DRAFT

Mental Health in Primary Care

Diagnostic and Treatment Guidelines

Based on the
WHO Primary Care Guidelines for Mental
Disorders

and
adapted for Sri Lanka

Endorsed by:
List relevant bodies here
Eg Sri Lanka Psychiatric Association
 Contents

Foreword……………………………………………………………………………..5

Introduction…………………………………………………………………………. 6

Section1. Policy and Services

General Health Policy…………………………………………………………………………..7
Mental Health Policy…………………………………………………………………………….7
Health Service structure, general tasks, mental health tasks…………………………..8

Section 2: What is mental health and why it is important

Rationale for addressing mental health……………………………………………………..9
Mental health, poverty and the International Development Targets……………………9
Defining mental health and mental illness…………………………………………………10
Causes and consequences of mental illness……………………………………………..11
Prevalence of Mental Disorders....................................................................................12
Global Burden of Disease…………………………………………………………………….13

Section 3: Physical health and mental disorders

Fever………………………………………………………………………………………………14
Reproductive health……………………………………………………………………………15
Child health ……………………………………………………………………………………..16
Malaria…………………………………………………………………………………………….17
HIV…………………………………………………………………………………………………18
TB…………………………………………………………………………………………………..20
Tobacco……………………………………………………………………………………………20
Diabetes……………………………………………………………………………………………20
Hypertension……………………………………………………………………………………..20
Myocardial infarction……………………………………………………………………………20
Cancer……………………………………………………………………………………………..21
Trauma…………………………………………………………………………………………….21

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 2 of 82

Section 4. General management issues
Mental Health Promotion, prevention and vulnerable groups………………………..22
Referral Criteria…………………………………………………………………………….….25
Health Management Information System....................................................................26
Registering a case………………………………………………………………………….…27
Roles and responsibilities for health centres and dispensaries..……………………28
Roles and responsibilities for district mental health coordinators…………………..29
Making effective use of volunteer community health workers………………………..30
Mediation guidelines…………………………………………………………………………..31
Management of violence………………………………………………………………………33
Suicide prevention………………………………………………………………………………34

Section 5: Specific mental and neurological disorders

Depression……………………………………………………………………………………….35
Anxiety…………………………………………………………………………………………….37
Unexplained somatic symptoms, hapa hapa syndrome…………………………………38
Dissociation……………………………………………………………………………………….39
Eating disorders…………………………………………not yet included ……………………
Sexual problems…………………………………………not yet included ………………...
Alcohol abuse…………………………………………………………………………….........40
Drug abuse………………………………………………………………………………………41
Acute psychosis………………………………………………………………………………..42
Bipolar disorder..............................................................................................................44
Schizophrenia................................................................................................................46
Epilepsy.........................................................................................................................48
Dementia........................................................................................................................50
Delirium/toxic confusional state……………………………………………………………51
Mental retardation…………………………………………………………………………… 52
Childhood emotional disorder………………………………………………………………54
Childhood conduct disorder…………………………………………………………………..…….…55
ADHD…………………………………………………………………………………………….57
Dyslexia…………………………………………………………………………………………58
Autism……………………………………………………………………………………………59

Section 6: Sri Lanka Mental Health Act and procedures.....................................61

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 3 of 82

Section 7: Other useful materials.................................................................63.
Alcohol Misuse - Definitions of Units…………………………………………………………………63
Checklists for use by professionals:
Cage questionnaire - screen for alcohol misuse..............................................63
Audit questionnaire - screen for alcohol misuse...............................................63.
Abbreviated mental test score - screen for dementia.........................................64
Social and Living Skills Checklist – to assess adequacy of care plan in Chronic Severe
Illness................................................................................................................65
? PREM form insert here
Interactive Summary Cards - for discussion by professional and patient together
Alcohol problems..............................................................................................67
Anxiety..............................................................................................................69
Chronic tiredness..............................................................................................71
Depression.......................................................................................................73
Sleep problems.................................................................................................75
Unexplained somatic complaints.......................................................................77
Working with Traditional Health Practitioners..........................................................79
Mental Health NGOs-Resource Directory..................................................................80
Local services - compile your own resource directory..........................................

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 4 of 82

Foreword

Health is “the complete physical, mental and social well-being and not merely the absence of
disease or infirmity” (World Health Organisation Constitution 1948).

Mental health is an integral part of health and plays an important role in the overall health of
individuals, families, communities and nations. Indeed, there is no health without mental health. It is
therefore important to include mental health in promotive, preventive, curative and rehabilitative
health care services in every stage of development in the human life cycle.
 Pregnancy, delivery and Newborn (up to 2 weeks of age)
 Early childhood (unto 5 years of age)
 Late childhood (6-12 years)
 Adolescence and youth (13-24 years)
 Adulthood (25-59 years)
 Elderly (60 years and above)

Each phase represents various age groups or cohorts, each of which has special needs including
mental health needs.

Sri Lanka has six service delivery levels (community, dispensary, sub district, district, province and
national ), and two parallel dimensions of work, namely public health and curative services:

In the ongoing Health Sector Reforms, emphasis is given to decentralization towards Primary
Health Care facilities and integration of health care services in order to provide quality health care
services, which are acceptable, equitable, accessible and affordable by all Sr Lankans.

In order to realize this goal, it is critical that the primary health care workers are empowered by
appropriate training on mental health to acquire the necessary knowledge, skills, competence and
attitude to recognize and manage mental health problems both in the community and Primary
Health Care facilities.

Director of Mental Health

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 5 of 82

Introduction

In Sr Lanka , as elsewhere in the world, at least one in three patients attending primary care has
some form of mental disorder.
Levels of disability are high and often worse than for common physical diseases. Simple effective
treatments are available for mental disorders and can be delivered in primary care.
The WHO Primary Care Guidelines were developed by WHO in 1996, adapted for the UK (1st
edition 1999, and 2nd edition 2004) and are now adapted for Sr Lanka (2010) through a process of
extensive consultation .
The Guidelines have been endorsed by the organizations listed below. They are intended to assist
good quality assessment and management of people with mental disorders attending dispensaries
and health centers. They will also be useful for general district, provincial hospital clinics and
emergency settings.
The guidelines will be regularly updated and all suggestions for improvement should be passed to
Director of Mental Health, Ministry of Health.

List relevant organizations who endorse

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 6 of 82

Section 1. Policy and services

General Health Policy

Vision:
A comprehensive and community based service is to be established which will optimise the mental
health of Sri Lankan people. This accessible and affordable service will promote the mental well
being of the community at large and ensure the dignity and human rights if all citizens, especially
those in vulnerable or disadvantaged circumstances.

Principles
 Provide mental health services at primary , secondary and tertiary levels
 Provide services of good quality where and when they are needed
 Provide services that will be organised at community level with community, family and
consumer participation
 Ensure mental health services will be linked to other sectors
 Ensure mental health services will be culturally appropriate and evidence based.
 Protect human rights and dignity of people with mental illness

Objectives:
 Ensure clarity of vision and purpose in the improvement of mental health and psychological
wellbeing of the citizens of Sri Lanka
 To treat mental disorders in an efficient and holistic manner.

Mission:
To improve Sri Lanka’s mental health services and make them locally accessible. The emphasis of
the service is on prevention of mental illness, promotion of mental wellbeing, treatment and
rehabilitation of people with mental illness, and maximising their normal life where illness does
occur.
Where admission to hospital is necessary, this should be as near a person’s home as possible. To
these ends there is a need to modernise existing services, create new and additional services,
recruit and train more skilled staff, and link to both other government and nongovernment sectors.

Based on the assessed needs, current services and principles of mental health care , seven areas
for action have been identified. .

1. Management at national and provincial levels

2. Organisation of services
3. Human resource development
4. Research and ethics
5. National Institute of Mental health
6. Tackling Stigma and Promoting Mental Wellbeing
7. Mental health legislation

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 7 of 82

 7.
Health Service structure, general tasks and mental health tasks

Health General Mental health tasks

system tasks
CHWs Promote Familiarity with predisposing, precipitating, perpetuating and protective factors and
health through consequences of mental disorders
education Mental health education
Support vulnerable people to prevent depression, e.g. bereaved, carers, orphans
Early detection of depression and psychosis and referral to PHC
Monitoring of compliance with medicines
Monitoring of side effects
Monitoring of early signs of relapse so can refer quickly to PHC
First aid management of violence and aggression
Early detection of delirium

Dispensaries Provide health Service

and health education, Integrate mental health into routine PHC and community work
centres prevention, Referral of difficult cases to District
treatment and Collect stats of MH consultations using diagnostic categories
rehabilitation Develop and keep simple case registers for people with severe mental illness to facilitate
follow up, prevention of relapse, outreach and planning for medicines
Liaise with community health workers including traditional health practitioners to enhance
support and reduce harm to people with mental illness
Consult with higher levels about criteria for referral
Educate local communities on prevention of mental disorders, recognition and where to
seek help (done through chiefs, home visits and education within health facilities)

Training and skills

Attend PHC in service training and continuing education programmes
Develop psychosocial skills
Improve attitudes to mental health issues
Improve effectiveness of skills

Good practice Guidelines

Use good practice guidelines

Drugs
Ensure availability of antidepressants, anti-psychotics and anti-epileptics in the primary
care clinic, and hence reduce use of benzodiazepines for mental disorders

District Secondary Clinical

outpatient referral Administrative
and Educative
inpatients Support and Supervision to dispensaries and health centres
Monitoring and Evaluation
Referral of difficult cases to Provincial level

Provincial Tertiary Clinical

outpatient referral Administrative
and inpatient Educative
Support and Supervision to districts
Monitoring and Evaluation
Referral of difficult cases to national level
National Clinical
outpatient Administrative
and Educative
inpatients Support and Supervision to provinces
Monitoring and Evaluation
Ministry of Strategic leadership, overall coordination of mental health services in Kenya, liaison to
Health specialist sector, primary care sector and community sector
Development and overview of national mental health policy
Development and review of mental health legislation
Development and review of national mental health guidelines and standards for mental
health care services
Capacity building, development of human resources and training of mental health
personnel
Administration and implementation of mental health act.
Collaboration with other sectors in mental health at national and international level.
Monitoring and evaluation and supervision of mental health services in the country
Development and review of national mental health strategic plan and programmes

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 8 of 82

Section 2. Mental health and why it is important

Rationale for addressing mental health:

Mental health has an important societal value

 mental and physical health are strongly interlinked
 mental health is an indivisible part of public health and contributes to the functions of society
and has an effect on overall productivity
 good mental health is an important resource for individuals, families, communities and nations
 mental health contributes to human, social and economic capital
 mental health concerns us all in our every day lives: in homes, schools, villages, streets,
workplaces and in leisure activities

Mental health problems constitute a heavy burden

 suffering
 disability
 mortality
 loss of economic productivity
 poverty
 family burden
 intergenerational burden-cycle of disadvantage
 intellectual and emotional consequences for children
 reduced access to and success of prevention and treatment programmes

Effective measures are available to treat mental illness

 social measures
 psychological treatments
 medicines
 occupational rehabilitation

Mental health, poverty and the International Development Targets

Mental illness contributes to poverty

 lost production from people being unable to work at all
 reduced productivity from people ill at work
 lost production from absenteeism
 accidents at work
 lost production from premature death
 loss of breadwinner for dependent family
 unwanted pregnancy
 untreated childhood disorders leads to educational failure, hence to unemployment and to
illness in adult life

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 9 of 82

  untreated parental disorders leads to childhood disorders and cycle of disadvantage

Action for mental health is a contributor to poverty reduction

 reduction of family burden
 maintenance of principal breadwinner
 educational attainment of children
 prevention of child labour
 compliance with physical health programmes, vaccination, hygiene, nutrition, medication
regimes for infectious diseases

Action for mental health impacts on International Development Targets.

 infant and child mortality will be reduced through improved treatment of post-natal
depression; reduced depression has proven links with increased attendance at ante-natal
and other clinics (such as vaccinations)
 maternal mortality is reduced through decreased suicides, cancer (less smoking, better
nutrition) and improved physical health through better mental well-being
 HIV infection rates for the 17-24 year old age group are reduced because improved mental
health reduces unsafe sex and levels of drug usage and addiction
 in addition, by causing somatic symptoms and by predisposing to frank physical illness,
mental disorders place a significant burden on general health systems all over the world

Defining mental health and mental illness

Positive mental health includes

 a positive sense of well-being
 individual resources including self esteem, optimism, and sense of mastery and coherence
 the ability to initiate, develop and sustain mutually satisfying personal relationships
 the ability to cope with adversity (resilience)
 these will enhance the person's capacity to contribute to family and other social networks, the
local community and society at large.

Mental health problems include

 psychological distress usually connected with various life situations, events and problems; ball
park prevalence: most of us!
 common mental disorders (e.g. depression, anxiety disorders in adults and emotional and
conduct disorders in children); ball park prevalence: 10-20% of adults in general population (but up to
40-50% in highly vulnerable populations), 30% of primary care attendees, 10% of children in general
population
 severe mental disorders with disturbances in perception, beliefs, and thought processes
(psychoses); ball park prevalence: 0.5% of general population
 substance abuse disorders (excess consumption and dependency on alcohol, drugs and
tobacco); ball park prevalence: very country specific.5% and above, growing
 abnormal personality traits which are handicapping to the individual and/or others; ball park
prevalence: not known
 progressive organic diseases of the brain (dementia); ball park prevalence of senile dementia: 5%
of over 65s and 20% of over 80s; hence demographic time bomb; tropical organic dementias: situation
specific; AIDS dementia growing problem

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 10 of 82

Causes and consequences of mental illness

Risk factors for mental disorders in adults

Social  life events (e.g. bereavement, job loss)
 chronic social adversity (macrosocial and microsocial including
unemployment, poverty, illiteracy, child labour, violence, war)
 lack of social supports
Psychological  poor coping skills
 low self esteem

Physical  nutrition
 infection
 trauma
 endocrine
 genetic

Consequences of mental illness in adults

 unemployment
 poverty
 marital breakdown
 intellectual, physical and cognitive damage to children
 physical illness
 death from physical illness
 suicide

Risk factors associated with mental disorder in children

Children with a mental disorder are more likely to
 live in low income families
 live with lone parents or have no parents
 have problems with police
 have bereavement
 have poor physical health
 have parents with no educational qualification
 have both parents unemployed
 have mentally ill parents

Consequences of untreated mental illness in children

 low academic achievement
 adult psychiatric problems
 unwanted pregnancy
 unhealthy lifestyles
 crime
 persistence of personality traits which handicap in the work place
 impaired parenting skills in later life; consequences for own children in later life-cycle of
deprivation

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 11 of 82

 Prevalence of Mental Disorders

Type of Disorder Prevalence across Prevalence in Sri Lanka

world
Psychological distress usually Most of us from time to Common
connected with various life time
situations, events and problems

Common mental disorders (e.g. 10% of children in Similar

depression, anxiety disorders in general population
adults and emotional and conduct
disorders in children) 10-20% of adults in Similar
general population (but
up to 40-50% in highly
vulnerable populations)
30-40% of primary care
30% of primary care attenders
attenders.

