Guideline

Mental Health Gap Action Programme (‎mhGAP)‎ guideline for mental, neurological and substance use disorders, [‎3rd ed.]‎.

Year of Publication

2023

Issuing Institution

World Health Organization

Links

WHO IRIS

Recommendations

74 included recommendations

Baclofen should be considered for treatment of adults with alcohol dependence post-detoxification

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Moderate

Structured and standardized psychosocial interventions should be considered for the treatment of alcohol dependence.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Digitally delivered interventions should be considered for adults with alcohol use disorders or with hazardous alcohol use. They should not replace provision of other forms of interventions and should ensure free and informed consent, safety, confidentiality, privacy and security.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Combined psychosocial and pharmacological interventions should be offered for adults with alcohol dependence.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Selective serotonin reuptake inhibitors (SSRIs) should be considered for adults with panic disorder. If SSRIs are not available, consider offering tricyclic antidepressants (TCAs). SSRIs should be considered for adults with generalized anxiety disorder (GAD).

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Brief, structured psychological interventions based on principles of cognitive behavioural therapy (CBT) should be offered for adults with generalized anxiety disorder (GAD) and/or panic disorder

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

When brief, structured psychological interventions based on principles of cognitive behavioural therapy (CBT) are offered for adults with generalized anxiety disorder (GAD) and/or panic disorder, different delivery formats should be considered based on available resources as well as individual preferences, including: y individual and/or group face-to-face; y digital/online and/or face-to-face; y guided and/or unguided self-help; y specialist and/or non-specialist.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Stress management techniques, namely relaxation and/or mindfulness training, should be considered for adults with generalized anxiety disorder (GAD) and/or panic disorder.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Structured physical exercise should be considered for adults with generalized anxiety disorder (GAD) and/or panic disorder

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Benzodiazepines are not recommended for the treatment of adults with generalized anxiety disorder (GAD) and/or panic disorder. For emergency management of acute and severe anxiety symptoms, benzodiazepines may be considered, but only as a short-term (3–7 days maximum) measure.

Status

Updated

Recommended against

Strong

Certainty of evidence

Low

Collaborative care should be considered for adults with depression and/or anxiety and physical health conditions.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

For children 6 years old and above and adolescents who have an attention deficit hyperactivity disorder (ADHD) diagnosis, methylphenidate may be considered, provided that: ADHD symptoms are still causing persistent significant impairment in at least one domain of functioning (education, interpersonal relationships, occupation), after the implementation of environmental modifications in schools, at home or in other relevant settings; a careful assessment of the child/adolescent has been conducted; the child/adolescent and the caregivers, as appropriate, have been informed about ADHD treatment options and supported in decision-making; methylphenidate prescription is made by, or in consultation with, a specialist.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Child and adolescent mental disorders (CAMH). Universally delivered psychosocial interventions that use curriculum-based, family based, exercise-based methods and/or social and personal skills development to improve emotional regulation should be considered for promotion of psychosocial well-being in children.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Psychosocial interventions that include cognitive behavioural therapy (CBT), psychoeducation and family-focused treatment approaches should be offered to children whose parents have mental health conditions for the prevention of depression and anxiety.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Psychosocial interventions focused on social skills training and developmental behavioural approaches should be offered to improve development, well-being and functioning in children and adolescents with autism.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Cognitive behavioural therapy (CBT) should be offered to children and adolescents with autism with anxiety.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Psychosocial interventions focused on social skills training and cognitive interventions should be considered to improve development and functioning in children and adolescents with attention deficit hyperactivity disorder (ADHD).

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Moderate

Psychosocial interventions focused on organizational skills training should be considered to improve development and functioning in children and adolescents with attention deficit hyperactivity disorder (ADHD).

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Beginning-to-read interventions should be offered to improve communication and academic performance in children with disorders of intellectual development.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Early communication interventions involving direct instruction approaches should be considered for improving expressive phonological skills and reducing stuttering for children with developmental speech disorders.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Psychosocial interventions using cognitive learning techniques to enhance communication and social competencies should be considered for children and adolescents with neurodevelopmental disabilities.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Structured physical exercise should be considered to improve development, including social and communication development, and functioning in children and adolescents with autism.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Structured physical exercise should be considered to improve motor skills and functioning, including attention and executive functioning, and reduce anxiety and problem behaviours in children and adolescents with attention deficit hyperactivity disorder (ADHD)

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Specialized instructional techniques should be considered to improve academic performance, including writing skills, reading comprehension and maths, in children and adolescents with developmental learning disorders.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Task-oriented instruction should be considered to improve motor skills and task performance in children with developmental coordination disorders.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Structured physical exercise and activity should be offered to improve development outcomes, including motor skills and functioning, in children and adolescents with cerebral palsy

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Pharmacological interventions are not recommended in children and adolescents with anxiety disorders

Status

Updated

Recommended against

Strong

Certainty of evidence

Low

Antidepressant medicines are not recommended for the treatment of children 12 years of age and below with depressive episode/disorder

