Mental, Neurological and Substance Use Disorders

Publication Date: November 20, 2023
Last Updated: November 20, 2023

Alcohol use disorders

Baclofen should be considered for treatment of adults with alcohol dependence post-detoxification. (C, M )
620
Structured and standardized psychosocial interventions should be considered for the treatment of alcohol dependence. (C, L )
620
Digitally delivered interventions should be considered for adults with alcohol use disorders or with hazardous alcohol use. They should not replace provision of other forms of interventions and should ensure free and informed consent, safety, confidentiality, privacy and security. (C, L )
620
Combined psychosocial and pharmacological interventions should be offered for adults with alcohol dependence. (S, M )
620

Anxiety

Selective serotonin reuptake inhibitors (SSRIs) should be considered for adults with panic disorder. If SSRIs are not available, consider offering tricyclic antidepressants (TCAs). SSRIs should be considered for adults with generalized anxiety disorder (GAD). (C, L )
620
Brief, structured psychological interventions based on principles of cognitive behavioural therapy (CBT) should be offered for adults with generalized anxiety disorder (GAD) and/or panic disorder. (S, M )
620
When brief, structured psychological interventions based on principles of cognitive behavioural therapy (CBT) are offered for adults with generalized anxiety disorder (GAD) and/or panic disorder, different delivery formats should be considered based on available resources as well as individual preferences, including:
  • individual and/or group face-to-face
  • digital/online and/or face-to-face
  • guided and/or unguided self-help
  • specialist and/or non-specialist
(C, L )
620
Stress management techniques, namely relaxation and/or mindfulness training, should be considered for adults with generalized anxiety disorder (GAD) and/or panic disorder. (C, L )
620
Structured physical exercise should be considered for adults with generalized anxiety disorder (GAD) and/or panic disorder. (C, VL )
620
Benzodiazepines are not recommended for the treatment of adults with generalized anxiety disorder (GAD) and/or panic disorder. For emergency management of acute and severe anxiety symptoms, benzodiazepines may be considered, but only as a short-term (3–7 days maximum) measure. (S, L )
620
Collaborative care should be considered for adults with depression and/or anxiety and physical health conditions. (C, L )
620

Child and adolescent mental disorders

For children 6 years old and above and adolescents who have an attention deficit hyperactivity disorder (ADHD) diagnosis, methylphenidate may be considered, provided that:
  • ADHD symptoms are still causing persistent significant impairment in at least one domain of functioning (education, interpersonal relationships, occupation), after the implementation of environmental modifications in schools, at home or in other relevant settings
  • a careful assessment of the child/adolescent has been conducted
  • the child/adolescent and the caregivers, as appropriate, have been informed about ADHD treatment options and supported in decision-making
  • methylphenidate prescription is made by, or in consultation with, a specialist
(C, L )
620
Universally delivered psychosocial interventions that use curriculum-based, familybased, exercise-based methods and/or social and personal skills development to improve emotional regulation should be considered for promotion of psychosocial well-being in children. (C, VL )
620
Psychosocial interventions that include cognitive behavioural therapy (CBT), psychoeducation and family-focused treatment approaches should be offered to children whose parents have mental health conditions for the prevention of depression and anxiety. (S, L )
620
Psychosocial interventions focused on social skills training and developmental behavioural approaches should be offered to improve development, well-being and functioning in children and adolescents with autism. (S, L )
620
Cognitive behavioural therapy (CBT) should be offered to children and adolescents with autism with anxiety. (S, M )
620
Psychosocial interventions focused on social skills and cognitive intervention training should be considered to improve development and functioning in children and adolescents with attention deficit hyperactivity disorder (ADHD). (C, M )
620
Psychosocial interventions focused on organizationa skills training should be considered to improve development and functioning in children and adolescents with attention deficit hyperactivity disorder (ADHD). (S, M )
620
Beginning-to-read interventions should be offered to improve communication and academic performance in children with disorders of intellectual development. (S, M )
620
Early communication interventions involving direct instruction approaches should be considered for improving expressive phonological skills and reducing stuttering for children with developmental speech disorders. (C, VL )
620
Psychosocial interventions using cognitive learning techniques to enhance communication and social competencies should be considered for children and adolescents with neurodevelopmental disabilities. (C, L )
620
Structured physical exercise should be considered to improve development, including social and communication development, and functioning in children and adolescents with autism. (C, L )
620
Structured physical exercise should be considered to improve motor skills and functioning, including attention and executive functioning, and reduce anxiety and problem behaviours in children and adolescents with attention deficit hyperactivity disorder (ADHD). (C, VL )
620
Specialized instructional techniques should be considered to improve academic performance, including writing skills, reading comprehension and maths, in children and adolescents with developmental learning disorders. (C, VL )
620
Task-oriented instruction should be considered to improve motor skills and task performance in children with developmental coordination disorders. (C, VL )
620
Structured physical exercise and activity should be offered to improve development outcomes, including motor skills and functioning, in children and adolescents with cerebral palsy. (S, L )
620
Pharmacological interventions are not recommended in children and adolescents with anxiety disorders. (S, L )
620
Antidepressant medicines are not recommended for the treatment of children 12 years of age and below with depressive episode/disorder. (S, L )
620
If psychosocial interventions alone prove ineffective in adolescents (13–17 years) with moderate-to-severe depression, referral to or consultation with a specialist should be offered, to undertake a more comprehensive assessment and to explore initiation of fluoxetine in combination with psychological treatments. (S, L )
620