Severe mental disorders with 0.5% of general 2-3%

disturbances in perception, beliefs, population
and thought processes (psychoses)

Substance abuse disorders (excess Very country specific. Not known

consumption and dependency on 5% and above, growing.
alcohol, drugs and tobacco)

Abnormal personality traits which Not known but probably Not known
are handicapping to the individual around1-5%
and /or others

Progressive organic diseases of the Senile dementia: Similar

brain (dementia) 5% of over 65s and 20%
of over 80s; hence
demographic time bomb.

Tropical organic
dementias :
situation specific

AIDS dementia: growing

problem.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 12 of 82

Global Burden of Disease

The Global Burden of mental and neurological disorders

 neuropsychiatric disorders form 10.5% of global burden of disease (DALYs) in 1990 and is
expected to form 15% in 2020
 neuropsychiatric disorders form 5 of the 10 leading causes of disability
 neuropsychiatric disorders form 28% of years of life lived with a disability
 depression forms more than 10% of years of life lived with a disability
 suicide is the 10th leading cause of death

Additional Global Burden of behavioural problems

 unsafe sex 3.5%
 alcohol 3.5%
 tobacco 3%

Global Burden of some infectious diseases for comparison

 TB 3-4%
 Measles 3-4%

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 13 of 82

Section 3. Physical health and mental disorder

Fever and psychological symptoms

Presenting Complaints  fever

 confusion
 withdrawal
 hallucinations and delusions

Possible Causes  Malaria

 Typhoid
 TB
 HIV/AIDS

Associated Features  sweating

 dehydration
 physical injuries
 rope marks to hands and legs

Differential Diagnosis  Other acute infections

 Metabolic causes e.g., diabetes thyrotoxicosis
 Puerperal psychosis
 Brain Tumours

Urgent Investigations  Blood slide for malaria parasites

 Haemogram to rule out acute infections

Later Investigations  Typhoid – Widal

 ZN for sputum - if coughing
 Eliza for HIV if available

Management  Sedation (if patient is severely disturbed) otherwise wait to

establish cause then sedate as required
 Rehydrate as indicated
 Specific treatment as indicated e.g. malaria, TB etc.
 Antipyretics as indicated

Referral  Where no cause is evident and fever persists

 Gravely ill patient
 Seizures
 Severe dehydration
 Complications e.g., stroke, vomiting blood

Caution: Though fever is sometimes associated with mental illness, there are other instances
where organic factors might be the primary cause of symptoms including hypothyroidism
(depression), thyrotoxicosis (anxiety). In the early stages of HIV infection, many unexplained
symptoms may be the earliest indication of infection.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 14 of 82

Reproductive health

Family Planning  depression is common in men and women

 depressed women are less likely to access family planning services
 aggressive and substance abusing men are less likely to agree to
use condoms
 menstruation and menopausal symptoms are not well understood
in the community

Safe motherhood and  depressed women are less likely to

child survival - access antenatal and post natal care
- avoid nutritional deficiency: folate and iron
- immunise infants
- manage oral dehydrations of infant diarrhoea
- breastfeed successfully
- avoid smoking
- use treated bed nets
- combat violence and abuse
- avoid unsafe sex
 post natal depression is common
 mothers also get depressed after hysterectomies, abortion and still
birth
 if depression in parents is not treated, it leads to cognitive, physical
and psychological consequences for the children.
 perinatal psychoses affect the care of the child

Management of  depressed adults

STD/HIV/AIDS - have lower immunity
- less likely to comply with treatments
- less likely to attend clinics
 people with STDs need prompt treatment to avoid social isolation,
depression, suicidal tendencies and psychosis
 complaints of vaginal discharge with no infection are often clue to
depression or concern about sexual problems

Promotion of  depressed young adults less likely to be assertive and safe

adolescence and youth  unprotected sex leads to unwanted pregnancy, abortions,
health complications and depression and STDs
 substance abuse in young people damages reproductive health
Integration of services  mental health is intrinsic to reproductive health and services need
and quality of care to be integrated at primary and secondary levels
 cancers in the reproductive system can lead to stress and
depression
 menopause/andropause can cause stress and depression
Management of  depressed young women more vulnerable to Chlamydia because
infertility of lack of condom use and lowered immunity
 women who are unable to have children are considered social
misfits, isolated and discriminated against, leading to stress,
depression, suicide or promiscuity
Gender issues and  men with substance abuse, personality disorder or depression are
reproductive rights more likely to commit domestic violence, psychological and sexual
abuse.
 victims of FGM experience stress, depression, difficulty in child
birth, damage to child, still births and depression
 domestic violence precipitated by substance abuse leads to
depression

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 15 of 82

Child health

Integrated management of  physical illness in children have psychological, cognitive and

childhood disorders social consequences for child, so ensure management is
holistic
 childhood emotional and conduct disorders associated with
malnutrition, trauma and childhood physical illnesses
 sick children often have depressed mothers; assess and treat
the mother as well as the child

Strengthen health systems  health systems are not yet geared up to address childhood
mental disorders and learning disabilities

Promote adolescent and  children of depressed mothers are less likely to

youth health - be immunised
- be well nourished
- go to school
 treating maternal depression improves compliance with
vaccination, nutrition, oral rehydration and hygiene regimes to
reduce infectious diseases in children

Childhood mental and  low academic achievement

behavioural problems  adult psychiatric problems
result in:  unwanted pregnancy
 criminal behaviour
 personality traits which handicap in labour market
 lack of healthy lifestyles
 impact on health of next generation

Action  support parents and children

 treat depression in mothers as well as physical illnesses
 integrate the management of childhood illnesses, addressing
emotional and conduct disorders, dyslexia etc as well as
physical illnesses

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 16 of 82

Malaria and mental health

Good mental health and  use of treated bed nets for self, spouse and children
avoidance of malaria  control of and avoidance of mosquitoes
 boosted immunity and cytokine levels

Poor mental health and  depressed people are:

malaria - less likely to use treated bed nets
- have reduced immunity and cytokine levels
- less likely to comply adequately with treatment regimes for
themselves and their children

Diagnostic confusion  depressed people often present with headache, aches and
between malaria and pains, and general feeling of being unwell; they are often
depression diagnosed as having malaria despite normal blood film and no
fever

 recent research
- Wellcome/Kenya study: only 10% of suspected malaria
cases referred to district hospitals actually have malaria
- studies in health centres in Kenya showed no one at PHC
level was diagnosed with depression despite prevalence of
depression in PHC being around 30-40% of attenders; they
are mostly erroneously diagnosed with malaria instead

Consequences of wrong  repeated antimalarials

diagnosis of malaria - contributing to resistance
 reducing immunity
- by removing low grade parasitaemia
 adding to primary care workload
- by repeated consultations as “malaria” has not improved
 adding to costs incurred
- by unnecessary extra investigations and expensive new
drugs

Summary of various  most adults with depression do not have malaria, although
diagnostic overlaps they are erroneously treated for it
 but some adults with depression will also have malaria
 and some adults with malaria will also be depressed
 some adults with psychotic symptoms are in fact delirious from
malaria -cerebral malaria
 some adults with actual psychosis also have malaria

Possible associations
No malaria Malaria Cerebral
malaria
No depression or psychosis
Depression
Psychosis

Solution-accurate bio- If person presents with malaria type symptoms but no fever or
psycho-social assessment parasites, always assess for depression

 Adults : integrate the malaria diagnostic process for adults with

attention to identification and treatment of depression
 Children: always treat malaria symptoms in children with
antimalarials (because it is better to be mistaken than run the
risk of cerebral malaria in a child).
 NB There is now international debate about the
treatment of children who have negative blood films-please
follow the current MOH treatment guidelines for malaria.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 17 of 82

HIV and mental health

Mental health is highly relevant to human behaviour, including sexual behaviour. 29.5 million
people in Sub-Saharan Africa live with the HIV/AIDS virus. The impact of this is:

- a deteriorating quality of life for infected people

- additional strain on the already over-stretched health and social care system
- increased number of orphans
- decreased productivity
- reduced workforce
- increased poverty
- reduced life expectancy

Mental disorders  substance abuse, psychological conditions, personality disorders

increase risk can influence risk behaviours for HIV/AIDS infection

Plan mental health  develop self esteem, “how to say no”, anti-bullying/ coping
promotion in schools to: strategies; these help reduce subsequent substance misuse and
HIV infection
 reduce risk of contracting HIV with unprotected sex or drug use
 ensure girls are supported to be assertive and confident in ensuring
their sexuality and safety
 address particular difficulties where use of condoms is not widely
culturally accepted by men
 encourage abstention from drugs and harm reduction in those who
use drugs

Mental health influences  our emotions, beliefs, relationships with others and behaviour habits
immunity can influence our immune system
 long-term stress suppresses immune system to fight viral as well as
bacterial and parasitic infections and thus creating fertile
environment for pathogens
 mental health influences prognosis of HIV
- beliefs: believing that you must die from being HIV-infected can
trigger fear, decreases in immunity, avoidance of health
promoting behaviour leading to shorter life span
- grief: if held and not expressed it can trigger a decrease in
immunity and speed up the progression of disease

Mental health promotion  self-disclosure to trusted support provides a boost to immunity

improves prognosis of system functioning
HIV  self-assertiveness promotes the strength and quantity of natural
killer cells of the immune system

Body care:  regular sleep, good nutrition, physical exercise, breathing

HIV causes mental  HIV enters the brain shortly after first infection, leading to
disorders malignancy, opportunistic infections, vascular lesions and
encephalitis; in advanced HIV, there is chronic loss of general
cognitive function, leading to apathy, withdrawal and deterioration of
personality
 as in other major life threatening illness, from the impact of having a
fatal disease, e.g. adjustment disorder, persistent depression,
affective psychosis and suicidal risk

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 18 of 82

HIV damages the brain  AIDS Dementia Complex: characterized by marked impairment in
cognitive functioning, involving the ability to observe, concentrate,
memorize, and quickly and flexibly process information; can lead to
irritability, poor coordination, apathy and social withdrawal
 Cryptococcal meningitis, TB meningitis, opportunistic disease
 tumours

Management of HIV  life with HIV is no longer necessarily a shortened life.

 serious illness should motivate the individual to assess his/her prior
behaviour and create goals and strategies for the near future.
 thorough assessment and proper diagnosis
 bio-psycho-social aspects – treat the person, not the virus!

Medical Management

Antiretroviral regime  Triple therapy to suppress virus growth and prevent mutants
 Niverapine
 AZT
 Lamivudine

Treat other physical  e.g. TB

disease

Address psychological  acute stress, depression, suicidal ideation, substance abuse

issues at stage of  social isolation due to fear isolation, retreat
diagnosis  poor coping strategies that could suppress the immune system
 fear of stigma leading to secrecy, silence, guilt, this inhibits ability to
own their confusion, anger & grief.
 feeling of betrayal

Address psychological  anticipate or experience stigma

issues after diagnosis  changes in relationship patterns
 social isolation
 changes in productivity due to opportunistic infections
 concerns about accessibility of ARVs
 helplessness
 alienation

Psychological  pre & post counselling for HIV-testing.

interventions:  assess and treat depression
 psycho-education
 social skills development
 assertiveness training - coping strategies
 social support
 self acceptance, acceptance by family/friends and co-workers
 patient’s ability to access help both the emotional and problem-
solving realms e.g. expression of feelings, emotions, and thoughts,
and accessing information from others
 self-help groups
 treat the person as well as the virus

Advice for family and  personal safety

friends  HIV can only be transmitted by exchange of blood, semen, saliva
 safe sex

Prognosis improved by  social support

 ARVs
 healthy lifestyle
 treat any depression

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 19 of 82

TB and mental illness
People with TB may also have chronic depression. If this is not treated, it will reduce the likelihood
of the person complying with the medication regime

Tobacco and mental illness

Tobacco use is associated with depression and anxiety. If these are not treated, it reduces the
chance of the person being able to give up tobacco, leading to long term health risks.

Diabetes and mental illness

Type 1 diabetes (insulin dependent diabetes mellitus) occurs when the pancreas’ ability to secrete
insulin is markedly impaired. Hyperglycaemic symptoms emerge, generally before 20 years of age,
when 80-90% of islet cells fail to produce insulin.

Around 90% of diabetics have type II diabetes. Type II diabetes is characterised by peripheral
resistance to action of insulin and decreased insulin secretion, in spite of elevated glucose levels.
Patients with type II diabetes can often avoid or postpone the need for insulin treatment by a well
regulated diet or exercise programmes.

People with diabetes are more likely to have anxiety and depression than the general population.
(33-45% of people with diabetes have depression or anxiety). Such anxiety and depression, and
their associated social difficulties, makes the person with diabetes less likely to comply with their
dietary and exercise regimes as well as medication, and hence more prone to relapse and diabetic
crises. It is therefore crucial to address psychosocial issues for each person with diabetes, monitor
for the presence of depression and anxiety, and treat promptly.

Hypertension and mental illness

Hypertension can be caused by both physical (genetic predisposition, overweight, lack of exercise,
physical disease) and by stress related factors.

People with hypertension are more likely to have anxiety and depression, and its presence makes
the person less likely to comply with dietary and exercise regimes, as well as medication, and
hence more likely to relapse.

Myocardial infarction and mental illness

People with myocardial infarctions are more likely to have depression than the general population,
and if they do have depression, they are five times more likely to die in the six months following the
heart attack. Therefore it is crucial to assess and treat depression in people with heart disease.

