Acute Emergencies and Mental Health

Acute Emergencies and Mental Health: the
implementation of mental health services for

populations affected by mass violence.
DRAFT
Médecins Sans Frontières-Suisse

December 2006
1
Acute Emergencies and Mental Health: the implementation of mental health
services for populations affected by mass violence (natural catastrophes and
armed conflicts).
Index:
1. Objectives___________________________________________________
2. Overview of Mental health in acute emergencies_____________________
Mental health morbidity in acute emergencies_______________________
The implementation of the mental health intervention_________________
3. The recognition of patients presenting at medical consultation with a possible
mental health problem__________________________________________
Patients with acute onset of psychological distress____________________
Patients with a psychiatric disorder or in use of psychotropic medication__
4. Patients staying in psychiatric hospitals_____________________________
5. Mental Health care and advocacy__________________________________
6. Continuation of Mental Health services_____________________________
7. The mental health of health workers________________________________
8. Mental Health Human Resources in Acute Emergencies________________
Annex 1 recommended social interventions in acute emergencies____________
Annex 2 Hopkins symptom checklist and procedures for local translations and
adaptation_______________________________________________________
Annex 3 Basic psychiatric drugs kit for 250 patients for one month__________
Annex 4 Equivalence of different psychiatric drugs_______________________
Annex 5 Profile of the most commonly used psychiatric drugs______________
Annex 6 Treatment of most frequent mental disorders_____________________
Annex 7 Children’s developmental milestones___________________________
Annex 8 Children in psychological distress during acute emergencies________
Annex 9 Psychological First Aid Manual_______________________________
Annex 10 Patient’s forms (adult &child)_______________________________
Annex 11 TOR for mental health coordinator___________________________
Annex 12 Log frame for mental health intervention_______________________
Annex 13 Monthly report template____________________________________
References_______________________________________________________
2
Acute Emergencies and Mental Health: the practical implementation of mental
health services for populations affected by mass violence (natural catastrophes
and armed conflicts).
Draft 1 . Only for internal use. Please do not distribute.
Renato Souza
1. Objectives:
This document aims to provide guidance to operational and medical managers
regarding an essential package of mental health activities that needs to be
implemented in the immediate aftermath of acute emergencies (natural catastrophes
and armed conflicts) where there is mass population displacement and casualties and
populations are exposed to acute extreme stress.
These activities have as an objective to provide mental health care as part of medical
care to populations exposed to an acute emergency where the incidence and
prevalence of mental health problems are expected to have a sudden increase and
people with mental disorders tend to become extremely vulnerable and with less
chances of having their basic and medical needs addressed.
As a humanitarian medical organisation MSF-CH believes in the provision of quality
medical care to the most vulnerable members of the society and due to its capacity to
work in periods of crisis and insecurity, MSF-CH commits itself to implement Mental
Health Care as part of medical care from the moment medical activities start.
This document is largely based on the experience acquired in the Lebanon emergency
mission during the month of August 2006 where for the first time MSF-CH decided to
implement mental health care based on 3 pillars of mental health care in acute
emergencies:
1. To provide psychological first aid to populations experiencing high levels of
psychological distress due to the acute emergency.
2. To maintain adequate levels of psychiatric care to patients with mental
disorders (new cases or previous cases that presented deterioration related to
increased amount of stressors).
3. To guarantee adequate levels of care (medication and non medication needs)
to patients with severe mental disorders staying in psychiatric inpatient
facilities/institutions.
MSF-CH understands that there are other areas of mental health (including social
support) that could have a beneficial effect on the mental health of populations
exposed to acute emergencies. Although acknowledging its relevance, as a medical
organisation, MSF-CH will advocate and mobilise other actors to get involved in the
implementation of these non-medical activities. A minimum package of social
interventions is described in the annex according to WHO recommendations.(annex
1)
3
2. Overview of mental health in acute emergencies:
2.1 Mental health morbidity in acute emergencies:

According to the WHO, in general populations, severe mental illness that severely
disables daily functioning (psychosis, severe depression, severe disabling anxiety and
epilepsy) is approximately 2-3% (12 month prevalence). These people may
experience inability to undertake life-sustaining care (or self care of their children);
incapacitating distress and social unmanageability. The 2-3% rate is likely to go up
roughly with about 50% to 3-4% after exposure to severe trauma. Trauma may
exacerbate previous mental illness, may turn moderate depression into severe
depression and cause a severe presentation of trauma-related stress disorder in some
people.
In general populations, 12-month rates of mild and moderate mental disorders
(mostly depression and anxiety disorders including Post traumatic Stress Disorder-
PTSD) is on average about 10% (World Health Survey 2000 data). This rate is likely
to go up about to 20-25% after exposure to severe trauma as it happens in acute
emergencies. Over the years, through natural recovery, rates may go down and settle
at 15%. These rates of common mental disorder vary to some extend with culture,
disaster and assessment method but give a rough indication of the size of the problem.
In general populations exposed to disasters, large proportions (more than 50%) of the
populations will be experiencing signs of psychological distress that either do not
amount to a diagnosable mental disorder or can take the form of anxiety or
depressive symptoms or medically unexplained physical symptoms (MUPS).
Because of the mainly somatic presentation of symptoms of psychological
distress, a significant proportion of these patients usually present themselves at
OPD settings.
The implementation of medical mobile clinics during the acute emergency in Lebanon
in 2006 illustrates the amount of people with a clinical picture reflecting mental health
problems that presents itself to medical care during the acute emergency period.
Table 1: Proportion of cases of mental health problems * in OPD Mobile Clinic