Conditions related to stress

Psychological interventions should be considered for adults with post-traumatic stress disorder (PTSD). Namely, these include:
  • individual face-to-face cognitive behavioural therapy (CBT) with a trauma focus
  • group face-to-face CBT with a trauma focus
  • digital/remote CBT with a trauma focus
  • eye movement desensitization and reprocessing (EMDR)
  • stress management
(C, L )
620
Psychological interventions should be offered for children and adolescents with posttraumatic stress disorder (PTSD). Namely, these include:
  • individual face-to-face cognitive behavioural therapy (CBT) with a trauma focus
  • group face-to-face CBT with a trauma focus
  • eye movement desensitization and reprocessing (EMDR)
(S, M )
620

Dementia

Psychosocial interventions – namely mindfulness-based interventions, multicomponent interventions, psychoeducation and psychotherapy/counselling – should be offered for carers of people living with dementia. (S, L )
620
Respite care should be considered for carers of people living with dementia. (C, L )
620
Depression and anxiety in carers of people living with dementia should be assessed and treated in line with mhGAP recommendations for depression and anxiety. (S, L )
620
There was insufficient evidence to update the recommendation, so the existing recommendation remains valid. Psychological interventions – namely cognitive behavioural therapy (CBT), interpersonal therapy (IPT), structured counselling and behavioural activation therapy (BAT) – should be considered for people living with dementia and mild-to-moderate depression. (C, L )
620
Physical activity interventions – namely physical exercise delivered 3–4 times per week for 30–45 minutes for more than 12 weeks – should be offered to people living with dementia. (S, H )
620
Non-pharmacological interventions – namely CBT, cognitive stimulation therapy and cognitive training (in alphabetical order) – should be considered for people living with dementia. (C, L )
620

Depression

In adults with moderate-to-severe depression, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine or sertraline (SSRIs) or amitriptyline (TCA) should be considered. (C, VL )
620
In adults with moderate-to-severe depression who have benefited from initial antidepressant treatment, continuation of the antidepressant treatment should be considered for at least six months after remission. Treatment should be regularly monitored, with special attention to treatment adherence, change in depressive symptoms and possible adverse effects. (C, VL )
620
Structured psychological interventions should be offered for the treatment of adults with moderate-to-severe depression, namely behavioural activation therapy (BAT), brief psychodynamic therapy (DYN), cognitive behavioural therapy (CBT), interpersonal therapy (IPT), problem-solving therapy (PST) and third wave therapies (3WV). (S, M )
620
In adults with moderate-to-severe depression, psychological interventions or combined treatment should be considered based on individual preferences and careful consideration of the balance of benefits and harms. Antidepressant medicine alone for adults with depression (moderate to severe) should only be considered when psychological interventions are not available. Providers should keep in mind the possible adverse effects associated with antidepressant medicines, and individual preferences. (C, L )
620