People with depression are 1.5-2 times more likely to develop heart disease than people without
depression. Therefore effective treatment of depression is important for prevention of heart
disease.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 20 of 82

Cancer and mental illness
50% of people with cancer have depression and anxiety, mostly as a result of their cancer. This
prevalence increases to 80% with advanced cancer. The meaning of cancer is usually that of
possible death, with pain, possible disability or disfigurement, loss of independence and self
esteem, and possible loss of significant relationships. The normal response to cancer is similar to
the response when one hears catastrophic news of any kind: initial denial, an acute turmoil phase
or 1-2 weeks, and a period of adaptation, when hope returns with a treatment plan and clear
course of action. However, around half will develop clinical depression which impairs survival rates
and is therefore crucial to assess and treat.
In patients with advanced cancer, a sudden change in mood, behaviour or cognitive function
(delusions, hallucinations, agitation, confusion,) developing over a few hours or days is most likely
due to metabolic changes causing delirium. Many people with delirium in advanced cancer are
also depressed.

Trauma and mental illness

Depression, anxiety and psychosis contribute only a little to the overall prevalence of accidents.
Alcohol, drug abuse and severe personality disorders are major contributors to accidents.
Psychiatric disorders are found in 50% adults with accidental injuries.
25% of people presenting in casualty have high blood levels of alcohol. 65-85% accidents are
caused by human error, and certain personality characteristics (mild antisocial tendencies,
aggressiveness, impulsiveness, thrill and adventure seeking, type A behaviour) are associated with
involvement in accidents.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 21 of 82

Section 4. General management issues

Mental Health Promotion

Definition
 action to enhance the mental well-being and resilience of individuals, families, organizations
and communities
 action to empower/enable individuals, families, organizations and community to take control
of their own destiny/life

Mental health promotion goals

 enhance value and visibility of mental health at national, local and individual levels
 protect, maintain and improve mental health

Rationale for mental health Promotion

 positive mental health contributes to the human, social and economic capital of society-
increased productivity at different levels
 reduce the burden of mental illness
Mental health, poverty and the International Development Targets
 effective interventions are available- can be adapted to local situation
 international/regional/local collaboration is helpful

Strengthening Individuals
 increase emotional resilience through interventions designed to promote self-esteem
 the health worker can
o support parents, carers, individuals
o mobilise social support
o develop life skills e.g. effective communication, problem solving, parenting,
decision-making
o liaise with teacher
o encourage nutrition, vaccinations, hygiene, exercise

Strengthening communities
 increase social support, social inclusion and participation
 health worker can
o mobilise community
o set up self help groups
o initiate youth clubs
o improve community safety and safe environments
o give mental health education within maternal and child health clinics, schools,
youth groups, churches and mosques, workplace, police, prisons
o give talks to community leaders and others
o utilise media and events
o organise celebrations of World Mental Health Day to educate public

Strengthening Society
 develop enhancing structures to mental health e.g. policy development, policy guidelines
 reduce structural barriers to mental health e.g. unemployment, discrimination, access to
training, education and services
 World Mental Health Day

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 22 of 82

Prevention of Mental health problems

Primary Prevention
 support vulnerable people to stop them from getting ill
 health workers and CHWs can consider who is vulnerable and give/mobilise support e.g. to
carers

Secondary Prevention
 treat ill people quickly to reduce length of illness
 health workers and CHWs can be alert to symptoms of illness

Tertiary Prevention
 rehabilitate back to normal functioning
 health workers and CHWs can organise opportunities for rehabilitation

Summary of Mental health promotion and prevention approaches

 value mental health in same way as physical health

 there is no health without mental health
 value social supports
 create/facilitate social settings which enhance social networks
 give practical information
 not a waste of time to talk to someone for five minutes to strengthen them
 don’t just be a “next, next, next” health worker!
 inter-sectoral dialogue, linkages and cooperation

Vulnerable groups

Carers are very important and need support.

 adult carers
 child carers and children heading households

Women and Children

 children are a nation's most precious resource but services for children and adolescents are
often the least developed and resourced
 children's cognitive and emotional development is greatly influenced by the mental health of
their parents, especially mother, and particularly when mother is main carer
 in addition to general rates of adult illness, women experience higher rates of depression in
adulthood and higher rates of illness around time of childbirth. if untreated, these disorders
severely affect mother's relationship with children, which in turn damages child's cognitive and
emotional development and physical growth.
 particular childhood disorders for consideration include emotional and conduct disorders,
epilepsy, mental retardation, cerebral malaria, specific learning problems e.g. dyslexia
 all children with epilepsy should receive adequate medication (cheap but nonetheless in very
short supply in low income countries)
 school teachers should receive training in detecting and managing dyslexia, which is a
significant contributor to conduct disorder and depression in children and to antisocial
behaviour in adult life

Men who drink over safe limits.

Street children
 vulnerable to hunger, cold, economic and sexual exploitation, drug addiction, sexual
promiscuity, sexually transmitted diseases, criminalisation, imprisonment, sexual and physical
abuse
 health workers may be able to provide food, clothing, bedding and use contact to establish
relationship and help them rejoin family or bring them into homes, hostels schools, training
workshops and self financing projects e.g. running café

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 23 of 82

Orphanages and children's homes
Children's homes may contain children
 who have been abused and neglected
 whose home life has broken down
 children with
- developmental delay and retardation
- speech delay and problems in articulation
- fits
- severe overactivity or aggression
- chronic physical illness
- physical disability and handicap

Therefore care workers in children's homes need information, support and guidance in the
management of such problems.

Prisons
Mental illness and suicide are much more common in the prison population than in general
population. Therefore need systems to
 divert psychosis to hospital
 treat less severe illness in prison
 prison health care staff need to be familiar with assessment and management of mental
disorders
 prison staff need to be familiar with depression and management of suicidal risk

Intellectual handicap
Children and adults with intellectual handicap should be able, encouraged and supported to lead as
normal a life as possible. They have
 special educational needs
 social, physical and psychological needs
 specific neurological problems e.g. cerebral palsy, epilepsy. Essential medicines are needed
to ensure that intellectual deficit is not aggravated by these associated conditions

Older people
 risk of dementia increases exponentially with age over 65
 people with dementia are at risk of neglect (starvation, abuse, hypothermia, neglect of
physical illness).
.
Sensory impairment
 deafness is particularly associated with psychological symptoms
 profound early deafness interferes with speech and language development, emotional
development and educational attainment
 blindness causes difficulty and physical hazard
 Ii previously sighted people, blindness causes considerable distress and depression
.
Refugees and internally displaced people
Refugees and internally displaced people suffer from
 all the usual mental disorders such as depression, anxiety, somatic symptoms and psychosis,
which are all more common in refugees and IDPs because of the added stresses which they
encounter, and increased vulnerability from malnutrition etc,
 increased rates of post traumatic stress disorder.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 24 of 82

General Criteria for Referral from Health Centres to District Hospital Services

 delirium

 depression which does not respond to 8 weeks treatment with antidepressant

 suicidal person

 psychosis associated with violence

 psychosis complicated by substance abuse

 psychosis which does not respond to 2 weeks treatment with antipsychotics

 epilepsy for investigation , diagnosis and management plan

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 25 of 82

Health management information system (HMIS).

What is HMIS?

A system of collecting, recording, keeping and reporting including dissemination of health related
information (Mental Health).

It has a clear flow of communication from service point to decision/policy level and vice versa.

Structure and flow of HMIS:

Ministry
↑↓
Provincial
↑↓
District
↑↓
Health Centre or Dispensary

Health management information is used for

 planning for
- drug supply
- services required
- space for accommodation of patients
 evaluation of services
 communication

What information should be recorded for each patient?

 new patients :
- identification information
- diagnosis
- management plan
- home visits
 follow-up patients:
- all of above plus progress report

Use of HMIS at Health Centre and Dispensary level

 Health worker must be able to
- collate the information, make general interpretation of the information and use the information
to improve care.
- identify common mental health conditions in the area. (what kinds of illnesses, who is
vulnerable, when do people get ill, why do they get ill)
- follow-up those who miss their appointments
- psycho education to families and clients on adherence to medication
- ensure adequate medicine supply
- write summary reports for the DHMT

What information should be collated by Health Centres and Dispensaries and passed to the
District Health Management Team in the Quarterly Reports

 number of new cases for each diagnostic category

 number of follow-up patients for each diagnostic category
 number of home visits conducted
 number of outreach activities conducted
 medicines supplied and used
 problems encountered
 strategies for improvement

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 26 of 82

What diagnostic categories should be recorded in the patient register?
 Mixed anxiety –depression
 Depression
 Anxiety
 Post Traumatic Stress Disorder
 Acute psychosis
 Schizophrenia
 Bipolar disorder
 Drug abuse
 Alcohol abuse
 Childhood emotional disorders
 Childhood conduct disorders
 Learning disabilities
 Dementia
 Toxic Confusional States/Delirium
 Epilepsy
 Child abuse
 Other

What Demographic Information should be recorded in the patient register?

 Serial Number
 Name
 Age
 Date of birth
 Sex
 Occupation
 Marital status
 Religion
 Tribe
 Diagnosis-use above list to select from. Do not use a general term like neurosis, it should now
be possible to make a clearer diagnosis like depression or anxiety.
 Address
 Ten cell leader
 Date of attendance

Registering a case

Statistics are vital for planning including determining drug supply, service required, space for
patients accommodation, staff continuing education needs in order to improve the quality of mental
health care at different levels of service delivery. Statistics are also useful in evaluation of service s
provided.

There should be at least two register books, one for new patients (first attenders) and the other for
follow-up patients.

There should be a confidential medical file on each patient.

 Identification information
 Interviews conducted
 Diagnosis
 Management plan
 All patients’ files should be kept at the Health Centre.
 Proper filling system should be maintained to ensure patients’ records are not misplaced.
 Patient’s progress report including treatment should be written in his/her file.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 27 of 82

Roles and responsibilities at Health Centres

Clinical roles
 identification, diagnosis, treatment, follow up, referral
 address physical, psychological and social axes simultaneously
 use good practice guidelines
 use psychosocial skills
 rational prescribing of psychotropics and antimalarials
 reduce use of benzodiazepines
 conduct outreach and home visits
 liaise with community health workers
 liaise with families

Community mental health education

 liaise with and educate other sectors
 schools, police, prisons, NGOs, traditional healers, social welfare, community leaders, religious
groups

Skills
 attend CPD programmes in house and elsewhere
 develop psychosocial skills
 receive on job support, supervision and training from district level

Administration
 proper use of registration book and patient files
 collect data on consultations using diagnostic categories
 ensure availability of
 antidepressants, antipsychotics, anti-epileptics by auditing and ordering on time
 develop and maintain simple case registers of people with severe mental illness
 for follow up, relapse prevention, outreach and planning for medicines
 access transport for outreach
 communicate and liaise with district
 mental health coordinator, medical officer, clinical officer and nursing officer

Monitoring and evaluation

 monitor and evaluate routine consultations
 undertake operational research into locally relevant questions

Roles and responsibilities of District Health Management Team

 integrate mental health into work of DHMT.
 include mental health in annual plans of DHMT
 integrate mental health into supervision of health centres and dispensaries
 include mental health in quarterly reports to DMO and PMO.
 include mental health in intersectoral liaison.
 include mental health in HMIS,
 include mental health in R and D

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 28 of 82

Roles and responsibilities of District Mental Health Coordinator

Administration
 be a member of the district health management team
 be a member of the district PHC core team
 liaise with district health management team on all issues which affect the delivery of mental
health services at PHC and District level

Reporting and Planning

 prepare and submit reports to District Medical Officer of Health, Provincial Medical Officer of
Health and the Director of Mental Health on all issues which affect the delivery of mental health
services at PHC and District level
 contribute to District health plans
 contribute to inter-sectoral collaboration on mental health in areas of jurisdiction

Support staff in District MH IP and OP clinics

 ensure adequate functioning of key structural issues: lights, fans, water, toilets, beds, sheets,
food supply.
 perform clinical duties, with reference to clinical roles on page 28
 liaise with the families of mentally ill people
 ensure adequate medicine supply

Clinical and liaison

 manage a programme of / or deliver psychosocial treatments
 liaise with local police, prisons, child protection, schools and other institutions of learning,
religious bodies, NGOs, CBOs and traditional health practitioners
 communicate with primary care about referrals, referral criteria, shared care, information
transfer, medicines, guidelines
 support, supervise, monitor and evaluate district mental health services

Monitoring and Supervision

 support, facilitate, supervise local PHC clinics (health centres and dispensaries) to enable
them to undertake tasks listed on page 28
 monitor and evaluate their performance and suggest service improvements and developments

Community mental health education

 work with local media (radio, TV, electronic and print) to produce mental health programmes for
public airing and viewing.
 contribute to school health education programmes on positive mental health, life skills,
depression, epilepsy, substance abuse and other key and topical programmes
 prepare and distribute mental health educational materials

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 29 of 82

Making effective use of volunteer community health workers

Volunteer community health workers can

 create a link between PHC and Community
 create awareness
 identify families caring for sick people
 persuade families to bring relative to PHC
 supervise treatment by home visits
 monitor side effects
 detect of relapse at an early stage
 provide social support to vulnerable and sick
 immunisation
- look for depressed mothers
 antenatal and postnatal care
- look for depression and psychosis
 physical infections
- look for depression
 home based care for HIV and TB
- look for depression

Give CHWs information about

 symptoms and signs of depression, psychosis etc
 medication and side effects
 early detection of relapse
 how to mobilise support

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 30 of 82

Medication guidelines

Disorder Medication Dosages Side-effects

Epilepsy phenobarbitone
30mg start dose 60mg od  drowsiness,
and 100 mg max dose 100 mg bd  hyperactivity in
phenytoin children
50 and 100mg 50 to 200 mg
Carbamazepine 600 – 1200mg  drowsiness
200mg  hypertrophic
Na valprovate 800 – 1200mg  gums
200mg  liver function
abnormalities

Delirium first treat underlying

cause of delirium!

haloperidol 1.5 to 15 mg in 3 divided

1.5 mg doses. Half dose to  dry mouth ,
and 5 mg elderly!  blurred vision,
 constipation
Alcohol withdrawal, only  stiffness
diazepam for admitted patients: 10-
5 mg 50 mg a day in divided
doses

Dementia haloperidol 1.5mg in divided doses  dry mouth, blurred

only when 1.5mg per day. vision, constipation,
severe tremor.
restlessness, 1mg – 4mg  jaundice,
sleeplessness, Risperidone 2mg hypertension, skin
for short time reaction, cardiac
arrhythmia

