WHO | mhGAP
medically unexplained
OVERVIEW
Note: it was Launched by the WHO in the
year 2005 in response to the wide gap
between the resources available and
resources urgently needed to address the
large burden of MNS (Mental Neurological
and substance disorder)
● They are prioritizing the third world
country (where the resources are
not really available of the poorest of
the poor)
The mhGAP Intervention Guide (mhGAP-
IG) for
● mental, neurological, and
substance use disorders for non-
specialist health settings, is a
technical tool developed by WHO to
assist in the implementation of
mhGAP.
● The Intervention Guide has been
developed through a systematic
review of evidence followed by an
international consultative and
participatory process.
● The mhGAP-IG presents integrated
management of priority conditions
using protocols for clinical decision-
making.
● The priority conditions
○ Depression
○ Psychosis
○ bipolar disorders
○ Epilepsy
○ developmental and
behavioral disorders in
children and adolescents
○ Dementia
○ alcohol use disorders
○ drug use disorders
○ self-harm/suicide
○ other significant emotional or
complaints.
The mhGAP-IG is a model guide and has
been developed for use by health-care
providers working in non-specialized health-
care settings after adaptation for national
and local needs.
OUTLINE OF PRESENTATION
● Background of mhGAP
● Objectives of mhGAP
● Development of mhGAP-IG
● Parts of mhGAP-IG
● Framework of Implementation
● Building Partnership
● Case Scenario
WHO: Mental Health
● “A state of well-being in which the
individual realizes his or her own
abilities can cope with normal
stresses of life can work
productively and fruitfully, and is
able to make a contribution to his or
her community”
○ Stress is a normal part of our
living and we can’t escape
the stress
○ CBQ: Topmost stress
management- Large circle of
positive friends
○ Unresolved stress can lead
to-> Burnout-> anxiety
BACKGROUND:
● Depression is one of the leading
causes of disability
● Suicide is the second leading
cause of death among 15-29 years
old
○ Developmental process
● People with severe mental health
disorder conditions die
 prematurely-due to preventable
physical conditions
● 1 psychiatrist for every 100,000
people
● Fewer neurologist
● Neuropsychiatrist- more on
cognitive and more on organic
○ Parkinson’s disease
○ Dementia
Philippines:
● Mental Illness is the third most
common disability
● Around 6 million Filipinos are
estimated to live with depression
or/and anxiety
● 412 psychiatrist
● The suicide rate of 3.2
● 3-5% of the total health budget is
spent on mental health
● 14% of the global burden of
disease is attributed to a mental
health disorder
● Most of the people affected- 75% in
many low-income counties- do not
have access to the treatment they
need
Mental Health Gap Action Program
(mhGAP)
● WHO, 2008
○ Scale-up servicing for mental
neurological and substance
use disorders for countries
especially with low and lower
incomes
objectives
● To reinforce the commitment of
government, international
organization, and other stakeholders
to increase the allocation of financial
and human resources for the care of
MNS disorder patient
● To achieve much higher coverage
with key intervention in the counties
with low and lower-middle incomes
that have a large proportion of the
global burden of the MNS program.
Development of the mhGAP intervention
guide (mhGAP-IG)
● A resource to facilitate the delivery
of mhGAP evidence-based
guidelines in non-specialized
health care settings
● Grounded on the best available
Scientific and epidemiological;
evidence on priority condition
● Research in recent years have
demonstrated the feasibility of
delivery o pharmacological and
psychological interventions in
non-specialized health care
settings
○ Version 1-2010
○ Version 2-2015
Note: RHU, ZCMC, Medical Health Center
● We also have the MAP- Medical
assistance program they intertwine
○ In some cases when there’s
an excess surplus on MCHS
they give it to ZCMC ward 9
○ But still, it’s not enough
Priority Conditions:
● Depression (DEP)
● Psychoses (PSY)
● Epilepsy (EPI)
● Child and Adolescent Mental and
Behavioral Disorder (CMH):
Before they are under ASD-Autism
Spetrum disorder but not they are
not under DSM-V
○ AUTISM
○ ADHD
● Dementia (DEM)
 ● Disorder Due to Substance Use
(SUB)
○ Caffeine
● Self-Harm/Suicide SUI
Note: “Training of Trainers”- is a program
established by the DOH to train the Primary
Health Care provider, Nurses, Midwives
● Trained to how to follow the
Algorithm of mhGAP program and
how to use the mhGAP-IG
● However, people who are trained
in the Head office by the DOH are
the MHO(municipal health officers)
AND NURSES
Conduct disorder- like bullying is no
longer diagnose together in DSM 5 the
Bullying is now separate meaning that
Bullying Disorder is a separate diagnosis
OCD- Part of Anxiety Disorder
● Key features are Hair Pulling
whenever they feel anxious
● Bald Portion of the head
● BUT IN DSM-V the hair pulling alone
is now a separate diagnosis- hair-
pulling disorder (Trichotillomania)
OCD- Part of Anxiety Disorder
● Key features are Hoarding
● But in DSM-V it is now a separate
diagnosis “Hoarding Disorder”
Parts of mhGAP-IG
● Essentials Care and Practice
○ The heart of your module
○ Open Communication: Broad
openings, leading question
○ Make a safe and warm
environment
○ Active Listening
● Master Chart
● Module
○ Assessment
○ Management
○ Follow-up
Framework for Country Action
● Political commitment
○ Main foundation
● Establish a core group of
stakeholders with expertise for
guidance
