self-harm
1. Create a safe and private atmosphere for the person to share thoughts.
» Do not judge the person for being suicidal.
fer to talk with the person alone or with other people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example:
» [Start with the present]
How do you feel? » Do you think about hurting yourself?
» [ Acknowledge the person's feelings] You look sad/
» Have you made any plans to end your life?
upset. I want to ask you a few questions about it. » If so, how are you planning to do it?
do you see your future? What are your hopes » Do you have the means to end your life?
for the future? Have you considered when to do it? ome people with similar problems have told me that they felt life was not worth living. Do you go Have you ever attempted suicide? to sleep wishing that you might not wake up in the morning? 3. If the person has expressed suicidal ideas:
» Maintain a calm and supportive attitude
» Do not make false promises.
Basic Management Plan
1. If the person has attempted suicide, provide the necessary medical care,
monitoring and psychosocial support
» ovide medical care:
» Monitor
the person continuously while they are still
◆ reat those who have inflicted self-harm with the at imminent risk of suicide (see below for guidance).
same care, respect and privacy given to others. Do not fer psychosocial support (see below for guidance).
punish them.
◆ reat the injury or poisoning.
onsult a mental health specialist if available.
▸ or acute pesticide intoxication, see
(WHO, 2008).
In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. 2. If the person is at imminent risk of suicide or self-harm,
monitor and provide psychosocial support
Monitor the person
fer psychosocial support:
Create a safe and supportive environment for the DO NOT start by of fering potential solutions to the person. Remove all possible means of self-harm/ person's problems. Instead, try to instil hope. For suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers ▸ M
any people who have been in similar situations or staff stay with the person at all times.
– feeling hopeless, wishing they were dead – have DO NOT routinely admit people to general medicine then discovered that there is hope, and their wards to prevent acts of suicide. Hospital staff may feelings have improved with time. not be able to monitor a suicidal person sufficiently. Help the person to identify reasons to stay alive.
However, if admission to a general ward for the Search together for solutions to the problems.
medical consequences of self-harm is required, Mobilize carers, friends, other trusted individuals monitor the person closely to prevent subsequent acts and community resources to monitor and support of self-harm in the hospital. the person if they are at imminent risk of suicide. Regardless of the location, ensure that the person Explain to them about the need for 24-hour-per-day is monitored 24 hours a day until they are no longer monitoring. Ensure that they come up with a concrete at imminent risk of suicide.
and feasible plan (e.g. who is monitoring the person at what time of the day).
Of ◆ fer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support .
» Consult a mental health specialist if available.
3. Care for the carers as described in the Principles of Reducing Stress
4. Maintain regular contact and follow-up
Make sure there is a concrete plan for follow-up
» Follow up frequently in the beginning (e.g. weekly
sessions and that the carers take responsibility for
for the first 2 months) and decrease frequency ensuring follow-up as the person improves (every 2–4 weeks). General Principles of Care).
» F ollow up for as long as the suicide risk persists.
regular contact (e.g. via telephone, text At every contact, routinely assess suicidal thoughts messages or home visits) with the person. Significant
Mental Health Complaints
While this guide has covered key mental, neurological and substance use (MNS)
conditions relevant to humanitarian settings, it does not cover all possible mental
health conditions that can occur. Therefore, this module aims to provide basic guidance
on initial support for adults, adolescents and children who suffer from mental health
complaints that are not covered elsewhere in this guide.
Other mental health complaints include
(a) various physical symptoms that do not have physical causes and
(b) mood and behaviour changes that cause concern but do not fully meet
the criteria of the conditions covered in other modules of this guide.
These may include complaints involving mild depressive disorder and a range
of subclinical conditions.
Other mental health complaints are considered significant when they impair
daily functioning or when the person seeks help for them.
Assessment question 1: Is there a physical cause that fully explains
the presenting symptoms?
» Conduct a general
physical examination followed by
» Manage any physical cause identified and recheck
appropriate medical investigations. if the symptoms persist. Assessment question 2: Is this an MNS condition discussed in another
module of this guide?
» Exclude:
Harmful alcohol or drug use
Significant symptoms acute str
ess )
▸ ore feature:
▸ ore features:
se of alcohol or drugs that is causing harm to ∙ otentially traumatic event within the last month
self and/or others. ∙ ymptoms started after the event
)
∙ elp-seeking to relieve symptoms or has
▸ ore features:
considerable difficulty with daily functioning urrent acts of self-harm; current thoughts and because of the symptoms.
plans of suicide, or Significant symptoms grief
)
ecent thoughts, plans and acts of self-harm in ▸ ore features:
a person who is severely distressed, agitated, ∙ ymptoms started after a major loss
unwilling to communicate or withdrawn.