Schizophrenia haloperidol 1.5 mg to 10 mg in 2

1.5mg divided doses  see above

chlorpromazine 100 to 400 mg in 2

25mg and 100 mg divided doses  see above
25 (1ml)
Fluphenazine every 4 weeks
decanoate first start dose (1/2ml)  tremor, akinesia,
25 mg/ml akathisia

Risperidone 2mg –
6mg
Acute haloperidol 1.5 mg to 10 mg in
psychotic 1.5 mg 2 divided doses a day  see above
disorder
chlorpromazine 100 mg to 400 mg in 2
25 mg and 100 mg divided doses a day
 see above
Risperidone 2mg-
6mg

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 31 of 82

Disorder Medication Dosages Side-effects

Bipolar haloperidol
disorder 1.5 mg 1.5 mg to 10 mg in two  see above
divided doses

chlorpromazine 100 to 400 mg in two

25 mg and 100 mg divided doses  see above

LiCO3 500mg –
750mg
Depression Imipramine 25mg 50 to 100mg in 2 divided  sedation, orthostatic
doses hypotension
Fluoxetine 20mg 20mg- 60mg  Sedation

Guide to start Phenobarbital treatment in children of 2 years and above and in adults

Age Age Age Age

2-5 yrs 6-10 yrs 11-14 yrs 15 yrs and
older

Start doses 30 mg 60 mg 60 mg 60 mg

After 4 weeks 45 mg 75 mg 90/100 mg 90/100mg

if still having fits
After 8 weeks 60 mg 90/100 mg 120 mg 120 mg
if still having fits
After 12 weeks 90 mg 120 mg 150 mg 150 mg
if still having fits
After 16 weeks refer 150 mg 180/200 180/ 200
if still having fits mg mg
After 20 weeks refer refer refer
if still having fits

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 32 of 82

Managing violent patients
How to handle agitated and aggressive patients

What is violence?  behaviour that intentionally inflicts, or attempt to inflict

physical harm
 behaviour that is threatening, hostile, or damaging in a
non-physical way

Causes of violence/aggression  impulsive aggression could be:

- environmental influences e.g. long standing
childhood victimization, violent lifestyle
- biological abnormality e.g. head injury
- genetically transmitted

Mental illness associated with  personality disorders

violence/aggression  substance abuse
 schizophrenia
 epilepsy
 mental retardation
 dementia
 head injuries-personality changes
 depression

What to do  take a quick brief history from relatives or friends to

identify:
- the cause and severity of violence
- rate of onset
- precipitating factors
- present and type of hallucination
- maladjustment

Management Guidelines  get help, exercise caution, allow for escape, identify
yourself
 try to calm the patient; speak gently (e.g. ‘I can see
that you are very upset’); avoid any sudden or
threatening action.
 listen to the patient
 do not loosen any bonds
 do not contradict or argue with the patient
 do not make false promises
 attempt to negotiate treatment (medication to calm
you)
 try to persuade the patient to surrender any weapon in
his/her possession
 do not attempt any heroics
 if the patient has to be restrained, ensure there is
enough help to control each limb without hurting the
patient
 approach from behind

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 33 of 82

Suicide Prevention

 Suicide is a major cause of death worldwide.

 It is widely under-reported and a large proportion of undetermined deaths are actual suicides.
 Most people who kill themselves are psychologically disturbed at the time.
 The UN has called for all countries to have a national suicide prevention programme.

Steps in pathway to suicide Specific actions to prevent suicide

Factors causing depression  policy on employment, education, social

welfare, housing, child abuse, children in care
and leaving care, substance abuse,
 media guidance, public education,
 school mental health promotion (coping
strategies, social support, bullying)
 workplace mental health promotion
 action on alcohol and drugs
 action on physical illness and disability

Depressive illness and other  support of high-risk groups.

illnesses with depressive thoughts  professional training about prompt detection,
assessment, diagnosis and treatment

Suicidal ideation  good risk management in primary care

 “building safety into the product” ie make sure
your assessments are throrough

Suicidal plans  taboo enhancement

 good practice guidelines on looking after
suicidal people in primary and secondary
care

Gaining access to means of suicide  controlling access to means of suicide

 e.g. guns, pesticides, paracetamol,
chloroquine

Use of means of suicide  prompt intervention

 good assessment and follow up of dsh and
suicide attempts

Aftermath  audit and learn lessons for prevention

 responsible media policy

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 34 of 82

Section 5. Specific mental and neurological disorders
Depression - F32#
A disorder of persistent low mood

Presenting complaints  the patient may present with one or more physical symptoms,
such as headache or ‘tiredness all the time’
 irritability
 anxiety, insomnia, worries about social problems such as
financial or marital difficulties, increased drug or alcohol use,
or (in a new mother) constant worries about her baby or fear
of harming the baby

Diagnostic features  low or sad mood  anxiety

 loss of interest or pleasure.  poor concentration
 disturbed sleep  suicidal thoughts or acts
 disturbed appetite  loss of self confidence
 guilt or low self-worth  fatigue or loss of energy
 pessimism or hopelessness  agitation or slowing of
about the future movement or speech
 decreased libido

Differential diagnosis  Acute psychotic disorder - F23 (if hallucinations] or delusions

[e.g. strange or unusual beliefs] are present)
 Bipolar disorder - F31 (if patient has a history of manic
episodes [e.g. excitement, rapid speech, elevated mood]).
 Alcohol misuse - F10 or Drug use disorder -F11# (if heavy
alcohol or drug use is present).
 Unexplained somatic complaints, F44

Information for patient and  depression is a common illness and effective treatments are
family available.
 depression is not weakness or laziness.

Advice and support to  assess risk of suicide: ask a series of questions about suicidal
patient and family ideas, plans and intent (e.g. does the patient think life is not
worth living? Has the patient thought they would rather be
dead? Has the patient often thought of death or dying? Does
the patient have a specific suicide plan? Has he/she made
serious suicide attempts in the past? Close supervision by
family or friends, or hospitalization may be needed. Ask about
risk of harm to others. )
 identify current life problems or social stresses.
 plan short-term activities, which give the patient enjoyment or
build confidence.
 advise to stop alcohol use.
 support the development of good sleep patterns and
encourage a balanced diet.
 encourage the patient to resist pessimism and self-criticism
and not to act on pessimistic ideas (e.g. ending marriage,
leaving job.
 if physical symptoms are present, discuss the link between
physical symptoms and mood (see ‘Unexplained somatic
symptoms — F45’).

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 35 of 82

Medication  Imipramine is a very effective antidepressant
- use 50-100 mg in one or two doses
- start with 25 mg,
- build up to the normally effective dose of 50 mg over
seven to 10 days.
- if the patient is suicidal, only dispense a few days at a
time, and involve the relative to supervise, or admit to
hospital if possible
- in elderly people or patients with cardiac disease, caution
is advised.
- continue full-dose antidepressant medication for at least
four to six months after the condition improves to prevent
relapse.
- withdraw antidepressant medication slowly.
 Fluoxetine for mild to moderate depression

Referral to district hospital  if there is a significant risk of suicide or danger to others,

psychotic symptoms or severe agitation.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 36 of 82

Anxiety - F41
Generalized anxiety and Panic disorder. A disorder of persistent or recurrent anxiety, with no
significant low mood. If low mood is prominent, follow depression guideline.

Presenting complaints  physical symptoms, e.g. headache, dizziness, shortness of

breath, or a pounding heart
 insomnia
 unexplained, intense fear.

 when occurring consistently, it is diagnosed as generalised

anxiety disorder, and when occurring in episodes, it is
diagnosed as panic disorder.

Diagnostic features  multiple symptoms of anxiety or tension include:

- physical arousal (e.g. dizziness, sweating, a fast or
pounding heart, a dry mouth, stomach pains, sensations
of choking, or chest pains)
- mental tension (e.g. worry, feeling tense or nervous, poor
concentration, fear that something dangerous will happen
and the patient won’t be able to cope)
- physical tension (e.g. restlessness, headaches, tremors,
or an inability to relax).
 a first panic attack is often such a terrifying event that it often
leads to fear of another panic attack; this may provoke new
attacks.
 history and medical examination should rule out medical
conditions that may cause similar symptoms (e.g. arrhythmia,
thyrotoxicosis, cerebral ischaemia, coronary disease, and
asthma

Differential diagnosis  Depression - F32# (if low or sad mood is prominent).

 Alcohol misuse - F10# or Drug-use disorders - F11#
 Certain physical conditions (e.g. thyrotoxicosis) or
medications may cause anxiety symptoms

Information for patient and  stress, worry and panic have both physical and mental
family effects, are quite common and can be treated
 learning skills to reduce the effects of stress are the most
effective relief
 anxiety often produces frightening physical symptoms: chest
pain, dizziness or shortness of breath are not necessarily
signs of a physical illness; they will pass when anxiety is
controlled
 mental and physical anxiety reinforce each other.
concentrating on physical symptoms will increase fear

Advice and support to  encourage the patient to use relaxation methods daily and to
patient and family do exercises to reduce physical symptoms of tension
 avoid using alcohol or cigarettes to cope with anxiety

Medication  medication is not common used in the management of

generalized anxiety; it may be used, however, if a significant
anxiety symptom persists
- Imipramine 25-75 mg a day in divided doses may be
helpful (especially if symptoms of depression are
present).
- No diazapam, or other benzodiazepines should ever be
used. They lead to misuse and addiction!!

Referral to district hospital  refer to district if symptoms are severe for more then 6
months.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 37 of 82

Unexplained somatic complaints - F45
A depressive disorder which presents with unexplained somatic symptoms

Presenting complaints  any physical symptom may be present

 symptoms may vary widely
 complaints may be single or multiple and may change over
time

Diagnostic features  medically unexplained physical symptoms; a full history and

physical examination are necessary to determine this
 frequent medical visits in spite of negative investigations
 symptoms of depression and anxiety are common
 some patients may be primarily concerned with obtaining
relief from physical symptoms, others may be worried about
having a physical illness and be unable to believe that no
physical condition is present (hypochondriasis)

Differential diagnosis Drug abuse— F11#

 if low or sad mood is prominent, see ‘Depression - F32#;
people with depression are often unaware of everyday
physical aches and pains

Generalized anxiety disorder - F41.1 if anxiety symptoms are
prominent

Acute psychotic disorders - F23 if strange beliefs about

symptoms are present, e.g. belief that organs are decaying
 an organic cause may eventually be discovered for the
physical symptoms
 psychological problems can co-exist with physical problems.

 depression, anxiety, alcohol misuse or drug use disorders

may co-exist with unexplained somatic complaints.

Information for patient and  stress often produces or exacerbates physical symptoms
family  cure may not always be possible; the goal should be to live
the best life possible even if symptoms continue

Advice and support to  advise patients not to focus on medical worries

patient and family  discuss emotional stresses that were present when the
symptoms arose
 explain the links between stress and physical symptoms and
how a vicious cycle can develop
 relaxation methods can help relieve symptoms related to
tension (such as headache, neck or back pain)
 encourage physical exercises and enjoyable activities; the
patient need not wait until all symptoms are gone before
returning to normal routines.

Medication  If depression or severe anxiety is also present:

- Imipramine 25-100mg a day in divided doses

Referral to district hospital  patients are best managed in dispensary or health centre

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 38 of 82

Dissociative (conversion) disorder - F45 (formerly Hysteria)
Dissociative disorder is a disorder of sudden dramatic symptoms which are inconsistent with known
disease, but are stress induced and not malingering. It can present either singly or en masse, e.g.
in high school students

Presenting complaints  patients exhibit unusual or dramatic physical symptoms, such

as seizures, amnesia, trance, loss of sensation, visual
disturbances, paralysis, aphonia, identity confusion or
‘possession’ states.
 the patient is not aware of their role in their symptoms - they
are not malingering.

Diagnostic features  onset is often sudden and related to psychological stress,

conflict or difficult personal circumstances, e.g. marital
difficulties, school related problems
 look for physical symptoms that are:
- unusual in presentation
- not consistent with known disease.
 in acute cases, symptoms may:
- be dramatic and unusual
- change from time to time
- be related to attention from others
 in more chronic cases, patients may appear unduly calm in
view of the seriousness of the complaint

Differential diagnosis  carefully consider physical conditions that may cause

symptoms.
 a full history and physical (including neurological) examination
are essential; early symptoms of neurological disorders (e.g.
multiple sclerosis) may resemble conversion symptoms
 if other unexplained physical symptoms are present, see
‘Unexplained somatic complaints — F45’.
 Depression - F32#: atypical depression may present in this
way

Information for patient and  physical or neurological symptoms often have no clear
family physical cause; symptoms can be brought about by stress.
 symptoms usually resolve rapidly (from hours to a few weeks)
leaving no permanent damage.

Advice and support to  encourage the patient to acknowledge recent stresses or

patient and family difficulties (though it is not necessary for the patient to link the
stresses to current symptoms)
 give positive reinforcement for improvement; try not to
reinforce symptoms
 advise the patient to take a brief rest and relief from stress,
then return to usual activities
 advise against prolonged rest or withdrawal from activities

Medication  no tranquilizers
 10mg iv diazepam may rapidly terminate an acute
dissociative state.
 do not continue the diazepam; if depressed, follow depression
guideline

Referral to district hospital  if unsure of the diagnosis, consider referral to district hospital

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 39 of 82

Alcohol misuse - F10
A disorder of continued excess consumption of alcohol

Presenting complaints  physical complications of alcohol use (e.g. ulcer, gastritis,

liver disease, hypertension)
 accidents or injuries due to alcohol use
 poor memory or concentration
 evidence of self-neglect (e.g. poor hygiene)
 failed treatment for depression
 depressed mood
 nervousness
 insomnia

There may also be:

 marital problems, domestic violence, child abuse or neglect,
missed work
 signs of alcohol withdrawal (sweating, tremors, morning
sickness, hallucinations, seizures).

Diagnostic features  heavy alcohol use (e.g. 3 or more beers a day, and local
home-made brews, over 28 units per week)
 physical problems (e.g. liver disease, gastrointestinal
bleeding)
 psychological harm (e.g. depression or anxiety due to
alcohol), or has led to harmful social consequences (e.g. loss
of job).
 strong desire or compulsion to use alcohol
 difficulty controlling alcohol use
 withdrawal (anxiety, tremors, sweating) when drinking is
ceased
 tolerance (e.g. drinks large amounts of alcohol without
appearing intoxicated)
 continued alcohol use despite harmful consequences.