Consultations. Beirut, 3 days of medical mobile clinics.
Number of cases
Physical Health Conditions 90 (77%)
Mental Health Conditions 27 (23%)
Total Consultations 117 (100%)
*mental health conditions were defined as any person presenting with a mental
disorder (on treatment or not) or new onset complains characterised by anxiety or
depressive symptoms or MUPS.
After further investigation by a mental health practitioner we found out that around
80% of those cases (defined as acute psychological distress) were patients with new
onset complains characterised by anxiety or depressive symptoms or MUPS and
4
around 20% were patients with a previous history of mental disorder (defined as
chronic psychiatric disorder). (See graph below)
Distribution of MH cases according to syndromic

diagnosis
120%
100%
% of MH cases
80%
60% Series1
40%
20%
0%
Acute Chronic Other Total
Syndromic diagnosis
An overall analysis of the data (from 04th of August to 07th of August) demonstrated
that mental health problems (described here as mental disorder) in general were the
most frequent cause of presentation to the medical mobile clinics during MSF-CH
medical mobile clinics activities in Beirut.
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The third point of concern relates to the 3rd pillar of mental health care during acute
emergencies. 15 days after the war had started, the only psychiatric hospital in the
south of Lebanon that had 250 admitted patients with severe mental disorders was cut
from its supplies of medication, medical material and the number of staff was reduced
to 3 wardens.
5
2.2 The implementation of the mental health intervention:
We don’t believe that this wave of patients presenting themselves with mental health
problems at the medical consultation point is a particularity of the Lebanon
intervention. Experience from different interventions has shown similar patterns. The
difference in Lebanon was the fact that better qualified human resources are in a
better position to identify those problems at the medical consultation and refer this
influx of patients to adequate mental health care.
It is clearly possible to reach a similar quality of mental health care in poor resource
countries via the proper allocation of mental health professionals in regions where
they don’t exist or even the possibility of capacitating less qualified staff to put in
place similar services.
What is needed is the commitment to see mental health morbidity as a cause of
suffering as any other medical condition and to set up mental health services in order
to give an adequate response to the needs of people presenting themselves to medical
consultation with symptoms related to mental health problems.
What is described below is how to set up a system where patients presenting at
medical consultations with symptoms related to mental health morbidity can be
properly assessed and referred to a parallel system of mental health care. We start
from the statement that a parallel system has to be put in place, as the capacity of
medical staff is restricted to the screening and referral (and prescribing psychiatric
medication when necessary) of patients to a parallel mental health care in acute
emergencies in MSF-CH.
3. The recognition of patients presenting at medical consultation with a possible

mental health problem:
At the initiation of medical activities, all medical staff needs to be trained on how to
recognise patients with mental distress. Patients with mental distress are divided in 2
main subgroups:
• Patients with an acute onset of psychological distress (acute psychological
distress)
• Patients with a psychiatric disorder and/or in use of psychotropic medication
(psychiatric condition)
3.1 Patients with an acute onset of psychological distress (Acute Psychological

Distress):
Some particular vulnerable groups are at higher risk of developing acute

psychological distress in acute emergency contexts. Special attention should be given
to the identification and referral of patients of these groups.
People at higher risk of developing severe psychological distress in an acute

emergency:
Children (specially without parents)
Multiple displacements
Medically ill
6
Elderly
With pre-existing psychiatric disorders
With physical disabilities
Adolescents
Pregnant women and women with small children that lost income generating
members of family.
Those exposed to grotesque scenes or extreme life threat (including disaster response
workers)
Those who experienced significant loss.
For adults: Any patient presenting at OPD with symptoms of anxiety or depression
or medically unexplained somatic symptoms (MUPS) of an acute onset after a full
medical examination and if no medical diagnosis can be established, should be
referred to mental health care.
Most frequent presentation of medically unexplained somatic symptoms (if no

explanation for the patient’s complains after proper medical assessment):
• headaches
• aches and pains all over the body
• chest pain
• heart beating fast (palpitations)
• dizziness
• low back pain
• abdominal pain
• difficulty in breathing
• tremor
Most frequent presentation of medically unexplained somatic signs:
• a worried or tense look in the face
Another possibility is to use some symptoms of the Hopkins Symptom Checklist in

order to screen patients with psychological distress that would need to be referred to
the mental health team.
If no explanation for the patient’s complains after proper medical assessment,

the clinician can ask about the following symptoms:
1. Suddenly scared for no reason
2. Faintness, dizziness or weakness
3. Nervousness or shaking inside.
4. Heart pounding or racing
5. Trembling
6. Feeling tense or keyed up
7. Headaches
8. Spells of terror or panic