Status

Updated

Recommended against

Strong

Certainty of evidence

Low

If psychosocial interventions alone prove ineffective in adolescents (13–17 years) with moderate-to-severe depression, referral to or consultation with a specialist should be offered, to undertake a more comprehensive assessment and to explore initiation of fluoxetine in combination with psychological treatments.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Psychological interventions should be considered for adults with post-traumatic stress disorder (PTSD). Namely, these include: individual face-to-face cognitive behavioural therapy (CBT) with a trauma focus; group face-to-face CBT with a trauma focus; digital/remote CBT with a trauma focus; eye movement desensitization and reprocessing (EMDR); stress management

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Psychological interventions should be offered for children and adolescents with posttraumatic stress disorder (PTSD). Namely, these include: individual face-to-face cognitive behavioural therapy (CBT) with a trauma focus; group face-to-face CBT with a trauma focus; eye movement desensitization and reprocessing (EMDR)

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Psychosocial interventions – namely mindfulness-based interventions, multicomponent interventions, psychoeducation and psychotherapy/counselling – should be offered for carers of people living with dementia.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Respite care should be considered for carers of people living with dementia

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Depression and anxiety in carers of people living with dementia should be assessed and treated in line with mhGAP recommendations for depression and anxiety

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Psychological interventions – namely cognitive behavioural therapy (CBT), interpersonal therapy (IPT), structured counselling and behavioural activation therapy (BAT) – should be considered for people living with dementia and mild-to-moderate depression.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Physical activity interventions – namely physical exercise delivered 3–4 times per week for 30–45 minutes for more than 12 weeks – should be offered to people living with dementia

Status

Updated

Recommended in favor

Strong

Certainty of evidence

High

Non-pharmacological interventions – namely CBT, cognitive stimulation therapy and cognitive training (in alphabetical order) – should be considered for people living with dementia.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

In adults with moderate-to-severe depression, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine or sertraline (SSRIs) or amitriptyline (TCA) should be considered.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

In adults with moderate-to-severe depression who have benefited from initial antidepressant treatment, continuation of the antidepressant treatment should be considered for at least six months after remission. Treatment should be regularly monitored, with special attention to treatment adherence, change in depressive symptoms and possible adverse effects

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Structured psychological interventions should be offered for the treatment of adults with moderate-to-severe depression, namely behavioural activation therapy (BAT), brief psychodynamic therapy (DYN), cognitive behavioural therapy (CBT), interpersonal therapy (IPT), problem-solving therapy (PST) and third wave therapies (3WV).

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

In adults with moderate-to-severe depression, psychological interventions or combined treatment should be considered based on individual preferences and careful consideration of the balance of benefits and harms. Antidepressant medicine alone for adults with moderate-to-severe depression should only be considered when psychological interventions are not available. Providers should keep in mind the possible adverse effects associated with antidepressant medicines, and individual preferences.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Adults using cannabis should be offered screening and brief intervention. Brief intervention should comprise at least a single session, incorporating individualized feedback and advice on reducing or stopping cannabis consumption, and the offer of follow-up care.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

Adults using psychostimulants should be offered screening and brief intervention. Brief intervention should comprise at least a single session, incorporating individualized feedback and advice on reducing or stopping psychostimulant consumption, and the offer of follow-up care

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

For adults with hazardous cannabis or psychostimulant use, or with disorders due to use of these substances who do not respond to brief interventions, referral for specialist intervention should be considered.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Dexamphetamine, methylphenidate and modafinil are not recommended for the treatment of cocaine or stimulant use disorders due to safety concerns.

Status

Updated

Recommended against

Conditional

Certainty of evidence

Low

Psychosocial interventions – namely cognitive behavioural therapy (CBT) and contingency management – should be offered to adults with cocaine and stimulant dependence.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Digital interventions should be considered for adults using drugs or with drug use disorders. They should not replace provision of other forms of interventions and should ensure informed consent, safety, confidentiality, privacy and security

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Recovery-oriented services on a voluntary basis should be considered for adults with drug-dependence. Namely, case management, long-term residential and continuing community care approaches, occupation-based therapies and peer support groups should be considered for recovery management of people with drug dependence.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

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

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

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

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Moderate

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

Status

Updated

Recommended in favor

Strong

Certainty of evidence

High

Monotherapy with lamotrigine or levetiracetam should be offered as first-line treatment for focal onset seizures in children and adults with epilepsy. If neither lamotrigine nor levetiracetam are available, then carbamazepine should be used as an alternate first-line treatment for focal onset seizures in children and adults with epilepsy. If the first monotherapy is not successful for focal onset seizures, an alternative first-line monotherapy should be tried. Lacosamide should be offered as a second-line monotherapy for focal onset seizures if none of the first-line medicines are effective. If antiseizure medicine monotherapy is unsuccessful in people with generalized onset seizures or focal onset seizures, prompt referral should be made to a specialist for consideration of other treatment options.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

High

In women and girls with epilepsy who are of childbearing potential, lamotrigine or levetiracetam should be offered as first-line monotherapy for both generalized onset seizures and focal onset seizures. Women with epilepsy should have seizures controlled as well as possible with the minimum dose of antiseizure medicines (ASMs) taken in monotherapy, wherever possible. Valproic acid (sodium valproate) is not recommended in women and girls of childbearing potential because of potential harm to the fetus

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

Standard breastfeeding recommendations remain appropriate for women with epilepsy taking the antiseizure medicines (ASMs) included in this review (phenobarbital, phenytoin, valproic acid [sodium valproate], carbamazepine, lamotrigine, levetiracetam, topiramate, lacosamide).