Differential diagnosis  symptoms of anxiety or depression may occur with heavy

alcohol use. Assess and manage symptoms of depression or
anxiety if symptoms continue after patient stops drinking. See
Depression -F32#’ or Anxiety - F41

Information for patient and  alcohol dependence is an illness with serious consequences
family  ceasing or reducing alcohol use will bring mental and physical
benefits
 drinking during pregnancy may harm the baby
 because abrupt abstinence can cause withdrawal symptoms,
medical supervision is necessary

Advice and support to  discuss costs and benefits of drinking from the patient’s
patient and family perspective
 give clear advice on changing drinking habits

Medication  Thiamine (150 mg per day in divided doses) should be given,

if available, orally for one month
 Diazepam for 3 days (day 1 20 mg, day 2 10 mg, day 3 5 mg)
incase of severe withdrawal symptoms.

Referral to district hospital  if severe withdrawal symptoms (fits, severe trembling, very ill)

Community action  case finding, community education

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 40 of 82

Drug misuse disorders - F11#
A disorder of repeated consumption of illegal drugs

Presenting complaints  family may request help before the patient (e.g. because the
patient is irritable at home or missing work.)
 patients may have depressed mood, nervousness or
insomnia
 patients may present with a direct request for prescriptions for
narcotics or other drugs, a request for help to withdraw or for
help with stabilizing their drug use
 they may present in a state of intoxication or withdrawal or
with physical complications of drug use, e.g. abscesses or
thromboses

Signs of drug withdrawal  opioids: nausea, sweating, hallucinations

include:  sedatives: anxiety, tremors, hallucinations
 stimulants: depression, moodiness

Diagnostic features  drug use has caused

- physical harm (e.g. injuries while intoxicated),
- psychological harm (e.g. symptoms of mental disorder
due to drug use)
- has led to harmful social consequences (e.g. loss of job,
severe family problems, or criminality)
 habitual and/or harmful or chaotic drug use
 difficulty controlling drug use
 strong desire to use drugs
 tolerance (can use large amounts of drugs without appearing
intoxicated)
 withdrawal (e.g. anxiety, tremors or other withdrawal
symptoms after stopping use)

Differential diagnosis  alcohol misuse - F10 often co-exists; polydrug use is common
 symptoms of anxiety or depression may also occur with heavy
drug use; if these continue after a period of abstinence (e.g.
about four weeks) see ‘Depression - F32#’ and ‘Generalized
anxiety - F41.1
 psychotic disorders -F23, F20
 delirium - F05

Information for patient and  drug misuse is a chronic, relapsing problem and controlling or
family stopping use often requires several attempts; relapse is
common
 ceasing or reducing drug-use will bring psychological, social
and physical benefits

Advice and support to  using some drugs during pregnancy risks harming the baby
patient and family  for intravenous drug-users, there is a risk of transmitting HIV
infection, hepatitis or other infections carried by body fluids
 discuss appropriate precautions (e.g. use condoms, and do
not share needles, syringes, spoons, water or any other
injecting equipment)

Medication  don’t give medication; drug users try to mislead you and will
try to get a prescription.

Referral to district hospital  if severe withdrawal symptoms (fits, severe trembling, very ill)

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 41 of 82

Acute psychotic disorders - F23

Presenting complaints  patients may experience:

- hallucinations, e.g. hearing voices when no one is around
- strange beliefs or fears
- apprehension, confusion
 families may ask for help with behaviour changes that cannot
be explained, including strange or frightening behaviour (e.g.
withdrawal, suspiciousness, threats)
 young adults may present with persistent changes in
functioning, behaviour or personality (e.g. withdrawal) but
without florid psychotic symptoms.

Diagnostic features  recent onset of:

- hallucinations (false or imagined sensations, e.g. hearing
voices talking about the person when no one is around).
- delusions (firmly held ideas that are often false and not
shared by others in the patient’s social, cultural or ethnic
group, e.g. patients believe they are being poisoned by
neighbours, receiving messages from television, or being
looked at by others in some special way).
- disorganized or strange speech
- agitation or bizarre behaviour

Differential diagnosis  Delirium - FO5 for other potential causes

 Schizophrenia - F20# if psychotic symptoms are recurrent or
chronic
 Bipolar disorder - F31 if symptoms of mania (e.g. elevated
mood, racing speech or thoughts, exaggerated self-worth) are
prominent
 Depression (depressive psychosis) - F32# if depressive
delusions are prominent, and if voices are talking to the
person instead of about them
 Epilepsy E#
 Alcohol withdrawal
 Drug psychosis

Information for patient and  acute episodes often have a good prognosis, but long-term
family course of the illness is difficult to predict from an acute
episode
 advise patient and family about the importance of medication,
how it works and possible side effects
 continued treatment may be needed for several months after
symptoms resolve

Advice and support to  ensure the safety of the patient and those caring for him/her:
patient and family - family or friends should be available for the patient if
possible
- try to ensure that the patient’s basic needs (e.g. food,
drink, shelter and safety) are met
 minimize stress
 do not argue with psychotic thinking (you may disagree with
the patient’s beliefs but do not try to argue that they are
wrong)
 if there is a significant risk of suicide, violence or neglect,
admission to hospital or close observation in a secure place
may be required; if the patient refuses treatment, legal
measures may be needed
 patient should start his normal activities (like work) after

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 42 of 82

 recovery
Medication  the drugs available on the essential drug list, which could be
used for this condition, include
- Chlorpromazine: 25mg, and 100 mg
- Haloperidol: 1.5mg
- other available medication (in the district hospital only):
Thioridazine 25 mg and 100 mg

 Prescription guidelines:
Haloperidol: 5 to 10 mg per day in 2 divided doses
Risperidone 2mg-6mg a day in 2 divided doses

 anti-anxiety medication such as diazepam may also be used

for the short term in combination with neuroleptics to control
acute agitation

 continue antipsychotic medication for at least six months after

symptoms resolve. Close supervision is usually needed in
order to encourage the patient to keep taking the medicine

 be alert to the risk of concurrent use of street drugs ( heroin,

cannabis) and alcohol

 monitor for side-effects of medication:

- the common side effect is Parkinsonian symptoms (e.g.
tremor, akinesia)
- treatment of side effects: may be managed with oral
promethazine 25 to 50 mg daily in one or two doses,
consider also dosage reduction
- acute dystonias or spasms may be managed with oral or
injectable promethazanine
- Akathisia (severe motor restlessness) may be managed
with dosage reduction of the neuroleptic medication

Referral to district hospital  referral should be made under the following conditions:
- as an emergency, if the risk of suicide, violence or neglect
is considered significant
- if there is non-compliance with treatment, problematic
side effects, failure of community treatment, or concerns
about co-morbid drug and alcohol misuse.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 43 of 82

Bipolar disorder F31 (manic depressive disorder)

Presenting complaints  patients may have a period of mania or excitement or severe

depression (see below)
 the patient may be brought in by relatives or police or
community leader because of the patient’s lack of insight that
he is ill

Diagnostic features  periods of mania with:

- increased activity and energy
- elevated mood
- decreased need for sleep
- increased importance of self

 periods of depression with:

- low or sad mood
- loss of interest or pleasure
- disturbed sleep
- guilt or low self-worth
- fatigue or loss of energy
- poor concentration
- disturbed appetite
- suicidal thoughts or acts.

 either depression or mania may be present; episodes may

change often; in severe cases, patients may have
hallucinations (hearing voices or seeing visions) or delusions
(strange or illogical beliefs) during periods of mania or
depression

Differential diagnosis  Alcohol misuse — F10 and Drug use disorder — F11# can
cause similar symptoms and both conditions may be present
 Schizophrenia

Information for patient and  sudden changes in mood and behaviour can be symptoms of
family the illness
 effective treatments are available; long-term treatment can
prevent future episodes
 if left untreated, manic episodes may become disruptive or
dangerous; manic episodes often lead to loss of job, legal
problems, financial problems or high-risk sexual behaviour;
patient should be brought to clinic when first symptoms occur

Advice and support to  during depression

patient and family - assess risk of suicide:
- close supervision by family or friends may be needed
- ask about risk of harm to others. (See ‘Depression -
F32#’).

 during manic periods:

- advise caution regarding impulsive or dangerous
behaviour
- close observation by family members is often needed
- if agitation or disruptive behaviour is severe,
hospitalization may be required

 describe the illness and possible future treatments

 encourage the family to consult, even if the patient is
reluctant
 work with patient, family and community to identify early
warning symptoms of mood swings, in order to avoid major

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 44 of 82

 relapse

Medication  Haloperidol: 4.5 mg –15 mg a day in 3 divided doses or

 Chlorpromazine: 100 mg to 400 mg a day in 2 divided
doses
- the doses should be the lowest possible for the relief of
symptoms, although some patients may require higher
doses

 Add Promethazine 25 to 100 mg a day in divided doses if

the patient has side effects dystonic reactions (muscle
spasms) or marked extrapyramidal symptoms (e.g. stiffness
or tremors).

 Valium 10 to 30 mg in divided doses may also be used

combined with chlorpromazine or haloperidol to control acute
agitation.

 Antidepressive medication is often needed during phases of

depression but can precipitate mania when used alone (see
Depression — F32#)

Referral to district hospital  if there is a significant risk of suicide or disruptive behaviour

and if treatment doesn’t help

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 45 of 82

Schizophrenia - F20

Presenting complaints  strange behaviour

 reports of hearing voices
 strange beliefs (e.g. having supernatural powers or being
persecuted)
 difficulties with thinking or concentration
 extraordinary physical complaints (e.g. having animals or
unusual objects inside one’s body)
 problems or questions related to anti-psychotic medication
 problems in managing work, studies or relationships.
 families may seek help because of apathy, withdrawal, poor
hygiene, or strange behaviour.

Diagnostic features  Chronic recurrent problems longer than 4 weeks with the
following features:
- social withdrawal
- low motivation, interest or self-neglect
- disordered thinking (exhibited by strange or disjointed
speech).
 Periodic episodes of:
- agitation or restlessness
- bizarre behaviour
- hallucinations (false or imagined perceptions e.g. hearing
voices)
- delusions (firm beliefs that are often false e.g. patient
believes they are an important person; may believe they
are a special prophet, receiving messages from television
or radio, being followed or persecuted).

Differential diagnosis  Depression - F32# (if low or sad mood, pessimism and/or
feelings of guilt)
 Bipolar disorder - F31 (if symptoms of mania excitement,
elevated mood, exaggerated self-worth are prominent)
 Alcohol misuse - F10 or Drug use disorders -F11#,
chronic intoxication or withdrawal from alcohol or other
substances (like banghi) can cause psychotic symptoms
 patients with chronic psychosis may also abuse drugs and/or
alcohol

Information for patient and  symptoms may come and go over time
family  medication will reduce the current difficulties and prevent
relapse
 stable living conditions (housing, support of relatives) are
important for effective recovery
 support of the relative is essential for compliance with
treatment and effective rehabilitation

Advice and support to  discuss a treatment plan with family members

patient and family  explain that drugs will prevent relapse, and inform patient of
side effects
 encourage patient to function at the highest reasonable level
in work and other daily activities
 minimize stress and stimulation:
- do not argue with psychotic thinking
- avoid confrontation or criticism
- during periods when symptoms are more severe, rest and
withdrawal from stress may be helpful
 keep the patient’s physical health, including health promotion
and smoking, under review

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 46 of 82

Medication  The drugs available on the essential drug list, which could be
used for this condition, include Chlorpromazine 25mg, and
100 mg, Haloperidol 1.5mg.
 Other available medication: Thioridazine 25 mg and 100 mg
and Fluphenazine deaconate 25mg/ml.

Prescription guidelines:
 Chlorpromazine: 100 to 400 mg a day in 3 divided doses.
Maintenance dose: 100 to 200 mg daily
 Haloperidol: 5 to 10 mg per day in 2 divided doses.
Maintenance dose 1.5 to 5 mg daily
 Risperidone 2-6 mg per day. Maintenance dose: 2-4mg
daily

 Fluphenazine deaconate: start with test dose 12.5mg, if no

side effects, give 25-50 mg every 4 to 6 weeks

 anti-anxiety medication such as diazepam may also be used

for the short term in combination with neuroleptics to control
acute agitation
 continue antipsychotic medication for at least six months
after symptoms resolve; close supervision is usually needed
in order to encourage the patient to keep taking the medicine
 monitor for side-effects of medication: a common side effect
is Parkinsonian symptoms (e.g. tremor, akinesia) may be
managed with oral promethazine 25 to 50 mg daily in one or
two doses, consider also dosage reduction
 acute dystonias or spasms may be managed with oral or
injectable promethzanine
 akathisia (severe motor restlessness) may be managed with
dosage reduction

Referral to district hospital  if the patient doesn’t respond on the medication and there is
a danger for the patient and the relatives if managed at home
(e.g. if patient is very aggressive)

Community action  rehabilitation

 compliance of treatment
 relatives support
 identification of other patients suffering from schizophrenia

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 47 of 82

Epilepsy -
Complex partial seizures/ generalized tonic clonic (kifafa)

Presenting complaints  irritability

 afraid for no reasons
 walking around picking objects
 dizziness
 seeing spot of light
 abnormal smell or taste
 tickling , burning sensation
 strange feeling in epigastria
 loss of consciousness
 jerking movement of face, body and limbs
 tongue bite and froth
 incontinence of urine or faeces
 headache
 confusion, memory disturbance

Diagnostic features  complex partial seizures:

- aura
- changed perception
- automatic movements (lip smacking, chewing)
- impaired consciousness but no complete loss
- confusion
- amnesia

 generalized tonic clonic:

- complete loss of consciousness
- sudden onset (no aura)
- tonic and clonic phase (jerking movements)
- tongue bite
- incontinence for urine and sometimes faeces
- amnesia
- post-ictal confusion

 the diagnosis of epilepsy depends on a good and clear

history; you may not have a chance to see an actual fit in
many of your patient, so objective evidence from the family-
member is absolutely crucial

 Status epilepticus: seizure persists for at least 20 minutes.

Emergency!