7
9. Feeling restless, can’t sit still
10. Blaming yourself for things
11. Crying easily
12. Poor appetite
13. Difficulty falling asleep and sleeping
14. Thoughts of ending your life
In addition, NGOs and other organisations working with victims of mass violence
should also be advised to refer patients presenting the following clinical picture (ref:
PFA : NPTSDC):
• Disoriented
• Confused
• Frantic
• Panicky
• Extremely withdrawn, apathetic or “shut down”
• Extremely irritable or angry
• Individuals who are exceedingly worried.
For children: the screening of symptoms has to be in line with the age group and
developmental stages. The screening table below describes signs or symptoms that
can help in the identification of children undergoing acute psychological distress. It is
our experience that children in severe psychological distress are rarely brought by
adults to the OPD set up; therefore, teachers and all staff working with children will
be in a better position to identify children in need. MSF-CH should liaise with such
professionals in order to receive their referrals and provide adequate mental health
care to the ones that present intense mental health symptomatology. Children with any
sign or symptom described below need to be referred to the mental health team for
further assessment and a treatment plan that will be mainly based on psychological
first aid.
Children’s psychological distress presentation:

Ages 0-5
Reactions/behaviour:
Helplessness and passivity Yes No
Generalised fear Yes No
Lack of verbalisation (e.g. selective Yes No
mutism, repetitive nonverbal traumatic
play)
Sleep disturbances (insomnia, night Yes No
terrors, nightmares)
Anxious attachment (e.g. clinging, not Yes No
wanting to be away from attachment
figures)
8
Regressive symptoms (thumb-sucking, Yes No
bedwetting, baby-talk)
Ages 6-12
Specific fears triggered by traumatic Yes No
reminders
Impaired concentration and learning Yes No
Sleep disturbances (insomnia, bad Yes No
dreams, enuresis)
Altered and inconsistent behaviour (e.g. Yes No
unusually aggressive and restless
behaviour)
Somatic complains-headaches, stomach- Yes No
aches, dizziness.
Ages 13 and up
Detachment, isolation. Yes No
Acting out behaviour (e.g. using alcohol, Yes No
drugs, sexual acting out)
Life threatening re-enactment, self Yes No
destructive or accident prone behaviour
Abrupt shifts in interpersonal Yes No
relationships
A person (adult or children) presenting one of the symptoms described after exclusion
of a medical cause, needs to be refereed to the mental health team for further
investigation. The mental health team will make a further assessment in order to try to
confirm the diagnosis of acute severe psychological distress, and at this point the
Hopkins symptom checklist can be used, if necessary, in its full version in order to
confirm a clinical impression. Procedures for developing a local translation of the
HSC are described in annex.
If the clinical picture of severe psychological distress is confirmed, the mental health
professional seeing the patient should offer “psychological first aid”.
Psychological first aid entails basic, non intrusive care with a focus on listening but
not forcing to talk; assessing needs and ensuring that basic needs are met;
encouraging not forcing company with significant others; protecting from self harm:
relaxation and sleep hygiene techniques, anxiety management and cognitive re-
restructuring when necessary. Psychotropic drugs can be used for a short period of
time in cases where symptoms of anxiety are overwhelming and do not respond to the
psychological care techniques described above.
Psychological first aid is offered by the mental health professional that is part of the
mental health team attached to the medical teams. This mental health professional
confirms the diagnosis and designs a treatment plan based on psychological first aid.
9
Flow chart of patients:
At medical consultation (or from other referrals):

• Assess and screen for symptoms of anxiety or depression or medically
unexplained somatic symptoms (or symptoms of distress for children)
• Assess and screen for current psychiatric disorder or in psychiatric
treatment. (Flow chart described later)
If one of previous options is positive, refer to mental health team
Mental Health team assessment
• New case of acute • Previous history of

psychological distress psychiatric disorder on
treatment (stable or
deteriorated)
• New case of psychiatric
disorder
• Psychological
first aid provided • Mental health team assess
by mental health the need to maintenance
team of psychiatric treatment
• Mental health team assess
the need for introduction
of psychiatric medication
If one of previous is positive :