Drug use disorders

Adults using cannabis should be offered screening and brief intervention. Brief intervention should comprise at least a single session, incorporating individualized feedback and advice on reducing or stopping cannabis consumption, and the offer of follow-up care. (S, VL )
620
Adults using psychostimulants should be offered screening and brief intervention. Brief intervention should comprise at least a single session, incorporating individualized feedback and advice on reducing or stopping psychostimulant consumption, and the offer of follow-up care. (S, VL )
620
For adults with hazardous cannabis or psychostimulant use, or with disorders due to use of these substances who do not respond to brief interventions, referral for specialist intervention should be considered. (C, VL )
620
Dexamphetamine, methylphenidate and modafinil are not recommended for the treatment of cocaine or stimulant use disorders due to safety concerns. (C, L )
620
Psychosocial interventions – namely cognitive behavioural therapy (CBT) and contingency management – should be offered to adults with cocaine and stimulant dependence. (S, L )
620
Digital interventions should be considered for adults using drugs or with drug use disorders. They should not replace provision of other forms of interventions and should ensure informed consent, safety, confidentiality, privacy and security. (C, VL )
620
Recovery-oriented services on a voluntary basis should be considered for adults with drug dependence. Namely, case management, long-term residential and continuing community care approaches, occupation-based therapies and peer support groups should be considered for recovery management of people with drug dependence. (C, L )
620

Epilepsy and seizures

In adults with established status epilepticus, i.e. seizures persisting after two doses of benzodiazepines, either intravenous fosphenytoin, intravenous phenytoin, intravenous levetiracetam, intravenous phenobarbital or intravenous valproic acid (sodium valproate) should be considered with appropriate monitoring. The choice of these medicines depends on local resources, including availability and facilities for monitoring. (C, L )
620
In children with established status epilepticus, i.e. seizures persisting after two doses of benzodiazepines, intravenous fosphenytoin, intravenous phenytoin, intravenous levetiracetam, intravenous phenobarbital or intravenous valproic acid (sodium valproate) should be considered with appropriate monitoring. The choice of these medicines depends on local resources, including availability and facilities for monitoring. (C, M )
620

Generalized onset seizures

Monotherapy with lamotrigine or levetiracetam, or valproic acid (sodium valproate), should be offered as first-line treatment for generalized onset seizures in men/boys and women/girls who are not of childbearing potential. In women and girls of childbearing potential with generalized onset seizures, lamotrigine or levetiracetam should be offered as first-line monotherapy. If the first monotherapy is not successful for generalized onset seizures, an alternative first-line monotherapy should be tried. Valproic acid (sodium valproate) is not recommended in women and girls of childbearing potential owing to the high risk of birth defects and neurodevelopmental disorders in children exposed to valproic acid (sodium valproate) in the womb. If lamotrigine, levetiracetam and valproic acid (sodium valproate) are not available for
generalized onset seizures, monotherapy with either phenytoin or phenobarbital can be considered. (S, H )
620