∙ elp-seeking to relieve symptoms or has
any of the above conditions are suspected, then considerable difficulty with daily functioning go to the appropriate module for assessment and because of the symptoms.
e depressive disorder (
▸ ore features (for at least 2 weeks):
1) physical causes are excluded, 2) the above MNS
∙ ersistent depressed mood
conditions are excluded and 3) the person is seeking
∙ arkedly diminished interest or pleasure in
help to relieve symptoms or has considerable difficulty
activities, especially those that were previously with daily functioning because of their symptoms,
then the person has another significant mental health
complaint.
∙ onsiderable difficulty with daily functioning
because of the symptoms.
It usually takes more than one meeting to exclude physical causes and the above MNS conditions.
▸ ore features:
∙ otentially traumatic event that happened more
than a month ago r ∙ ecurring frightening dreams, flashbacks* or
intrusive memories* of the events accompanied by intense fear or horror d ∙ eliberate avoidance of reminders of the event
∙ eightened sense of current threat (excessive
concern and alertness to danger or reacting strongly to loud noises or unexpected movements)c ∙ onsiderable difficulty with daily functioning
because of the symptoms.
Assessment question 3: If the person is an adolescent, is there a behavioural
problem?
» Interview both the adolescent and the car
ers to assess
» If the adolescent has a behaviour problem, ask further
for persistent or concerning behavioural problems.
Examples include: Extreme stressors in the adolescent' s past or current Initiating violence life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited Bullying or being cruel to peers emotional support, limited monitoring, mental condition in the carer) Risky sexual behaviour How the adolescent spends most of his or her time. ▸ if the adolescent works or goes to school)
How do you spend your time after work/school? Are there any regular activities that you do?A ▸ re you often bored?
What do you do when you are bored? Basic Management Plan
DO NOT prescribe medicines for "other significant mental health complaints"
(unless advised by a specialist).
DO NOT give vitamin injections or other ineffective treatments.
1. In all cases (whether the person presents with emotional, physical
or behavioural problems), provide basic psychosocial support as described
in the Principles of Reducing Stress and Strengthening Social Support
(
Address current psychosocial stressors.
» T each stress management.
social support.
2. When no physical condition is identified that fully explains a presenting
somatic symptom, acknowledge the reality of the symptoms and provide
possible explanations
DO NOT order more laboratory or other investigations nowledge that the symptoms are not imaginary and
unless there is a clear medical indication (e.g. abnormal
that it is still important to address symptoms that cause vital signs).
significant distress. Ordering unnecessary clinical investigations may for the person's own explanation for the cause
reinforce the person's belief that there is a physical of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and Clinical investigations can have adverse side-ef increase the person's adherence to management.
the person that no serious disease has been » Explain
that emotional suffering/stress often involves identified. Communicate the normal clinical and test the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links ◆ e did not find any serious physical problem. between the person's emotions/stress and symptoms.
I do not see a need for any more tests at this point. ourage continuation of (or gradual return to) daily » the person insists on further investigations,
consider saying: Performing unnecessary investigations can be harmful mber also to apply the Principles of Reducing because they can cause unnecessary worry and Stress and Strengthening Social Support 3. If the person is an adolescent who has behaviour problems
» ake time to listen to the adolescent's own perception
▸ N
ever use physical punishment. Use praise for good of the problem (preferably do this without the presence behaviour more than punishment for bad. of the carers).
▸ D
o not confront the adolescent when you are very
» ovide psychoeducation to the adolescent and their
upset. Wait until you are calm.
carers. Explain the following: Specific points for discussion with the adolescent: Adolescents sometimes develop problematic here are healthy ways to deal with boredom, stress behaviours when they are angry, bored, anxious or or anger (e.g. doing activities that are relaxing, sad. They need continuous care and support despite being physically active, engaging in community their behaviour.
Carers should make every ef fort to communicate with ▸ I t can be helpful to talk to trusted people about
the adolescent, even that it is difficult.
feeling angry, bored, anxious or sad.