• Refer to medical
practitioner (psychiatrist
if available) in order to
maintain or introduce
psychiatric medication
according to flow charts.
When to integrate mental health care in acute emergencies:
MSF-CH should integrate a parallel mental health team in its medical activities when
the percentage of patients coming to medical consultations presenting the
characteristics described above represent 10% or more of the consultations and there
is no other actor providing mental health care.
10
3.1.1. Psychological first aid-PFA (a manual is provided in annex):
The main goals of PFA are to reduce distress, assist with current needs, and promote
adaptative functioning (eliciting details of traumatic experience and losses is not part
of the process and is not recommended).
Where to provide: in MSF-CH settings, the mental health professional in the mental
health team provides PFA in an individual consultation (group PFA could be
considered in some situations) in a private place. The patients are referral from OPD
medical staff but could also be referral from other NGOs or organisations working in
the immediate aftermath of a mass violence event.
The mental health professional providing PFA has to provide the following 10 core
actions:
1. Establish a contact and engagement with the patient
2. To identify immediate needs and concerns, gather information and tailor PFA.
3. To use techniques of anxiety management in order to reduce the arousal of
overwhelmed patients and to use techniques of behavioural activation, and
identifying and modifying distortions in thinking to improve the functionality
of withdrawn, apathetic and depressed patients.
4. To provide information about stress reactions and coping in order to reduce
distress and promote adaptative functioning.
5. To enhance immediate and ongoing safety and provide emotional support.
6. To offer or refer to agencies that provide specific practical help in addressing
immediate needs and concerns.
7. To help to establish brief or ongoing contacts with primary support persons or
other sources of support.
8. To link patients to other needed services.
9. To book follow up consultations where levels of distress will be reassessed. A
treatment plan can be reformulated in each follow up session.
10. To refer patients to medical care (ideally psychiatric care) when distress levels
are not reduced or increase during the provision of psychological first aid.
Regarding children, on top of PFA for the parents, the following psychological
support topics should also be further explored (see annex for more details):
In general parents play a crucial role in the re-establishing of normal behavior

in children with high levels of distress. The following recommendations apply:
1. Parents should be advised to ensure enough time and a quite place to talk
to the children in order to understand their feelings and concerns.
2. Parents should be advised that children should not be exposed alone to
graphic depictions of violence through media and if accompanied not for
long time. Parents have to talk to children and understand how they feel
and what they think about what they are seeing.
3. Parents should reassure their children regarding their safety in simple
words. Discussions with children should be more oriented towards
practical problem solving and finding solutions rather than showing
11
exaggerated emotions or burdening the child with the parent’s own
concerns.
4. Parents are advised to give honest answers and information, as children
would usually know if the parent is not being honest.
5. Parents should create an open and supportive environment where children
know they can ask questions. Parents should devote their time to the re-
establishment of normalcy in the family environment as having meals
together, practicing routines together and playing with children when it is
allowed by the culture. Children should also be stimulated to play and
interact with peers.
6. Parents should discuss with children that they are safe with them and it is
not possible to promise that more bombs and attacks will not happen but
that they are going to be together.
7. Parents should stimulate children to play or draw in order to express
themselves.
8. Parents should do pleasurable activities with children on a daily basis.
9. Parents should be advised not to use violence under any circumstance.
10. Be alert to continuous sleep problems, bedwetting, mutism, isolation, lack
of appetite and attacks of fear as they sign that more intensive and daily
follow up consultations are needed.
11. Be alert to violence and abuse within the family or settlement environment
for children who do not improve with the described interventions.
All these interventions can be promoted by members of the mental health team
where the mental health professional and relatives (or family) work together
during the psychological consultations. Playing and drawing material that is
culturally acceptable should be used during the consultations.
3.2. Patients with a psychiatric disorder or in use of psychotropic medication

(psychiatric condition):
When patients fulfilling this category are identified at the OPD consultations, they
also have to be referred to the mental health team.
The mental health team will, as previously, perform a mental health assessment and
decide on one of the following options:
• Patient with previous history of psychiatric disorder and stable on treatment.
• Patient with previous history of psychiatric disorder and presenting
deterioration in clinical status.
• Patient with a new psychiatric disorder in need of psychiatric treatment.
It is important to mention that in most of the settings where MSF-CH works, the
scarcity of resources and the weakness of public health services culminate in a
situation where it is very rare to see patients receiving an adequate psychiatric
treatment.
Therefore, as a rule, if in an acute emergency a significant number of OPD
consultations are for patients already in use of psychotropic medication, a medical
professional with experience in psychiatry needs to be integrated in the mental health
team (e.g. psychiatric clinical officer or psychiatrist or psychiatric nurse).
12
Rule of thumb:
If there is significant proportion of patients coming to OPD describing current use of
psychiatric medication, a doctor or clinical officer or nurse with experience in
psychiatry needs to be incorporated in the mental health team.
In settings where there are no psychiatric professionals available, it will fall in the
competency of the mental health workers to assess the patient and take a clinical
decision in one of the 3 possibilities described above.
• Patient with previous history of psychiatric disorder and stable on treatment:
These patients have to be kept on the medication that they are using. The
environmental stressor is a risk factor for relapse, if they have not relapsed at this
time, we should put efforts on making them remain stable. In the acute emergency
phase, it is recommendable not to change their medication.
In some situations, MSF-CH does not have the medication that the patient is
taking and other sources of that medication are also not accessible.
In the previous situation, the presence of a medical person experienced in
psychiatric care is desirable as the manipulation/titration of psychotropics pose
high risk of relapse of the psychiatric condition.
In annex, we present the list made by MSF-CH with essential psychotropic drugs
for a volume of 250 psychiatric patients per month. The list covers the most
frequent psychiatric conditions and first and second line drug treatment for these
conditions.
The patients should be offered the possibility of having their medication changed
to a medication that is present in the essential list, this should only be done by a
medical person experienced in psychiatric care and the patient needs weekly
follow up for a minimum period of one month. In order to facilitate this process,
in annex we provide a list of psychotropic medication with their equivalent
dosages.
• Patient with previous history of psychiatric disorder and presenting