Focal onset seizures

Monotherapy with lamotrigine or levetiracetam should be offered as first-line treatment for focal onset seizures in children and adults with epilepsy. If neither lamotrigine nor levetiracetam are available, then carbamazepine should be used as an alternate first-line treatment for focal onset seizures in children and adults with epilepsy. If the first monotherapy is not successful for focal onset seizures, an alternative first-line monotherapy should be tried. Lacosamide should be offered as a second-line monotherapy for focal onset seizures if none of the first-line medicines are effective. If antiseizure medicine monotherapy is unsuccessful in people with generalized onset seizures or focal onset seizures, prompt referral should be made to a specialist for consideration of other treatment options. (S, H )
620
The efficacy of antiseizure medicines (ASMs) is not thought to differ in males and females. As such, this recommendation builds on EPI3 and focuses on the medicines that are now being preferentially recommended as therapeutic options. In women and girls with epilepsy who are of childbearing potential, lamotrigine or levetiracetam should be offered as first-line monotherapy for both generalized onset seizures and focal onset seizures. Women with epilepsy should have seizures controlled as well as possible with the minimum dose of ASMs taken in monotherapy, wherever possible. Valproic acid (sodium valproate) is not recommended in women and girls of childbearing potential because of potential harm to the fetus. (S, VL )
620
Standard breastfeeding recommendations remain appropriate for women with epilepsy taking the ASMs included in this review (phenobarbital, phenytoin, valproic acid [sodium valproate], carbamazepine, lamotrigine, levetiracetam, topiramate, lacosamide). (S, VL )
620
Nocturnal supervision should be considered for prevention of sudden unexpected death in epilepsy (SUDEP). (C, VL )
620

Overarching areas

Psychosocial interventions – namely psychoeducation using problem-solving and cognitive-behavioural approaches (either individual or family-based), self-help interventions and mutual support groups – should be considered for carers of persons with psychosis or bipolar disorder. (C, M )
620
Psychosocial interventions – namely psychoeducation using problem-solving and cognitive-behavioural approaches (either individual or family-based), self-help interventions and mutual support groups – should be considered for carers of persons with substance use disorder. (C, VL )
620

Psychosis and bipolar disorder

Oral antipsychotic medicines – namely aripiprazole, chlorpromazine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone – should be offered for adults with a psychotic disorder (including schizophrenia), carefully balancing effectiveness, sideeffects and individual preference. (S, M )
620
Clozapine should be considered for adults with a treatment-resistant psychotic disorder (including schizophrenia) under mental health specialist supervision, carefully balancing effectiveness, side-effects and individual preference. (C, M )
620
Maintenance therapy with antipsychotic medicine for a minimum of 7–12 months should be offered in adults with a first episode of psychosis (including schizophrenia) in remission, carefully balancing effectiveness, side-effects and individual preference. (S, M )
620
Maintenance therapy with mood stabilizers or antipsychotic medicines should be considered for at least six months for adults with bipolar disorder in remission, carefully balancing effectiveness, side-effects and individual preference. (C, L )
620
Long-acting injection (LAI) antipsychotic medicines – namely fluphenazine, haloperidol, paliperidone, risperidone and zuclopenthixol – should be considered as an alternative to oral antipsychotic medicines for adults with psychotic disorders (including schizophrenia) requiring long-term treatment, carefully balancing effectiveness, side-effects and individual preference. (C, M )
620
Oral antipsychotic medicines – namely aripiprazole, olanzapine, paliperidone, quetiapine, risperidone – should be considered under specialist supervision for adolescents with psychotic disorders (including schizophrenia), carefully balancing effectiveness, side-effects and individual preference. (C, L )
620
Clozapine should be considered for adolescents with a treatment-resistant psychotic disorder (including schizophrenia) under specialist supervision, carefully balancing effectiveness, side-effects and individual preference. (C, L )
620
Psychotropic medicines (antipsychotic medicines, namely aripiprazole, olanzapine, quetiapine, risperidone; and mood stabilizers, namely lithium) should be considered under specialist supervision for adolescents with bipolar disorder (current episode manic), carefully balancing effectiveness, side-effects and individual preference. (C, VL )
620
Oral antipsychotic medicines (namely aripiprazole, haloperidol, olanzapine, paliperidone or quetiapine) or mood stabilizers (namely carbamazepine, lithium, valproic acid [sodium valproate]) should be offered to adults with bipolar disorder (current episode mania), carefully balancing effectiveness, side-effects and individual preference. (S, L )
620
Valproic acid (sodium valproate) should not be used in women and girls of childbearing potential, owing to the high risk of birth defects and neurodevelopmental disorders in babies in utero. (S, L )
620
Mood stabilizers (namely carbamazepine, lithium, valproic acid [sodium valproate]) or oral antipsychotic medicines (namely aripiprazole, olanzapine, quetiapine) should be considered for maintenance treatment for adults with bipolar disorder in remission, carefully balancing effectiveness, side-effects and individual preference. (C, L )
620
Valproic acid (sodium valproate) should not be used in women and girls of childbearing potential with bipolar disorder in remission, owing to the high risk of birth defects and neurodevelopmental disorders in babies in utero. (S, L )
620
Fluoxetine, olanzapine, quetiapine, valproic acid (sodium valproate) or venlafaxine should be considered for adults with bipolar depression. If fluoxetine or venlafaxine are chosen, they should be co-administered with a mood stabilizer (namely quetiapine, olanzapine, carbamazepine, valproic acid [sodium valproate], lithium). (C, VL )
620
Treatment based on cognitive behavioural therapy (CBT) should be considered for adults with psychotic disorders (including schizophrenia) in the acute phase of the condition where sufficient specialist support is available. (C, M )
620
Psychosocial interventions – namely family interventions, family psychoeducation, psychoeducation and cognitive behavioural therapy (CBT) – should be offered to adults with psychosis (including schizophrenia) during the maintenance phase, either alone or in combination. (S, M )
620
Individual psychological interventions – namely cognitive behavioural therapy (CBT), family psychoeducation, medicine adherence therapy, online psychoeducation or psychoeducation – should be considered as adjunctive to pharmacological interventions in the treatment of adults with bipolar disorder in remission. (C, L )
620