● Acquisition of the necessary human
and financial resources
Assessment of needs and resources
● Describe the status of the burden of
MNS disorder
● Identify human, financial, and
materials resources
● Examine the coverage and quantity
of essential intervention, and any
reason for low or ineffective
coverage
● Describe any current policies that
are relevant to MNS
● Synthesize the information to
highlight important gaps that must
be addressed for scaling up care for
MNS
Development of a policy and legislative
infrastructure
● Draft or revise the policy to set out
its visions, values, and principles, its
objectives, and key areas for action
● Incorporate existing knowledge
about the improvement of treatment
and care and prevention of MNS
disorder
● Involve all relevant stakeholders
● Work with other relevant sectors,
and review other relevant policies
and
● Develop means for implementation
of the policy
Delivery of the intervention package
● Decisions about how best to deliver
the chosen intervention at a health
facility, community, and household
levels are critical to ensure
 maximum impact, high quality, and
equitable coverage of the
intervention
○ In this portion, we tap on
people and we train them
Strengthening of Human Resources
● Appropriate pre-service and in-
service training of different cadres of
health professional with curricula
that are needs-based and fit-for-
purpose
● Improvement of access to
information and knowledge
resources
● Development of supportive
supervisions and development of
simplified diagnostic and treatment
tools
○ MHO
○ Chief hospital of Non-
specialized hospital
○ Family medicine
Mobilization of financial resources
● Accurate costing
● Probable need to increase the
budget
● External funding could be used
Monitoring and Evaluation
● The indication for measurement can
be programmed inputs and activities,
program outputs, outcomes, and
impact/health status
○ Satellite clinic on City
health
Building relationship
● UN agencies
● Governments minutes
● Donors
● NGOs and WHO collaborating
centers
● Civil society
1. All are the basis for a disease to be
considered under ”priority
conditions”: Except for one:
a. Effects in mortality rate
b. High economic cost
c. Contradiction top socio-
cultural belief
d. NOTA
2. In which year did WHO launched the
official resources to facilitate the
delivery of mhGAP guidelines
a. 2008
b. 2009
c. 2010
d. NOTA
3. Which part of the mhGAP-IG guides
the clinician to relevant modules
a. Assessment
b. Essential Care and Practice
c. Master chart
d. NOTA
4. All are examples of significant
groups/individual that is essential for
a successful implementation of
mhGAP except for one
a. Unicef
b. Family members
c. Social Scientist
d. None of the Above
5. Which of the following is NOT a
recommended measure under
“Assessment of Needs and Actions”
a. Describe the status of the
burden of MNS disorders
b. Synthesize the information to
highlights important gaps that
must be addressed for
scaling up care for MNS
disorder
c. Draft of Revise policy to
set out as vision, values
and principles, its
objectives and key areas
for actions
 d. NOTA
6. Which of the following is NOT a
“priority conditions”
a. Dementia
b. Bipolar disorder
c. ADHD
d. None of the Above
7. Which of the following consistent
with promoting and respect and
dignity for people with MNS
conditions. Choose the best answer.
a. making a decision on behalf
of a person with an MNS
condition, with the best
internet in mind
b. Using correct medical
terminology to explain the
thing, even if complicated
c. Ensuring consent to
treatment is received from
the carer and/or family
d. Ensuring privacy in the
clinical setting
8. Which of the following is NOT a
target user/group of mhGAP-IG?
a. Community Health Nurse at
Boal heath center
b. Physician at LUUK district
Hospital
c. Nurse at Lung Center of
the Philippines
d. NOTA
9. Several feedback and evaluation
shaped the recision and
development of an updated version
of mhGAP-IG that WHO officially
published on year
a. 2014
b. 2010
c. 2015
d. 2016
10. Which of the following is NOT
included in the framework provided
by WHO
a. Political commitment
b. Situation analysis
c. Mobilization of Financial
Resources
d. NOTA
11. Dsfdf
12. Which of the following is the
emergency presentation of Self-
harm/Suicide?
a. Loss of consciousness,
bleeding from a self-
induced wound, current
thoughts of self-harm
b. The smell of alcohol on
breath, dilated pupils,
tremors
c. acute/continuous conclusion,
loss of consciousness
d. NOTA
13. Each module is in a different color
and corresponds for each priority
condition to allow easy
differentiation. Which of the following
is the correct color assigned for
“DISORDER DUE TO SUBSTANCE
USE (SUB)”
a. Disorder Due to Substance
Use (SUB)
b. Disorder Due to Substance
Use (SUB)
c. Disorder Due to Substance
Use (SUB)
d. Disorder Due to Substance
Use (SUB)
14. Sdfdsf
15. Dfdfsdf
16. In response to the wide gap between
the resources available and the
resources urgently needed to
address the large burden of mental,
neurological, and substance use
disorder, WHO launched one year
a. 2005
b. 2006
 c. 2007
d. 2008
17. The following are the sample
intervention to strengthening human
resources except:
a. Appropriate pre-service and
in-service cadres of health
professionals with curricula
that are need-based and fit-
for-purpose
b. Development of supportive
supervision
c. Describe any current
policies that are relevant to
MNS disorder and the
status of their
implementation
d. Development of Simplified
diagnostic and treatment
tools.