deterioration in clinical status:
When the mental health workers identify deterioration in the clinical status of a
patient with a previous psychiatric disorder, the immediate reaction should be to
provide psychological first aid.
The patient should then be referred to medical personnel that could adjust the dose
of the medication.
The presence of a medical personnel experienced in psychiatric care is ideal as a
manipulation of the psychiatric medication or change to another medication will
be needed.
In the absence of those personnel, the psychiatric drug in use should be increased
as follows (only for adults or pregnant women not in the first 3 months of
pregnancy):
13
• Patients with clinical depression and anxiety disorders (Panic disorder,
OCD, generalised anxiety disorder, PTSD, social phobia):
Amytriptiline can be increase by 50mg every week until the dose of 150mg.
Anticholinergic side effects have to be monitored at every consultation.(e.g.
dry mouth, constipation, urine retention, blurred vision)
Fluoxetine can be increase by 20mg every two weeks until the dose of 60mg.
Chlomipramine can be increased by 50mg every week until the dose of

150mg.
Anticholinergic side effects have to be monitored at every consultation. .(e.g.
dry mouth, constipation, urine retention, blurred vision)
• For patients on benzodiazepines:

Doses of diazepam can be increased up to 20 mg per day for adults with no
risk of respiratory depression (mainly elderly or previous respiratory or
cardiac pathology are at risk). For pregnant women there is risk of severe
abstinence syndrome in the newborn. All patients on benzodiazepines should
be advised to return to consultation, as long-term use of benzodiazepines
should be avoided.
• Patients with psychotic syndromes (bipolar disorder and schizophrenic

syndromes):
Haloperidol (if there are hallucinations or delusions) can be increased by 2,5
mgs per week to a maximum dose of 10mg per day. The use of an
anticholinergic is highly desirable as biperidene up to 6 mg or benzhexol 8 mg
per day. Close monitoring of parkinsonian side effects need to be done at
every consultation.
Chlorpromazine (if there are hallucinations or delusions) can be increased by

50 mg per week to a maximum dose of 300 mg per day. Close monitoring of
parkinsonian side effects need to be done at every consultation. Sedation and
postural hypotension need to be monitoring specially in the elderly and people
with low body mass index.
Risperidone (if there are hallucinations or delusions) can be increased by 2 mg

per week to a maximum dose of 8 mg per day.
Althought less frequent with this class of anti-psychotics, monitoring of
parkinsonian side effects need to be done at every consultation and an
anticholinergic is desirable as biperidene up to 6 mg or benzhexol 8 mg per
day in case parkinsonian side effects appear.
Carbamazepine (for patients with bipolar disorder) can be increase by 200 mg

per week to a maximum dose of 800 mg per day. After this dose serum levels
should be monitored. Monitoring of nausea, difficulty walking, constipation,
sedation, allergic reactions and hyponatremia should be in place.
Sodium valproate (for patients with bipolar disorder) can be increased weekly
14
by 200mg to a maximum dose of 1000 mg. After this dose serum levels should
be monitored. Close monitoring of nausea, drowsiness, diarrhea, jaundice,
signs of liver failure and pancreatites should be in place.
Lithium carbonate (for patients with bipolar disorder) should never be