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Very low

Nocturnal supervision should be considered for prevention of sudden unexpected death in epilepsy (SUDEP).

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

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

Status

Updated

Recommended in favor

Conditional

Oral antipsychotic medicines – namely aripiprazole, chlorpromazine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone – should be offered for adults with a psychotic disorder (including schizophrenia), carefully balancing effectiveness, side-effects and individual preference.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Clozapine should be considered for adults with a treatment-resistant psychotic disorder (including schizophrenia) under mental health specialist supervision, carefully balancing effectiveness, side-effects and individual preference.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Moderate

Maintenance therapy with antipsychotic medicine for a minimum of 7–12 months should be offered in adults with a first episode of psychosis (including schizophrenia) in remission, carefully balancing effectiveness, side-effects and individual preference.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Maintenance therapy with mood stabilizers or antipsychotic medicines should be considered for at least six months for adults with bipolar disorder in remission, carefully balancing effectiveness, side-effects and individual preference.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Long-acting injection (LAI) antipsychotic medicines – namely fluphenazine, haloperidol, paliperidone, risperidone and zuclopenthixol – should be considered as an alternative to oral antipsychotic medicines for adults with psychotic disorders (including schizophrenia) requiring long-term treatment, carefully balancing effectiveness, side-effects and individual preference

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Moderate

Oral antipsychotic medicines – namely aripiprazole, olanzapine, paliperidone, quetiapine, risperidone – should be considered under specialist supervision for adolescents with psychotic disorders (including schizophrenia), carefully balancing effectiveness, side-effects and individual preference.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Clozapine should be considered for adolescents with a treatment resistant psychotic disorder (including schizophrenia) under specialist supervision, carefully balancing effectiveness, side-effects and individual preference.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Psychotropic medicines (antipsychotic medicines, namely aripiprazole, olanzapine, quetiapine, risperidone; and mood stabilizers, namely lithium) should be considered under specialist supervision for adolescents with bipolar disorder (current episode manic), carefully balancing effectiveness, side-effects and individual preference.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Oral antipsychotic medicines (namely aripiprazole, haloperidol, olanzapine, paliperidone or quetiapine) or mood stabilizers (namely carbamazepine, lithium, valproic acid [sodium valproate]) should be offered to adults with bipolar disorder (current episode mania), carefully balancing effectiveness, side-effects and individual preference

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Bipolar disorder (current episode mania). Valproic acid (sodium valproate) should not be used in women and girls of childbearing potential owing to the high risk of birth defects and neurodevelopmental disorders in babies in utero.

Status

Updated

Recommended against

Strong

Certainty of evidence

Low

Mood stabilizers (namely carbamazepine, lithium, valproic acid [sodium valproate]) or oral antipsychotic medicines (namely aripiprazole, olanzapine, quetiapine) should be considered for maintenance treatment for adults with bipolar disorder in remission, carefully balancing effectiveness, side-effects and individual preference.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Valproic acid (sodium valproate) should not be used in women and girls of childbearing potential with bipolar disorder in remission owing to the high risk of birth defects and neurodevelopmental disorders in babies in utero

Status

Updated

Recommended against

Strong

Certainty of evidence

Low

Fluoxetine, olanzapine, quetiapine, valproic acid (sodium valproate) or venlafaxine should be considered for adults with bipolar depression. If fluoxetine or venlafaxine are chosen, they should be co-administered with a mood stabilizer (namely quetiapine, olanzapine, carbamazepine, valproic acid [sodium valproate], lithium).

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Treatment based on cognitive behavioural therapy (CBT) should be considered for adults with psychotic disorders (including schizophrenia) in the acute phase of the condition where sufficient specialist support is available

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Moderate

Psychosocial interventions – namely family interventions, family psychoeducation, psychoeducation and cognitive behavioural therapy (CBT) – should be offered to adults with psychosis (including schizophrenia) during the maintenance phase, either alone or in combination.

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Individual psychological interventions – namely cognitive behavioural therapy (CBT), family psychoeducation, medicine adherence therapy, online psychoeducation or psychoeducation – should be considered as adjunctive to pharmacological interventions in the treatment of adults with bipolar disorder in remission

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

Persons with thoughts or plans of self-harm in the last month or acts of self-harm in the last year. Safety planning type-interventions, i.e. interventions based on principles of safety planning which are multicomponent or supplemented with follow-up or support, can be considered.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

Stand-alone digital interventions based on evidence-based interventions such as cognitive behavioural therapy (CBT), dialectical behaviour therapy (DBT), problem-solving therapy (PST) and mindfulness should be considered as support for persons with suicidal thoughts.

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low