18. Which of the following is considered
an effective therapeutic
communication technique skill?
a. Limited eye contact
b. Speaking to the person only
and not to the carer
c. Facilitates open
communication
d. Using closed-ended question
19. Which of the following is incorrect.
a. map stands for Mental Gap
Action Program
b. mhGAP aims to scale up
services for mental,
neurological, and
substance used disorder
for countries with low and
lower-middle incomes
c. mhGAP is a resource to
facilitate the delivery of
mhGAP evidence-based
guidelines that was launched
the year 2008
20. Which of the following should you
take the care of someone who has
had an episode of self-harm or a
suicide attempt?
a. Medication will be made
available so they can keep
the person sedated
b. Restrict the person’s contact
with family, friends, and
another concerned individual
in case it is too overwhelming
c. Remove access to any
means of self-harm and try
and provide extra
supervision for the person
d. Forced vomiting is an
emergency treatment if the
suspect any self-harm or
suicide
.Purpose of Milieu Therapy
● Correct the redefine perception of
stressors
● Correct the maladaptive behavior
● Develop adaptive coping
● Acquired interpersonal and stress
management skills
● Manipulate the environment so that
all aspects of clients hospital
experiences are considered
therapeutic
● The client is expected to learn
adaptive coping, interaction, and
relationship skill that can be
generalized to other aspects of his
or her life
● Achieving client Autonomy
Principles of Milieu Therapy
● To promote fundamental respects
for an individual (staff and client)
● To use the opportunities for
communication between client and
 staff for maximum therapeutic
benefit
● To encourage the client to cut at a
level equal to their ability and to
enhance their self-esteem
● To promote socialization
● To provide opportunities for clients
to be part of unit management
● The individual is held responsible for
his own action.
● The client is expected to learn
adaptive coping, interaction and
relationship skill that can be
generalized to other aspects of his
or her life
● Achieving client autonomy
● Peer pressure is utilized to reinforce
rules and regulations.
● A team approach is used
● Group discussions and temporary
seclusions are favored approaches
for acting out behavior
● The nurses, the function is to act in a
way that consistently promotes
these goals.
CHARACTERISTICS OF MILIEU
THERAPY
● Distribution of Power
○ The milieu therapy approach
involves “flattening” the
control hierarchy so all
participants have a voice in
decisions making
○ This process may include the
whole population of the
treatment unit, or a governing
council may take the final
decision based on input from
various smaller group of
clients and staff members
● Open Communication
○ In the therapy, treatment
decisions are often made by
the client themselves, who
therefore need information to
make effective decisions
○ It is not necessary to
communicate personal but
clients and staff need to be
aware of individual treatment
goals to ensure everyone is
working toward the same
goals.
● Structured interaction
○ It is an interaction approach
that all staff members
approach the client in a
consistent manner,
acknowledging specific
diagnostic areas, therapy
shortening treatment time.
● Work-Related Activities
○ 1st: Clients need to choose
the type of work they wish to
perform
○ 2nd: Work activity should be
geared towards developing
skills that will be useful in
actual job situation
○ 3rd: A variety of activities
provide the opportunities to
test different areas for future
job interest.
● Community and Family
Involvement in the Treatment
Process
○ C;ients are kept in their usual
environment, for example a
day treatment centre, or
halfway house, and continue
most of their activities while
receiving treatment.
● Adaptation of the Environment to
meet the Developmental Need
○ To develop his full potential
an individual must have an
environment adapted to his
current need.
 ○Adapting the environment to ○ Dispose of all needles safely
meet these multiple needs is and out reach of client
challenging due to the ○ Do not allow smoking
extension of milieu therapy to ○ Restrict or monitor the use of
all age group and the matches and lighters
inclusion of family members ○ Keep aways sharp
with an individuals of varying instruments from patient
ages within the treatment ○ Identify potential weapons
milieu e.g. mop handles, hammers
COMPONENTS ○ Do not leave medicines
● The Trust Relationship unattended or unlocked
○ One of the key to therapeutic ○ Be aware of items that are
environment is the harmful ingested, e.g.
establishment of trust mercury in manometers
○ Trust is the foundation of .
therapeutic relationship, and
limit settings and consistency
are its building blocks
● Building Self-Esteem
○ Set and maintain limits
○ Accepts the clients as a
person
○ Be non-judgemental at all
times
○ Structures the clients time
and activities
○ Initially provides the client
with task, responsibility and
activities
○ Allow the client to make his
own decisions whenever
possible.
● Limit Setting
○ State the expectation or
limits as clearly, directly
and simply as possible
○ The consequence that will
follow the clients
exceeding the limits also
must be clearly stated at
the outset
○
● Maintain Self-Environment