increased in the absence of recent serum level. If serum levels available,
increase up to 1,200-1,800 mg/day in 3 divided doses to achieve serum lithium
concentrations between 0.6 and 1.2 mmol/L.
For parkinsonian side effects benzhexol can be used up to the dose of 8mg per
day; or biperidene up to 6 mg per day.
* Higher doses can be prescribed by specialists in psychiatry.
All patients should receive adequate information about their disease, the necessity
of the treatment and dose adjustment, the purpose of drug treatment and the main
side effects of each drug that they are taking. The family should always be
provided with the same information after patient’s consent for disclosure. In the
annex, a full description of the most frequently used psychiatric drugs, their uses,
dosage and main side effects.
If there is suspicion of pregnancy; lithium, carbamazepine, valproate, clonazepam
and other benzodiazepines, tryciclic antidepressants and all antipsychotics should
be avoided. In case of high risk of relapse of a severe mental disorder, these drugs
can be used but not on the first 3 months of pregnancy. Appropriate ante-natal
care and availability of specialised care for the new born is strongly recommended
in these cases.
• Patient with a new psychiatric disorder in need of psychiatric treatment:
This part is of particular importance as we realise that most of the countries where
MSF works, the integration of mental health care in primary health care is far
from being implemented. Most medical personnel have not been trained in the
diagnosis and treatment of psychiatric disorders but the data presented in the
introduction of this paper shows a dire picture.
Patients with common mental disorders present themselves at OPD but are not
diagnosed neither treated; patients with severe mental disorders are neglected due
to cultural and local customs that relate psychotic behaviour as possession or a
higher power punishment.
In an acute emergency, we still follow the flow of patients that has been described
in this paper, therefore when an OPD doctor suspects of a patient with a mental
disorder, he/she will refer this patient to the mental health team. The mental health
team has to confirm the diagnosis and assess the necessity of psychotropic
medication. As medication can only be prescribed by medical personnel, the
mental health team has to refer the patient to a doctor that can prescribe the
appropriate medication when the diagnosis of a psychiatric disorder is confirmed
by the mental health team.
15
We present a model of syndromic assessment of mental disorders that can be used
to help the mental health team and the medical personnel to refine the diagnosis
and be able to treat the mental health condition. In acute emergencies where the
number of these patients shows to be high, a doctor with experience in psychiatric
care is desirable. (The flow charts below only show the syndromic diagnostic
approach, the treatment procedures are described in annex.)
The following description aims to help in diagnosing patients that might be

presenting a new onset mental disorder.
Patients with strange and disruptive behaviour:

Typical presentation:
• Aggressive behaviour
• Confused behaviour
• Agitated behaviour bizarre or unusual behaviour
IS THIS DELIRIUM?
If the person appears confused and out of touch with reality
Especially if there is evidence of infection (fever, neurological signs), head injury
(signs of injury on the head) or stroke
If so, treat for confusion (in annex)
ASK ABOUT ALCOHOL OR DRUG WITHDRAWAL OR INTOXICATION

Such as history of problem drinking or drug abuse, smell of alcohol
If so, treat for alcohol or drug dependence (in annex)
ASK ABOUT PSYCHOTIC SYMPTOMS

Such as hallucinations (hearing voices) or delusions (ideas incongruent with
reality)
If so, treat for psychosis (in annex)
ASK ABOUT RECENT DEPRESSED MOOD

Such as suicidal ideas (guidelines for screening in annex), loss of weight and poor
sleep
If so, treat as for suicidal behaviour (in annex)
ASK ABOUT RECENT TRAGIC EVENTS

Such as sudden loss or violence
If so, treat as for bereavement (in annex)
Or post traumatic mental illness (in annex)
16
Patients with symptoms that are medically unexplained that persist for more
than 2-3 weeks without improvement after provision of psychological first
aid:
Such symptoms include:
• Aches and pains (including headaches)
• Tiredness, fatigue
• Palpitations
• Dizzinnes
• Bowel complains (constipation/loose motions)
• Sudden loss of motor function
• Chest pains
• Difficulty breathing
RULE OUT A DEFINITE PHYSICAL ILLNESS

By clinical history and examination of relevant organ system
If required, investigations such as X-ray, hemogram, etc…
IF NO PHYSICAL ILLNESS OR IMPROVEMENT ON USUAL

TREATMENT
ASK ABOUT STRESSES AND PROBLEMS THAT HAVE NOT BEEN
ADDRESSED DURING SESSIONS OF PSYCHOLOGICAL FIRST AID
For example intra-familiar violence and other forms of violence (including
sexual violence) in the displacement accommodation, no access to basic
humanitarian needs as protection, food and water and sanitation.
If so, help the patient to reach organizations that can address those needs.
If necessary discuss with management team for possibilities of advocacy on
behalf of the patients
ASK ABOUT SYMPTOMS OF DEPRESSION OR ANXIETY

Such as loss of interest in daily activities, feelings of sadness tension or worry,
sleep and appetite problems, suicidal ideas.(depression checklist in annex)
TREAT FOR DEPRESSION OR ANXIETY

If symptoms are present provide:
Education about the condition
Reassurance
Relaxation exercises
Problem solving counseling
Antidepressants (in annex)
17
Patients that could be presenting problems related to abuse or dependence of
substances:
Suspect alcohol/drug dependence in the following situations:
• Poor physical health
• Stomach or liver disease (alcohol)
• Skin infections (intravenous drug use)
• Repeated accidents and unexplained injuries
ASK RELEVANT QUESTIONS ABOUT DRINKING AND/OR DRUG USE