Differential diagnosis  syncope, fainting

 hypoglycaemia.
 psycho-genic seizures
 panic attack, shortness of breath, choking, chest pain.
 tetanus

Information for patient and  epilepsy can be treated successfully

family  drugs have to be taken for many years
 discontinuation of medication may result in recurrence of
seizures
 sudden discontinuation may result in life threatening status
epilepticus
 it may take several days before the drugs show effect
 patient should not be close to fire
 do not combine with herbal drugs
 disease is not contagious

 child should go to school and have normal life

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 48 of 82

Advice and support to  do not over protect the child.
patient and family  talk about epilepsy in the family and in the community
 patient with epilepsy can marry
 epilepsy is treatable and can be controlled effectively with
regular medication; Phenobarbital is cheap, effective,
available and therefore the drug of choice

Medication  Carbamazepine: dose not to exceed 120 mg daily in divided

doses. Side effect: drowsiness, neurological side effects
 Phenytoin: dose 50-100mg daily; side effect: - hypertrophy
of gums, drowsiness, ataxia, nystagmus

Status epilepticus:
 monitor pulse, respiration and blood pressure; prevent
aspiration, maintain clear airway
 Diazepam iv (very slowly, 1mg/min) or rectally
- children under 5 years: up to 5 mg
- children 5 to 10 years: 10 mg
- older children: 15 mg
- adults: 20 mg

Referral to district hospital  Children under 5 with fits should be referred to the district
hospital for further examination; in case of frequent fits start
treatment already; they will be referred back to the health
worker for the follow up.

 Patients above 5 years: if patient doesn’t respond on

Phenobarbital, phenytoin or a combination of the two refer to
the district hospital (see schedule on medication sheet)

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 49 of 82

Dementia - F00

Presenting complaints  failing memory, disorientation, gradual change in behaviour

and behaviour disturbance, wandering or incontinence
 patients may complain of forgetfulness, decline in mental
functioning, or feeling depressed

Diagnostic features  slow decline in memory, initially for recent events, names,
faces of relatives
 decline in thinking, orientation and speech
 patients may have become disinterested and don’t take
initiative
 decline in everyday functioning (e.g. dressing, washing,
cooking)
 patients may become easily upset, tearful or irritable
 common with advancing age (5% over 65 years; 20% over
80 years), very rare in youth or middle age
 ask history from relatives!
 tests of memory and thinking include:
- ability to repeat the names of three common objects
immediately and recall them after three minutes
- ability to accurately identify the day of the week, the
month and the year
- ability to give their full name and names of their relatives

Differential diagnosis  depression may cause memory and concentration problems

similar to those of dementia, especially in older patients; if
low or sad mood is prominent, see ‘Depression — F32#’.

 common treatable causes of sudden worsening of memory

disturbance and confusion in elderly:
- urinary tract, chest, skin or ear infection
- onset or exacerbation of cardiac failure
- prescribed drugs, especially psychiatric and
antiparkinsonian drugs and alcohol
- cerebro-vascular ischaemia or hypoxia.
- acute constipation

Information for patient and  dementia is frequent in old age.

family  memory loss and confusion may cause behaviour problems
 Memory loss usually proceeds slowly; physical illness or
other stresses can increase confusion
 patient might get more confused when put in a strange
environment

Advice and support to  patient needs a good diet and exercise.

patient and family

Medication  Haloperidol: 1.5 mg a day, or

 Chlorpromazine: 25-50 mg a day may sometimes be needed
to manage some behavioural problems (e.g. aggression or
restlessness).
 behavioural problems change with the course of the
dementia; therefore, withdraw medication every few months
on a trial basis to see if it is still needed
 don't give promethazine (can cause delirium in elderly)
 don't combine haloperidol with amitriptyline

Referral to district hospital  refer to a district hospital if complex physical problem

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 50 of 82

Delirium - F05
Acute organic confusional states caused by physical illness)

Presenting complaints  families may request help because patient is confused or

agitated.
 patients may appear uncooperative or fearful
 delirium may occur in patients hospitalized for physical
conditions

Diagnostic features  acute onset, usually over hours or days, of:

- confusion (patient appears - loss of orientation
disoriented, struggles to - visions or illusions
understand surroundings) - suspiciousness
- clouded thinking or awareness - wandering attention
- poor memory - visual hallucinations
- withdrawal from others - disturbed sleep (reversal of
- agitation sleep pattern).
- emotional upset - autonomic features e.g.
sweating, tachycardia
 symptoms often develop rapidly and may change from hour
to hour.
 delirium may occur in patients with previously normal mental
function or in those with dementia; milder stresses (e.g.
medication and mild infections) may cause delirium in older
patients or in those with dementia

Differential diagnosis  identify and correct possible, underlying physical causes of

delirium, such as:
- infection, check temperature: e.g. malaria, HIV/Aids, typhoid,
pneumonia, urinary tract infection, especially in the elderly
- alcohol intoxication or withdrawal such as in people in police
custody, people admitted following RTAs
- drug intoxication, overdose or withdrawal (including prescribed
drugs)
- metabolic changes (e.g. liver disease, dehydration,
hypoglycaemia)
- head trauma
- hypoxia
- epilepsy.
 if symptoms persist and no physical cause identified, see
Acute psychotic disorders - F23

Information for patient and  strange behaviour or speech and confusion can be
family symptoms of a physical illness.

Advice and support to  take measures to prevent the patient from harming
patient and family him/herself or others
 presence of relatives helps to reduce confusion
 frequently reminding the patient the time and place will
reduce disturbed orientation
 hospitalization may be required because of agitation or
because of the physical illness, which is causing delirium.
mortality rate of patients with delirium is high

Medication  treat the underlying physical cause of delirium

 Haloperidol: 1.5 to 15 mg a day in three divided doses;
(give half the dose to elderly!)
 beware of drug side-effects (drugs with anticholinergic action
(promethazine=phenargan) and antiparkinsonian medication
can make the delirium worse or may cause delirium)
 in case of alcohol withdrawal syndrome: give
Diazepam 10 - 50 mg a day in divided doses.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 51 of 82

Referral to district hospital  for physical investigation and treatment.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 52 of 82

Mental retardation/learning disabilities -

Mental retardation is not an illness

Presenting complaints  parents may complain that child doesn’t develop like other
children.
 “milestones” delayed:
- laughing (6-8 weeks normally)
- sitting (6-8 months normally)
- crawling (9 month normally)
- walking (1 year to 1 ½ year)
- talking (first words 9 month to 1 years)
- simple sentences (2 to 3 years)

Diagnostic features IQ below average:

Mild Moderate Severe Profound
50-70 35-50 20-35 <20

 no toilet training possible, or toilet training delayed

 can not start school or poor school performance
 can not take care of him/her self (washing, dressing)

Differential diagnosis  role out physical diseases

 epilepsy: many retarded children have epilepsy

Information for patient and  give parents the proper information (tell the truth, don’t
family promise anything what can not be done!)
 the child will develop, but at a low pace, and will not develop
as a normal child

Advice and support to  the child should live an “as normal as possible” life, should
patient and family not be locked in the house; proper feeding, healthy diet
 teach child normal day to day things like washing, dressing,
sweeping, step by step

Medication  if child has fits, treat fits - see epilepsy guideline

 if very restless and serious behaviour problems:

Haloperidol: 1.5 mg ½ tbl od (not when child gets fits)
or
Chlorpromazine: 25mg 1 tbl od (not when child gets fits)
 stop the treatment after 4 weeks to assess if it is still
necessary

Referral to district hospital  in case of serious physical problems,

 if epilepsy doesn’t respond on medication

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 53 of 82

Disorders of childhood

Introduction  10-20% of young people may have mental or emotional

disorder at any one time, and may impair education and
subsequent employment
 developmental influences on the child include intelligence,
temperament, family environment and family relationships,
maltreatment, parental ill health and chronic and severe
physical illness
 obtain information from several informants e.g. parents,
teachers as well as child

Assessement  assess all potential areas of psychopathology

- achievement of developmental milestones
- fears, phobia, obsessions
- depressive symptoms
- inattention,
- delinquency and rule breaking conduct e.g. stealing
- problems with learning
- bizarre of strange ideas and behaviour
- use of alcohol and drugs
- relationships with parents, siblings and peers
- abuse
- suicidal behaviour

 assess impairment in functioning

 identify strengths and resources in the child and family

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 54 of 82

Emotional disorders -
Depression is common in adolescents

Presenting complaints  often presents with physical symptoms, frequently related to

school work

Diagnostic features  headache and other aches and pains

 difficulty in concentration
 poor sleep
 loss of appetite
 withdrawal from family and friends
 feeling bad about oneself
 becoming moody and irritable
 seeing life is pointless
 suicidal feelings and ideas
 irritability

 effects of depression
- poor school work
- poor relationship with family and friends
- increased risk of self harming
- drugs or alcohol misuse

 assess the situation with parents and adolescent to identify

the problem and cause
- how has your health been recently-sleep, concentration,
emotions
- have you been worried about anything recently
- have you shared these worries or concerns with anyone
else
- have you felt like ending your life/ how often? since
when?
- has anyone hurt you recently?
- have you been drinking alcohol or taking drugs?

Advice and support to  listen to adolescent’s account of feelings and concerns

patient and family  help adolescent make link between his/her feelings and
stressful situation he/she is facing
 suggest you could talk to parents and teachers
 make practical suggestions
 teach adolescent problem solving techniques to cope with
stress
 advise not to use alcohol or drugs
 follow up review

Medication  if none of above works, give antidepressant e.g. Fluoxetine

20mg mane or Imipramine 25mg orally at night.

Referral to district hospital  if symptoms are not resolving, and are interfering with
education
 if risk of harm to adolescent or others

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 55 of 82

Conduct disorders -
Impaired functional behaviour characterised by constant conflict with adults and other children;
antisocial behaviour leading to exclusion from school or trouble with the law

Causes  traumatic life experiences

- rejection or emotional abuse
- harsh punishments
- hostility
- broken relationships
 genetic vulnerability
 lack of positive joint activities with the child
 insufficient praise
 poor monitoring of the whereabouts of older children
 school failure

Presenting complaints  serious violations of rules and regulations

- often stays out at night despite parental objections
- often truant from school
- runs away from school
- may be involved in gang groups; take drugs

Diagnostic features  repetitive, persistent and excessive antisocial, aggressive or

defiant behaviour lasting six months or more
 oppositional-defiant behaviour in young children
- angry outbursts
- loss of temper
- refusal to obey commands and rules
- destructiveness
- hitting
 in older children and adolescents
- vandalism
- cruelty to people and animals
- bullying
- lying
- stealing outside the home, sometimes in house
- truancy
- drug and alcohol misuse
- criminal acts
- oppositional - defiant behaviour

Differential diagnosis  attention deficit/hyperactivity disorder

 hyperactivity
 depressive disorder
 specific reading retardation (dyslexia), generalised learning
disability
 autism spectrum disorders
 adjustment reaction

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 56 of 82

Information, advice and  antisocial behaviour is learnt and can be corrected by un-
support for patient and learning
family  educate parents and child on “effective communication”:
- promote positive joint activities between parents and child
- encourage praise and rewards for specific agreed desired
behaviours
- set clear house rules and give short specific commands
about desired behaviour
- provide consistent and calm consequences for
misbehaviour
- avoid arguments with child
- monitor the whereabouts of teenagers; get to know
his/her friends and parents; check with parents
 educate the child on
- anger management
- goal setting and self control
 work with parents and teachers where appropriate
 treat any co-existing condition

Referral  If problems mainly at\school, parents should request referral

to educational services
 If abuse is suspected, social services and child protection
officer must be involved

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 57 of 82

Attention Deficit Hyperactivity Disorder

Presenting complaints  restless, unable to sit in a chair through a full lesson

 fidgety, chattering and interrupting people
 difficulty in concentration or paying attention e.g. unable to
complete homework
 easily distracted and not finish what they have started
 impulsive, suddenly doing things without thinking first
 unable to wait their turn in games or in talking to others
 extremely demanding
 problems with learning and studies
 disorganised and untidy

Diagnostic features  at home

- difficulty with discipline
- irritates parents with impulsive behaviour and not listening
to them
 at school
- poor performance in studies
- irritates teacher with inability to sit quietly and interrupting
the class
 at play
- irritates his peers

Differential diagnosis  conduct disorder

 learning disability
 depression
 hearing impairment
 epilepsy
 comorbidity is common with developmental disorders,
antisocial behaviour, substance misuse, emotional and mood
disorders, autism.
Information ,
advice and support to  educate and support parents on dealing with child
patient and family  maintain consistency and structure: routines, stated
expectations of behaviour, family rules
 set realistic expectations, short-term goals and praise
success
 promote positive interaction with the child
 ensure adequate sleep
 establish constructive communication with school
 keep confrontation to a minimum
 refer for specialist care if no improvement

Medication  may be considered by a specialist in severe cases, following

a specialist assessment

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 58 of 82

Dyslexia

Causes  neurobiological
 may be aggravated by
- large class sizes
- poorly trained teachers
- language not commonly used at home
 mental retardation
 depression
 conduct disorder
 difficulties with hearing or vision
 drug misuse

Presenting complaints  learning difficulty that affects ability to read or deal with
numbers, irrespective of intelligence
 problems with concentration, perception and memory
 verbal skills, abstract reasoning, hand-eye coordination
 social adjustment (low self esteem), poor grades,
underachievement
 child may have difficulties with
- copying, spelling and writing
- understanding instructions
- numbers and mathematics
- reading
- behaviour problems

Information, advise and  a dyslexic child is not stupid, dumb or thick

support for patient and  teachers, parents and health worker need to work together to
family help the child
 teach reading and spelling through phonetics
 extra individual help with numeracy and literacy
 homework to be given early enough and left on the board for
long enough to ensure every child could write it down
 parents should assist dyslexic children through assignments
 position child in front seat
 help child to learn through more than one sense including
touch and movement
 organise extra time in exams
 continued support
 dyslexic children can be very intelligent, but get frustrated by
their difficulties
 crucial to assist as much as possible to enable children to
progress educationally
 children should be helped to build self confidence
- let child identify strengths and weaknesses
- discuss objectively and build on strengths
- promote positive thinking
- praise child for all their achievements, both non-academic
and academic
- value the child as a person

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 59 of 82

Autism Spectrum Disorder
Impairment in communication skills and social interactions; restricted, repetitive and stereotypical
patterns of behaviour

Causes  genetic factors

Presenting complaints  parents may complain of obvious developmental problems

- unresponsive to people or focusing intently on one item
for long periods of time
- outbursts of crying or screaming