Specific messages for the carers: lcohol and other substance use can worsen feelings ▸ ry to identify positive, enjoyable activities that
of anger and depression and should be avoided. you can do together. » Promote
participation in: ▸ e consistent with respect to what the adolescent
Formal and informal education is allowed to do and not allowed to do. Concrete, purposeful, common interest activities (e.g. ▸ raise or reward the adolescent for good
constructing shelters) behaviours and correct only the most problematic Structured sports programmes. member also to apply the Principles of Reducing Stress and Strengthening Social Support to this group of adolescents and their carers.
4. Follow-up
Advise the person to come back if the symptoms persist, » If no improvement is seen or the person or the carer
worsen or become intolerable.
insists on further investigations and treatment, consult a specialist.
Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions
5. Moderate-severe emotional
A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as This person's daily normal functioning is markedly fever, infection, injury or alcohol withdrawal. These impaired for more than 2 weeks due to a) episodes are characterized by loss of consciousness overwhelming sadness/apathy and/or b) exaggerated, with shaking of the limbs and sometimes associated uncontrollable anxiety/fear. Personal relationships, with physical injuries, bowel/bladder incontinence appetite, sleep and concentration are often affected. and tongue biting.
The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common.
2. Alcohol or other substance
use disorder
This category includes people with disabling forms of depression, anxiety disorders and post-traumatic A person with this disorder seeks to consume alcohol stress disorder (characterized by re-experiencing, or other addictive substances and has difficulties avoidance and hyper-arousal). Presentations of controlling consumption. Personal relationships, milder forms of these disorders are classified as work performance and physical health often "other psychological complaint".
deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 6. Other psychological complaint
3. Intellectual disability
This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. The person has very low intelligence, causing ruminating, poor concentration) or behaviour (e.g. problems in daily living. As a child, this person is slow inactivity, aggression, avoidance).
in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be The person tends to be able to function in most able to live independently or look after themselves day-to-day, normal activities. The complaint may be and/or dependants without support from others. a symptom of a less severe emotional disorder (e.g. When the disability is severe, the person may have mild forms of depression, of anxiety disorder or of difficulties speaking and understanding others and post-traumatic stress disorder) or may represent may require constant assistance.
normal distress (i.e. no disorder).
Inclusion criteria: This category should only be
4. Psychotic disorder
applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories.
The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused 7. Medically unexplained
or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, This category covers any somatic/physical complaint energetic, talkative and reckless. The person's that does not have an apparent organic cause.
behaviour is considered "crazy"/highly bizarre by other people from the same culture. This category Inclusion criteria: This category should only be
includes acute psychosis, chronic psychosis, mania applied a) after conducting necessary physical and delirium.
examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint.
Annex 2: Glossary 10 11
Abnormal accumulation of fluid in the abdomen, from various causes. A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects.
Psychological treatment that focuses on improving mood by engaging again in activities that Behavioural
are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy.
Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties.
Severe mental disorder characterized by alternation between manic and depressive episodes.
Bone marrow
Suppression of bone marrow function, which can lead to deficiencies in blood cell production.
General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Mental processes associated with thinking. These include reasoning, remembering, Cognitive
judgement, problem-solving and planning.
Psychological treatment that combines cognitive components (aimed at thinking differently, Cognitive behavioural for example through identifying and challenging unrealistic negative thoughts)
therapy (CBT)
and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities).
Psychological treatment based on the idea that people who were exposed to a traumatic Cognitive behavioural event have unhelpful thoughts and beliefs related to that event and its consequences.
therapy with a
These thoughts and beliefs result in unhelpful avoidance of the reminders of the event trauma focus (CBT-T)
and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs.
Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal.
Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person's culture or subculture (i.e., it is not an aspect of religious faith).
People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. The pupil (black part of the eye) is the opening in the centre of the iris that regulates Dilated /constricted
the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs.
A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text.
11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015).
Situation where a drug prescribed to treat one health condition affects another health condition in the same person.
Situation where two drugs taken by the same person interact with each other, altering Drug-drug interaction the effect of either or both drugs. Interactions can include lessening the effect of a drug,
enhancing or speeding up an effect, or having a toxic effect.
Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia.
Psychological treatment based on the idea that negative thoughts, feelings and behaviours Eye movement
result from unprocessed memories of traumatic events. The treatment involves standardized desensitisation and
procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. False perception of reality: seeing, hearing, feeling, smelling or tasting things that are Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction.
Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal.
Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Abnormally low concentration of glucose (sugar) in the blood.
Abnormally low concentration of sodium (salt) in the blood.
Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Psychological treatment that focuses on the link between depressive symptoms and Interpersonal therapy interpersonal problems, especially those involving loss, conflict, isolation and major life
Recurrent, unwanted, distressing memories of a traumatic event.
Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically
Partial or total loss of strength in any part of the body without any identifiable organic cause.
Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection.
Metabolic
Abnormality in the body's hormones, minerals, electrolytes or vitamins.
The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting.
Infection involving the brain and/or spinal cord.
Neuroleptic
A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure.
Group of drugs used to suppress inflammation. They are often used for pain relief inflammatory drugs
(for example, ibuprofen is an NSAID).
Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate.
Sudden drop of blood pressure that can occur when one changes position from lying to sitting Orthostatic
or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening.
Provision of more than one medicine at the same time for the same condition.
Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, Potentially traumatic destruction of a person's house, or major accidents or injuries. Whether or not these kinds of
event are experienced as traumatic will depend on the person's emotional response.
Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term "problem-solving counselling" is used when these techniques are used systematically over a number of sessions. An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder.
Provision of supportive care to people in distress who have recently been exposed to a crisis Psychological first aid event. The care involves assessing immediate needs and concerns; ensuring that immediate
(PFA)
basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Behaviour that is inappropriate to a child's actual developmental age but would be Regressive behaviour appropriate for someone younger. Common examples are bedwetting and clinginess
Respiratory
Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Episode of brain malfunction due to abnormal electrical discharges.
Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional.
Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs.
Condition where a person's circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness.
Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person's mood. Fluoxetine is an SSRI.
A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives.
Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, syndrome
sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs.
The act of deliberately causing one's own death. Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Diminishing effect of a drug when used at the same dose. It results from the body's habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect.
Toxic epidermal
Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. necrolysis
It is similar to but more severe than Stevens-Johnson syndrome.
Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling "high" or happy).
Trembling or shaking movements, usually of the fingers.
Sepsis caused by urinary tract infection.
Annex 3: Symptom Index
Acute Stress (ACU)Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD)Psychosis (PSY)Harmful Use of Alcohol and Drugs (SUB) Acute Stress (ACU) Grief (GRI)Moderate-severe Depressive Disorder (DEP) Acute Stress (ACU) Intellectual Disability (ID) Epilepsy/Seizures (EPI)Harmful Use of Alcohol and Drugs (SUB) Acute Stress (ACU)Grief (GRI)Moderate-severe Depressive Disorder (DEP) Difficulty carrying out usual activities
Post-traumatic Stress Disorder (PTSD)Psychosis (PSY)Intellectual Disability (ID)Harmful Use of Alcohol and Drugs (SUB) Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Moderate-severe Depressive Disorder (DEP)Suicide (SUI) Acute Stress (ACU) Epilepsy/Seizures (EPI) Intellectual Disability (ID) Acute Stress (ACU)Grief (GRI) Moderate-severe Depressive Disorder (DEP)Post-traumatic Stress Disorder (PTSD)Harmful Use of Alcohol and Drugs (SUB) Acute Stress (ACU) Grief (GRI)Post-traumatic Stress Disorder (PTSD) Acute Stress (ACU)Grief (GRI) Moderate-severe Depressive Disorder (DEP)Post-traumatic Stress Disorder (PTSD)Harmful Use of Alcohol and Drugs (SUB) Intellectual Disability (ID) Loss of energy
Moderate-severe Depressive Disorder (DEP) Acute Stress (ACU) Low interest, pleasure
Grief (GRI)Moderate-severe Depressive Disorder (DEP) Poor hygiene
Intellectual Disability (ID)Harmful Use of Alcohol and Drugs (SUB) Acute Stress (ACU)Grief (GRI) Moderate-severe Depressive Disorder (DEP)Post-traumatic Stress Disorder (PTSD)Harmful Use of Alcohol and Drugs (SUB) Moderate-severe Depressive Disorder (DEP) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Acute Stress (ACU)Grief (GRI) Moderate-severe Depressive Disorder (DEP)Psychosis (PSY) Acute Stress (ACU)Grief (GRI) Unexplainable physical symptoms
Moderate-severe Depressive Disorder (DEP)Post-traumatic Stress Disorder (PTSD) In every general health facility in humanitarian emergencies
at least one supervised health care-staff member should
be capable to assess and manage mental, neurological
and substance use conditions.
The mhGAP Humanitarian Intervention Guide (mhGAP-HIG)
is a simple, practical resource that aims to ensure this target.
mental health Gap Action Programme

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