1 Have you often in the last month found that you were not able to stop
drinking/using drugs once you had started?
2 Have you needed during the past month to have a drink/or drug in the morning
to get yourself going?
3 Have you during the past month failed to do what was normally expected of
you because of drinking/use of drugs?
IF ANY POSITIVE ANSWERS

Obtain a detailed history of alcohol and/or drug use in the past month
HEAVY DAILY
DRINKING/DRUG
ABUSE
Treatment for alcohol
or drug withdrawal
syndrome (in annex)
BINGE DRINKING OR OTHER

DRINKING PROBLEM NOT
ACCOMPANIED BY WITHDRAWAL
SYMPTOMS
OTHER TYPES OF DRUG ABUSE
Treatment of physical health problems
Health Education
Family counseling
Techniques to stay sober (e.g. monitoring
alcohol consumption)
Regular review
If depressed: treat accordingly (in annex)
Referral to Alcoholics Anonymous if
available.
18
Children with mental health problems (that do not improve with
psychological first aid) (PFA adapted to children is in annex):
Typical presentations would be:
• Naughty and undisciplined
• Withdrawn and quite
• Regressive behavior
TAKE A CAREFUL HISTORY OF DEVELOPMENT

Check for developmental milestones (in annex)
If history of delay, consider mental retardation (check annex for management
of behavioral problems).
ASK ABOUT BEHAVIOUR AT ACCOMODATION CENTER AND

FAMILY ENVIRONMENT
Investigate if child lost close family members or friends, witnessed traumatic
events or present intense worries or concerns or child has physical illness.
Verify the support system, protection issues, signs of violence and abuse or
neglect in the home environment and the mental state of caretakers.
Also consider:
Child abuse (discuss with coordination team)
Conduct disorder
Depression or PTSD (for the last two, consult HQ as the treatment in children
is in the domain of the specialist)
General Mental Health Indicators:
For purposes of operational and human resources planning 3 set of indicators

are important:
1. At OPD level:
• percentage of cases at OPD that have a mental health problem (done
at OPD level)
* patients with more severe medical diseases (at IPD) should also be screened
for those signs and symptoms.
2. At Mental Health Team level:

• percentage of cases with mental health problems that have acute
psychological distress.
• percentage of cases with mental health problems that have a
psychiatric condition.
3. Psychiatric hospitals have access to adequate supply of medication and basic
needs of patients are addressed.
19
4. Patients staying in psychiatric hospitals:
In times of war and mass displacement, those with established mental illnesses are
vulnerable to abuse, neglect, abandonment, and exploitation. Institutions, including
psychiatric facilities, are usually destroyed or abandoned, leaving patients without
protection, medication, or social support. Individuals with overt psychosis may be
found living in states of gross dereliction, commonly falling prey to malnutrition,
stigma, ostracism, and even violence. The mentally ill are at risk therefore of life-
threatening physical illness, death from misadventure, or violence and suicide.
MSF-CH accepts that the immediate support to patients living in psychiatric
institutions is of paramount importance during an acute emergency. This
responsibility also lies on the fact that MSF-CH might be the only organisation able to
reach those facilities and guarantee that during periods of crisis, this extremely
vulnerable group of patients receive adequate medical care and don’t have their
medication interrupted.
In order to do that, MSF-CH should:
• Proactively check if in the country where MSF-CH deploys medical relief
activities, there is a psychiatric hospital in need of medical supplies.
• Guarantee that the hospital has enough conditions to continue the medical
care of psychiatric patients.
• Advocate for continues medical care to patients living in psychiatric
institution.
In annex, we provide a list of essential psychiatric drugs developed for standard

psychiatric hospitals caring for 250 patients for a period of one month. This list might
need to be adapted depending on the region of the world where the hospital is located
and its psychopharmacological practices.
We should proactively send this standard kit together with the first deployment of
emergency supplies in order to avoid delays in the provision of medication to these
patients.
5. Mental Health Care and Advocacy:
We believe that is part of the job of mental health teams to continuously assess
violations of human rights and abuse against civilian populations and in particular
against our beneficiaries.
Refugee settlements and IDP camps can also pose particular threats to the most
vulnerable members of the society as women, children, the elder and people with
physical or mental disability.
MSF-CH believes that the clear documentation of these abuses could bring the
possibility of advocacy with the objective of improving the situation of specific
vulnerable populations.
Special consideration and attention has to be given to interpersonal violence where the
displaced population is staying, taken into consideration sexual, physical,
psychological violence and neglect and deprivation.
In the annex, a violence questionnaire is incorporated into the patient forms.
Psychological first aid is the essential mental health care that needs to be provided to
victims of violence including sexual violence. All victims of violence, recent or past,
20
need to be immediately referred to the medical personnel for medical assessment and
treatment. It is important to remember that victims of sexual violence can receive a
complete package of medical care (PEP, vaccination against tetanus and Hepatites B,
STI treatment, treatment of wounds and anticonceptional pills) in all MSF facilities.
Further programmatic details on that can be requested in the HQ.
6. Continuation of Mental Health Services:
Although threshold indicators can not still be established, it is important to keep in