Self-harm and suicide

Safety planning type-interventions, i.e. interventions based on principles of safety planning which are multicomponent or supplemented with follow-up or support, can be considered. (C, VL )
620
The evidence regarding effectiveness of stand-alone media campaigns (to raise awareness and sensitize the general public about suicide and its prevention) in reducing deaths from suicide, suicide attempts and acts of self-harm is insufficient to make a recommendation. (, )
620
Stand-alone digital interventions based on evidence-based interventions such as cognitive behavioural therapy (CBT), dialectical behaviour therapy (DBT), problem-solving therapy (PST) and mindfulness should be considered as support for persons with suicidal thoughts. (C, L )
620

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Mental, Neurological and Substance Use Disorders

Authoring Organization

Publication Month/Year

November 20, 2023

Last Updated Month/Year

November 27, 2023

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

Global

Document Objectives

The mhGAP guideline supports countries to strengthen capacity to deal with the growing burden of mental, neurological and substance use (MNS) conditions and narrow the treatment gap. This new edition includes 30 updated and 18 new recommendations, alongside 90 pre-existing recommendations. This is the third iteration of the guideline and reflects 15 years of investment in the mhGAP programme. The revised recommendations ensure that mhGAP continues to offer high-quality, timely, transparent, and evidence-based guidance to support non-specialist health workers in low-income and middle-income countries in providing treatment and care to individuals with MNS conditions.

Target Patient Population

All patients with mental health or substance use disorders

Target Provider Population

Non-specialized health workers at primary- or secondary-level healthcare facilities

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Outpatient

Intended Users

Addiction treatment specialist, counselor, nurse, nurse practitioner, physician, physician assistant, psychologist

Scope

Counseling, Diagnosis, Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D003863 - Depression, D004827 - Epilepsy, D019958 - Attention Deficit and Disruptive Behavior Disorders, D001289 - Attention Deficit Disorder with Hyperactivity, D001007 - Anxiety, D008603 - Mental Health, D019966 - Substance-Related Disorders, D012559 - Schizophrenia, D001523 - Mental Disorders, D016320 - Substance Abuse Treatment Centers, D001714 - Bipolar Disorder, D000428 - Alcohol Drinking, D003156 - Community Mental Health Services

Keywords

depression, alcohol, schizophrenia, anxiety, bipolar, epilepsy, ADHD, Mental health, Substance use disorders, bipolar disorder

Source Citation

Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.