Diagnostic features  abnormal or impaired development before the age of 3 in at

least one of the following
- selective social attachment or reciprocal social
interactions
- repetitive or expressive language, as used in social
communication
- restricted , repetitive and stereotyped pattern of
behaviour-functional or symbolic play
 social difficulties
- avoids eye contact, seem indifferent to others and prefers
being alone
- difficulties in interacting reciprocally with others:
 slower in learning to interpret what others are thinking
or feeling
 may ignore other people or be insensitive to their
needs, thoughts and feelings
 difficulties in seeing things from another perspective
 difficulties in regulating emotions e.g. crying in class or
verbal outbursts that seem inappropriate to those
around them
 communication difficulties
- delayed language development with no effort to do so
- use of language in unusual ways-repetition of phrases or
words over and over
- young children may show little interest in the speech of
others
- difficulties in understanding body language, facial
expressions, movements and gestures rarely match
- difficulties in expressing own body language-facial
expressions, movements and gestures rarely match what
they re saying
- difficult to let others know what they need
- some may remain mute throughout their lives
 behaviour difficulties
- odd repetitive movements e.g. flapping arms or walking
on toes. some suddenly freeze in position
- routinised behaviour, resistance to change: a slight
change in any routine can be extremely disturbing
- unusual persisten , intense pre-occupation or interests
e.g. intellectual, art
 other difficulties
- sensory problems e.g. sensitivity to sounds, textures,
taste and smell
- mental retardation
- seizures

Differential diagnosis  attention deficit hyperactivity disorder

 learning disability
 epilepsy

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 60 of 82

Information for patient and  identify patients strengths and potentials and build on the
family strengths
 family education and ongoing support
 help child develop full potential
 child’s education placement-special school or mainstream
with extra attention and assistance

Advice and support to  behavioural management to reinforce desirable behaviour
patient and family and reduce undesirable ones
 an effective treatment programme will build on the child’s
interest, and have a predictable schedule
- teach tasks as a series of simple steps
- engage attention in highly structured activities
- provide regular reinforcement of behaviour
- involve parents , teachers and other professionals e.g.
social workers
- physical activity to develop coordination and body
awareness
- social interactions
- medication-treat co-existing problem e.g. epilepsy

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 61 of 82

Section 6. Sri Lanka Mental Health Act and procedures, including
assessments

Guiding Principles of Kenya Mental Health Act

 regulates mental health care environment in the best interest of the

patient/client/consumer/user
 safeguards the Human Rights of the patient as guaranteed under International Human Rights
Instruments, Regional charters as well as National Constitutions and Legislations
 sets obligations of mental health care users and mental health care providers
 regulates access to mental health care, Provision of mental health care, treatment for
voluntary and involuntary patients and statutory treatment through criminal justice system
 regulates the manner in which the property of mentally-sick persons may be dealt by the
Courts of Law

International Instruments Safeguarding Rights Of People With Mental Disorders

 International Covenant on Economic, Social and Cultural Rights (ICECR)

 International Covenant on Civil and Political Rights (ICCPR)
 UN Declaration of Human Rights
 Convention for the protection of Human Rights and Fundamental Freedoms
 UN convention for the prevention of Torture and Inhuman or Degrading Treatment or
Punishment
 UN Convention on the Rights of the Child
 UN Principles for the protection of persons with Mental Illness and Improvement of Mental
Health Care (MI Principles)
 Standard Rules on equalisation of opportunities for persons with disabilities
 World Psychiatric Association’s Declaration of Madrid

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 62 of 82

Types Of Admissions

 voluntary admission
 involuntary admission
 emergency admission
 admission through criminal justice system as special category patient or mentally disordered
offender.

Schedules (forms) for voluntary admission

 MOH 613 - Application for Voluntary Admission R. 10

 MOH 637 - Application for Voluntary Admission – Child under 16. R.11

Schedules (forms) for involuntary admission

 MOH 614 Application for Involuntary Admission R. 12 (1)

 MOH 615 Recommendation for Involuntary Treatment
 MOH 638 Application for Emergency Admission R. 14
 MOH 639 Report on death or departure
 MOH 641 Application to extend the stay of a foreign patient in the institution
 MOH 616 Application by a relative/friend/guardian for care and custody of an involuntary
patient
 MOH 616 An Order directing delivery into care of relative or friend.
 MOH 640 Warrant of removal of involuntary patient to other countries.

Draft Mental Health Act - 2010

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 63 of 82

Section 7. Other useful materials
Checklists for use by professionals

CAGE questionnaire

Alcohol dependence is likely if the patient gives two or more positive answers
to the following questions

 Have you ever felt you should Cut down on your drinking?
 Have people Annoyed you by criticising your drinking?
 Have you ever felt bad or Guilty about your drinking?
 Have you ever had a drink first thing in the morning to steady your nerves or
get rid of a hangover (Eye-opener)?
The combination of CAGE questionnaire, MCV and GGT activity will detect about
75% of people with an alcohol problem.

Alcohol Use Disorder Identification Test (Audit) 1

Please circle the answer that is correct for you:

1. How often do you have a drink containing alcohol?

Never monthly 2–4 times 2–3 times 4 or more
or less a month a week times a week

2. How many standard drinks containing alcohol do you have on a typical day when
drinking?
1 or 2 3 or 4 5 or 6 7 to 9 10 or more

3. How often do you have six or more drinks on one occasion?

Never less than Monthly Weekly Daily or almost
monthly daily

4. How often during the last year have you found that you were not able to stop
drinking once you had started?
Never less than Monthly Weekly Daily or almost
monthly daily

5. How often during the last year have you failed to do what was normally expected
from you because of drinking?
Never less than Monthly Weekly Daily or almost
monthly daily

6. How often during the last year have you needed a drink in the morning to get
yourself going after a heavy drinking session?
Never less than Monthly Weekly Daily or almost
monthly daily

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 64 of 82

7. How often during the last year have you had a feeling of guilt or remorse after
drinking?
Never less than Monthly Weekly Daily or almost
monthly daily

8. How often during the last year have you been unable to remember what happened
the night before because you had been drinking?

Never less than Monthly Weekly Daily or almost

monthly daily

9. Have you or someone else been injured as a result of your drinking?

No Yes, but not in the last year Yes, during the last year

10. Has a relative or friend or a doctor or other health worker been concerned about
your drinking or suggested you cut down?

No Yes, but not in the last year Yes, during the last year

Scoring the Audit

Scores for each question range from 0 to 4, with the first response for each question (e.g. never)
scoring 0, the second (e.g. less than monthly) scoring 1, the third (e.g. monthly) scoring 2, the
fourth (e.g. weekly) scoring 3, and the last response (e.g. daily or almost daily) scoring 4. For
questions 9 and 10, which only have 3 responses, the scoring is 0, 2 and 4 (from left to right).

A score of 8 or more is associated with harmful or hazardous drinking, a score of 13 or more in

women, and 15 or more in men, is likely to indicate alcohol dependence.
1
Saunders, J. B., Aasland, O. G., Babor, T. F., de le Fuente, J. R. and Grant, M. (1993).
Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on
early detection of persons with harmful alcohol consumption - II. Addiction, 88, 791–803

Abbreviated Mental Test Score for Dementia

Each correct answer scores one mark. No half marks. A score of 6 or less suggests dementia.

1. Age
2. Time to nearest hour
3. An address, e.g. 42 West Street, to be repeated by the patient at the end of the test
4. Year
5. Name of hospital, residential institution or home address depending on where
patient is situated
6. Recognition of two persons, for example doctor, nurse, relative, home help etc
7. Date of birth
8. Year of Independence
9. Name of present President
10. Count backwards from 20 to 1.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 65 of 82

Social and living skills checklist1

This checklist is simply a list of areas that need to be considered in the care of someone
with a long-term, severe illness, in addition to more medical assessments such as the
individual's mental state, severity of symptoms and medication side effects.

Basic living skills Please circle

1. Is basic self-care adequate?
a. Personal hygiene and appearance Yes No
b. Clothing Yes No
c. Preparation of meals Yes No
d. Diet Yes No
e. Housework (e.g. washing dishes, laundry,
household hygiene, etc.) Yes No
f. Survival skills in community (e.g. shopping,
transport, crossing roads, etc.) Yes No

Physical health & medications / treatment

1. Has individual recently had a medical check-up?
(e.g. general health, optometry, dentistry, podiatry, etc.) Yes No
2. Are medication and health problems managed appropriately?
(e.g. non-adherence, side effects, etc.) Yes No
3. Is current medication (type and dose) satisfactory for:
a. Individual? Yes No
b. Carer? Yes No
c. health professional? Yes No

Housing
1. Is the housing situation adequate? Yes No
2. Is supervision adequate for this individual? Yes No
3. a. Is individual happy with his or her current housing situation? Yes No
b. Is health professional happy? Yes No
c. Are carers happy? Yes No
4. If not happy with housing, what kind of housing is preferred? Yes No

Finances
1. Is individual receiving all benefits to which he or she is entitled? Yes No
2. Is the individual's income adequate? Yes No
3. Can the individual budget and handle money effectively? Yes No
4. Can individual handle financial commitments without assistance? Yes No

Family and social supports

1. Are the individual's family and social supports adequate? Yes No
2. Do the individual and his or her family have:
a. Clear ideas about roles and responsibilities?
(Who does what?) Yes No
b. Adequate decision making skills? (Who decides and how?) Yes No
c. Skills for managing difficult behaviour? Yes No
d. Satisfactory communication of feelings?
(Content and expression) Yes No
e. Realistic expectations of one another? Yes No
f. Receptive attitudes to outside assistance? (Accepting help) Yes No

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 66 of 82

3. Do the individual and his or her family have adequate:
a. Communication skills? Yes No
b. Problem solving skills? Yes No

Employment
1. If employed, is the work situation satisfactory? Yes No
(e.g. punctuality, attendance, performance, social interactions, etc.)
2. If unemployed, is individual suitable for employment? Yes No
3. If unemployed, can the individual find work without assistance? Yes No

Legal
1. If subject to the Mental Health Act or legal proceedings, is the matter
being handled appropriately? Yes No

Leisure and social activities

1. Is individual happy with the way spare time is spent? Yes No
2. Is the carer happy? Yes No
3. Is individual happy with present friendships?
(quantity and quality) Yes No
4. Is individual happy with present leisure activities?
(quantity and quality) Yes No

Education
1. If the individual is currently undertaking a course of study, is
he or she coping with the demands of this study? Yes No
2. If a current course of study has been interrupted, has the
3. university (or other) been notified and supplied with supportive
4. the documentation for deferral of the course, etc.? Yes No
5. Is the individual satisfied with his or her current educational
status or situation? (e.g. further education may be desired). Yes No

Mental Health Services

1. Is the individual happy with the services? Yes No
2. Is the individual happy with:
a. primary care professional ? Yes No
b. Secondary care district professional? Yes No
c. Other mental-health workers? Yes No
d. Choice of treatment? Yes No
3. Is the individual aware of his or her options re treatment and services? Yes No

From: Andrews G & Jenkins R (Eds), 1999, `Management of Mental Disorders (UK Edition). Sydney.
World Health Organisation Collaborating Centre for Mental Health & Substance Abuse

Interactive summary cards

The pages that follow contain summaries of information about the six disorders most
common in primary care.

These are designed to be used interactively within the consultation, to help the practitioner
explain key features of the disorder to the patient and enter into discussion about a
possible management plan.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 67 of 82

Alcohol problems

There is one unit of alcohol in:

1⁄2 pint of ordinary strength beer, lager or cider
1⁄4 pint of extra strength beer, lager or cider
1 small glass of white (8 or 9% ABV) wine
2/3 small glass of red (11 or 12% ABV) wine
1 single measure of spirits (30 ml)

Common symptoms
‘High-risk’
drinking: Psychological: Physical:
Men Poor concentration Hangovers/blackouts
More than three units Sleep problems Injuries
alcohol/day Less able to think Tiredness/lack
(21 units/week)   clearly   of energy
Depression Weight gain
Women Anxiety/stress Poor coordination
More than two units High blood pressure
alcohol/day Impotence
(14 units/week) Vomiting/nausea
Gastritis/diarrhoea
Liver disease
Brain damage
Many have no
symptoms but
are at risk

Difficulties and arguments with family/friends

Difficulties performing at work/home
Withdrawal from friends and social activities
Legal problems.

Alcohol problems are treatable

Alcohol problems do not mean weakness
Alcohol problems do not mean you are a bad person
Alcohol problems do mean that you have a medical problem or a lifestyle problem.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 68 of 82

What treatments can help?
Both therapies are most often needed:
Supportive therapy: Medication:
to reduce drinking for moderate to severe withdrawal
to stop drinking for physical problems
for stress consider for relapse prevention.
for prevention of life problems
for education of the family members for support.

Set goals: acceptable levels of drinking

Who? How many drinks? How often?

Men No more than three units Each day (only for five days/week)

Women No more than two units Each day (only for five days/week)

Have two non-alcohol drinking days/week.

Keep in mind: the less the person drinks, the better it is.

Pregnancy
Physical alcohol dependence
Physical problems made worse Recommendation is
by drinking not to drink
Driving, biking
Operating machinery
Exercising (swimming, jogging, etc.)

Determine action: how to reach target levels

 Keep track of your  Engage in alternative Eat before alcohol
consumption activities at times that starting to drink
 Turn to family and/ you would normally Join a support group or
friends for support drink (e.g. when you Quench your thirst
 Have one or more are feeling bored or with non-alcoholic
non-alcoholic drinks stressed) drinks
before each drink  Switch to low Avoid or reduce time
 Delay the time of day alcoholic drinks spent with heavy-
that you drink  Decide on non- drinking friends
 Take smaller sips drinking days (2 days Avoid bars, cafes or
or more per week) former drinking places.

Review progress: are you keeping on track?

Questions to ask: Progress tips:
Am I keeping to my goals? Every week, record how much you
What are the difficult times? drink over the week
Am I losing motivation? Avoid these difficult situations or plan
Do I need more help? activities to help you cope with them
Think back to your original reasons for
cutting down or stopping

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 69 of 82

 Come back for help, talk to family and
friends.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 70 of 82

Anxiety
Common symptoms
Psychological: Physical:
Tension  Fear of going  Trembling Muscle tension
 Worry  crazy  Sweating  Nausea
 Panic  Fear of dying  Heart pounding Breathlessness
 Feelings of  Fear of losing  Light headedness Numbness
 unreality  control  Dizziness
 Stomach pains
 Tingling sensation

Disruptive to work, social or family life

Anxiety disorders are common and treatable
Anxiety does not mean weakness
Anxiety does not mean losing the mind
Anxiety does not mean personality problems
Severe anxiety does mean a disorder which requires treatment.

Common forms of anxiety

Generalised anxiety Panic disorder Social phobia Agoraphobia

:
persistent anxiety fear of dying fear of attention feeling trapped
tension fear of going crazy fear of criticism unable to get help
excessive worrying feeling unreal fear of embarrassment

What treatments can help?

Both therapies are most often needed:
Supportive therapy for: Medication:
 slow breathing/relaxation  for severe anxiety
 exposure to feared situations  for panic attacks.
 realistic/positive thinking
 problem-solving.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 71 of 82

About medication

Short term Side-effects Ongoing review

use for severe anxiety are important of medication use
can be addictive and to report  is recommended.
ineffective when used in
the long term Counseling
(emotional support and
 problem-solving) is always
recommended with medication

Slow breathing to reduce physical symptoms of anxiety

Breath in for three seconds and out for three seconds, and pause for three
seconds before breathing in again.
Practice 10 minutes morning or night (five minutes is better than nothing).
Use before and during situations that make you anxious.
Regularly check and slow down breathing throughout the day.

Change attitudes and ways of thinking

‘My chest is hurting and I can’t Instead: ‘I am having a panic attack, I
  breathe, I must be having a    should slow my breathing
  heart attack.’    down and I will feel better.’
‘I hope they don’t ask me a Instead: ‘Whatever I say will be OK, I
  question, I won’t know what    am not being judged. Others
  to say.’    are not being judged, why should I
be?’
‘My partner has not called as Instead: ‘They might not have been
  planned. Something terrible    able to get to a phone. It is
  must have happened.’    very unlikely that something
   terrible has happened.’

Exposure to overcome anxiety and avoidance

Easy stage Moderate stage Hard stage
(e.g. walking on own) (e.g. lunch with a friend) (e.g. shopping
with a friend)

Use slow breathing to control anxiety

Do not move to the next stage until anxiety decreases to an acceptable level.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 72 of 82

Chronic tiredness
Common symptoms
Compared with previous level of energy, and compared to people known to you:
Tired all the time Tire easily Tired despite rest

 Disruptive to work, social and family life

 Affects ability to carry out routine and other tasks
 Feelings of frustration.
Chronic Fatigue Syndrome is a much rarer condition, diagnosed when substantial
physical and mental fatigue lasts longer than six months and there are no
significant findings on physical or laboratory investigation.

Common triggers
Psychological triggers: Physical triggers: Medication:
 Depression  Anaemia  Thyroid  Steroids
 Stress   Bronchitis disorder  Antihistamines.
 Worry   Asthma  Influenza
 Anxiety.  Diabetes  Alcohol/
 Doing too much  Arthritis.  drug use
 Doing too little activity  Bacterial, viral and
other infections.

What treatments can help?

Both therapies are most often needed:
Supportive therapy for: Medication:
 depression  for other mental or physical disorders
 worry/anxiety  anti-depressants are sometimes useful
 stress/life problems  there are no effective medications
 lifestyle change specific to fatigue and the main treatment
 level of physical activity follows psychological lines

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 73 of 82

Behavioural strategies
 Examine how well you are sleeping
 Plan pleasant/enjoyable activities into your week
 Try to have regular meals during the day.
 Have a brief rest period of about 2 weeks, in which there are no extensive
activities
 After the period of brief rest, gradually return to your usual activities.
 Gradually build up a regular exercise routine
 Try to keep to a healthy diet.
 Do not push yourself too hard; remember to build up all activities gradually and
steadily.
 Use relaxation techniques, for example, slow breathing.

Slow breathing for relaxation

 Breath in for three seconds
 Breath out for three seconds
 Pause for three seconds before breathing in again
 Practice for 10 minutes at night (five minutes is better than nothing).

Increase level of physical activity

A little activity Daily activities — Activity that makes
one or two times a week not much effort you out of breath for
(e.g. walking) (e.g. fast walking, 20 minutes or more,
shopping, cleaning) three to five times a
week (e.g. jogging)

Inactive Some activity Active

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 74 of 82

Depression
Common symptoms
Mood and motivation: Psychological: Physical:
Continuous low mood  Guilt/negative  Slowing down or
 Loss of interest or  attitude to self agitation
 pleasure  Poor concentration/  Tiredness/lack of
 Hopelessness  memory   energy
 Helplessness  Thoughts of death  Sleep problems
 Worthlessness  or suicide  Disturbed appetite
 Tearfulness   (weight loss/increase)

 Difficulties carrying out routine activities

 Difficulties performing at work
 Difficulties with home life
 Withdrawal from friends and social activities.

Depression is common and treatable

 Depression does not mean weakness
 Depression does not mean laziness
 Depression does mean that you have a medical disorder which requires
treatment.
Common triggers
Psychological: Other: Illness: Medication:
Major life events eg.  Family history  Infectious  Antihypertensives
 Recent   of depression diseases  H2 blockers
 bereavement  Childbirth  Influenza  Oral
 Relationship  Menopause  hepatitis.  contraceptives
 problems  Seasonal changes  Corticosteroids.
 Unemployment  Chronic medical
 Moving house  conditions
 Stress at work  Alcohol and
 Financial   substance use
 problems.   disorders.
What treatments can help?
Both therapies are most often needed:
Supportive therapy for: Medication:
 stress/life problems  for depressed mood or loss of interest/
 patterns of negative pleasure for two or more weeks and at
 thinking   least four of the symptoms mentioned
 prevention of further earlier
episode  for little response to supportive therapy 
(counseling)
 for recurrent depression
 for a family history of depression.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 75 of 82

About medication
Effective Side-effects Time period
Usually works faster than must be reported, but Medication to be
other methods. generally start improving continued at least four
Treatment plan within 7–10 days. to six months after
must be strictly adhered to. Progress initial improvement.
Drugs  same medication Ongoing review
 are not addictive should continue is necessary over the
 interact in a harmful  unless a different next few months.
 way with alcohol decision is taken by
 improvement takes  the doctor
 time, generally three  medication should not
 weeks for a response be discontinued without
 do not take in   doctor’s knowledge
 combination with in case a drug is not
 St John’s wort.  effective, another drug
 may be tried.
Increase time spent on enjoyable activities
 Set small achievable, daily goals for doing pleasant activities
 Plan things to look forward to in future
 Keep busy even when it is hard to feel motivated
 Plan time for activities and increase the amount of time spent on these each
week
 Try to be with other people/family members.
Problem-solving plan
Discuss Options Set a time frame
problems with partner/family Work out possible to examine and resolve
members, trusted friend or solutions to solve problems.
counselor. the problems. Make an action plan
Distance Pros and cons for working through the
yourself to look at problems Examine advantages problems over a period
as though you were an and disadvantages of time.
observer. of each option. Review
Progress made in
solving problems.
Change attitudes and way of thinking
‘I will always feel this way; Instead: ‘These feelings are temporary.
  things will never change.’    With treatment, things will
   look better in a few weeks.’
‘It’s all my fault. I do not seem Instead: ‘These are negative thoughts
  to be able to do anything right.’    that are the result of
   depression. What evidence
   for this do I really have?’

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 76 of 82

Sleep problems
Common symptoms
Difficulty falling asleep  Early morning awakening
Frequent awakening  Restless or unrefreshing sleep

Difficulties at work and in social and family life

 Makes it difficult to carry out routine or desired tasks.

Common causes
Psychological:
Physical: Lifestyle: Environmental:
Medical
problems:
Depression  Overweight  Too hot or too cold  Noise
 Anxiety  Heart failure  Tea, coffee and  Pollution
 Worries  Nose, throat and alcohol  Lack of
 Stress.  lung disease  Heavy meal before  privacy
 Sleep apnoea  sleep  Over-
 Narcolepsy  Daytime naps  crowding.
 Pains.  Irregular sleep
Medications:  schedule.
 Steroids
 Decongestants
 Others.

What treatments can help?

Supportive therapy is the preferred treatment
Supportive therapy for: Medication:
 stress/life problems  for temporary sleep problems
 depression  for short term use in chronic problems
 worry  to break sleep cycle.
 changes in lifestyle and
sleep habits.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 77 of 82

About medication
Short term Side-effects Ongoing review
 use for short period  are important to report.  of medication use is
 of time. Harmful  recommended.
Long-term  when alcohol and other
 when used in the long  drugs are used.
 term, there may be
 difficulties stopping,
 leading to dependence.

Lifestyle change strategies

 Try to minimize noise  Try to avoid eating  Reduce mental and
in your sleep  immediately before  physical activity
environment, if going to sleep.  during the evenings.
necessary consider  Try to have your dinner  Increase your
ear plugs.  earlier in the evening, physical activity
 Try to make sure that rather than later.  during the day; build
the room in which you  Don’t lie in bed trying up a regular exercise
are sleeping is not too sleep. Get up and do routine.
hot or cold.  something relaxing until  Avoid daytime naps,
 Reduce the amount of you feel tired.  even if you have not
alcohol, coffee and tea  Have regular times for slept the night before.
that you drink,  going to bed at night  Use relaxation
especially in the and waking up in the techniques, for
evenings.  morning.  example, slow
breathing.

Slow breathing for relaxation

 Breath in for three seconds
 Breath out for three seconds

 Pause for three seconds before breathing in again

 Practise for 10 minutes at night (five minutes is better than nothing).

More evaluation may be needed:

 if someone stops breathing during sleep (sleep apnoea)
 if there is a daytime sleepiness without possible explanation.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 78 of 82

Unexplained somatic complaints
Common, unexplained physical problems
Headaches  Nausea  Skin rashes
Chest pains Vomiting Frequent urination
Difficulty in breathing Abdominal pain Diarrhoea
Difficulty in swallowing Lower back pain Skin and muscle
discomfort.

Associated worries and concerns

Associated symptoms and problems
Beliefs (about what is causing the symptoms)
Fear (of what might happen).

Physical symptoms are real

A vicious circle can develop:
Emotional stress can cause physical symptoms or make them worse.
Physical symptoms can lead to more emotional stress.
Emotional stress can make physical symptoms worse.

Headaches may all be

Difficulty in swallowing caused or made worse
Chest pain/difficulty in breathing by stress, anxiety
Abdominal pain/nausea/vomiting worry, anger, depression
Frequent urination/diarrhoea/impotence
Skin rashes

What treatments can help?

Supportive treatment most often needed:
Effective reassurance, after history and detailed physical examination.
Management of stress/life problems.
Treatment of associated depression, anxiety, alcohol problems.
Learning to relax.
Avoiding patterns of negative thinking.
Increasing levels of physical activity.
Increasing positive/pleasurable activities.

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 79 of 82

Useful strategies
Reassurance
Stress often produces physical symptoms or makes them worse.
There are no signs of serious illness.
You can benefit from learning strategies to reduce the impact of your
symptoms.
Slow breathing to reduce common physical symptoms
(eg muscle tension, hot and cold flushes, headaches, chest tightness)
Breath in for three seconds and out for three seconds and pause for three
seconds before breathing in again.
Practise 10 minutes morning or night (five minutes is better than nothing).
Use before and during situations that make you anxious.
Regularly check and slow down breathing throughout the day.
Change attitudes and way of thinking
‘I can’t understand why the tests Instead: ‘The pain is real, but I’ve been
are negative. I feel the pain; it    checked out physically and I
is probably something really    have had all the relevant tests.
unusual that I have.’    Many other things, such as
these pains.’ worry and stress, can cause
   these pains
‘Maybe my doctor has missed Instead: ‘It is very unlikely that these
 something. I should try    doctors have missed
 another doctor or better still    something. It is unlikely that a
 a specialist instead.’    Specialist would say anything
different. Maybe I should
examine whether stress,
tension, or my lifestyle is
contributing to the pain.’
‘Why won’t this pain go away. Instead: ‘This is not the first time that
 I’m not feeling well; I’ve    thought that there was
 probably got cancer.’   something terribly wrong and
in fact nothing serious
developed. I should learn to
relax and focus my thoughts
on other things to distract
myself from the pains.’
Increase level of physical activity
A little activity Daily activities — Activity that makes
one or two times a week not much effort you out of breath for
(eg walking) (eg fast walking, 20 minutes or more,
shopping, cleaning) three to five times a week
(eg jogging)

Inactive Some activity Active

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 80 of 82

Traditional Health Practitioners

THPs are a major health care resource. At least 50% population consult Traditional Health
Practitioners or Religious Healers at some time
People often simultaneously consult both traditional health practitioners and western medicine.
THPs are accessible, operate in the social context, and their interventions are sometimes
effective, so there are reasons for public health services to be in dialogue with traditional healers.

Common types of Traditional Health Practice

Aurvedic
Herbal
Spiritual
Combination of herbal and spiritual
Traditional surgeons
Traditional birth attendants
From elsewhere
Yoga
Homeopathy
Chinese herbal medicine
Acupuncture

Advantages of Traditional Health Practice

Community oriented with strong social support and detailed knowledge of client and family

Understand psychosocial dynamics of family and community

Use psychosocial interventions

Disadvantages of Traditional Health Practice

A rise of the corrupt THPs/quacks
Money oriented
Inadequate training/apprenticeship
Overdose of herbs
Herbs may interact with western medicines
Introduction of infection including HIV
Razor blades are often used, with no/inadequate attention to sterility.
Safety is sometimes/often a problem.

Potential for Collaboration

The Government of Kenya is encouraging professional accountability of THPs through registration.
It would be possible to train THPs to recognise and refer all cases of
delirium, psychosis, severe depression, epilepsy; and to promote safe practice.
There is a need to research THP methods, engage in mutual dialogue, establish agreed criteria for
referral and for sharing of information.

Working with Traditional Health Practitioners:

Identify genuine THPs within your working area
Visit them in their practice settings
Create a dialogue with the good ones
Invite them to your practice setting
Develop a system whereby both sides can learn from each other
Set strategies for cooperation and collaboration
Developing guidelines
Holding meetings/Discussion
Follow-up

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 81 of 82

Mental Health NGOs

Please complete for your area

Name Phone numbers and Address Services
email

Contact list for your local area

Please complete with your local details

NAME ROLE CONTACT DETAILS

Mental Health in Primary Care – Diagnostic and Treatment Guidelines Page 82 of 82