mind the following variables that will demand for a change in strategy:
• The end of the acute emergency.
• The acute emergency is transformed into a chronic conflict.
• The decrease in the percentage of patients with acute psychological distress
coming for OPD consultations.
• The re-establishing of previously available mental health services.
As soon as the situation permits, mental health care should be incorporated into the
existing system of primary health care as recommended by WHO, and the parallel
system created by MSF-CH in order to cope with the high influx of patients with
acute psychological distress will be withdrawal or transformed into support to the
integration via training and expertise.
The process of integration of mental health care into primary health care should focus
on the following key areas:
• Capacitation of primary health care medical staff to diagnose and treat mental
disorders.
• To develop community awareness on MH promotion and the availability of
mental health care at the community and at primary health care level.
• To establish a system of care and support at the community level for people
with severe mental disorders.
• To establish psychosocial support and care for children and adolescents who
faced trauma or loss /at school and community level)
A specific package of activities concerning this area will be provided as part of

another MSF-CH Mental Health document.
7. The mental health of health workers:
During an acute emergency, the kind of work which a health worker does and the
setting, which she works, may pose special stress and increase risk of burn out.
Some points are important to mention:
• When the health worker is also a victim of an external aggression, for
example, in a disaster or war situation – despite being a victim or having a
family member as a victim, the health worker may be required to ignore her
own needs in order to provide psychological care to people who have been
affected.
• The nature of the work and the risks involved in providing psychological care
during acute emergencies are also related to increased risk of burn out.
21
• The chaotic management of emergency missions and the extreme workload
certainly contribute to high levels of stress and chance of burn out.
Based on that, MSF-CH will offer psychological support to national staff and
expatriate staff involved in missions in contexts of acute emergencies.
Regarding expatriate staff, the set up of support falls under the responsibility of the
Department of Human Resources.
Regarding national staff, the medical coordinator should incorporate that component
inside the health policy for national staff. Emphasis should be put on the provision of
psychological support done by an external non-MSF mental health professional.
When such a professional does not exist, Human Resources Department and Renato
Souza can advise the capital teams on different possibilities.
8. Mental Health Human Resources in Acute Emergencies:
The MH team composition includes:

A MH coordinator (in general expatriate) is mandatory when deciding to set up MH
care in acute emergencies. The competencies are described in annex.
The MH workers should be preferentially psychologists or clinical counsellors. The

right number is one professional for an average of 8 MH consultations per day.
Therefore the number of referrals from the medical team to the MH team has to be
properly monitored.
In contexts where there are many patients on psychotropic drugs or where the MH
team recognises a high amount of people with mental disorders that would benefit
from psychiatric care immediately demands for a medical practitioner with experience
in psychiatry to be incorporated in the mental health team. The MH coordinator could
fill this task if he/she is a psychiatrist.
22
Annex 1:
Recommended Social Interventions in acute emergencies:
Sphere Key Social Intervention Indicators

1. People have access to ongoing, reliable flow
of credible information on the disaster and
associated relief efforts.
2. Normal cultural and religious events are

maintained or re-established (including
grieving rituals conducted by relevant spiritual
and religious practitioners). People are able to
conduct funeral ceremonies.
3. As soon as resources permit, children and
adolescents have access to formal or informal
schooling and to normal recreational activities.
4. Adults and adolescents are able to
participate in concrete, purposeful, common
interest activities, such as emergency relief
activities.
5. Isolated persons, such as separated or
orphaned children, child combatants, widows
and widowers, older people or others without
their families, have access to activities that
facilitate inclusion in social networks.
6. When necessary, a tracing service is
established to reunite people and families.
7. Where people are displaced, shelter is
organized with the aim of keeping family
members and communities together.
8. The community is consulted regarding
decisions on where to locate religious places,
schools, water points and sanitation facilities.
The design of settlements for displaced people
includes recreational and cultural space.
23
Annex 2:
Hopkins symptom checklist and procedures for local translation and adaptation:
The following questions you can indicate what complaints you have suffered the last seven days
(including this one). The questions in red need to be checked for cultural appropriateness.
1. Suddenly scared for no reason

Not at all A little Quite a bit Extremely
2. Feeling fearful
3. Faintness, dizziness or weakness

4. Nervousness or shaking inside.

5. Heart pounding or racing

6. Trembling
7. Feeling tense or keyed up

8. Headaches
9. Spells of terror or panic

10. Feeling restless, can’t sit still

11. Feeling low in energy

12. Blaming yourself for things

13. Crying easily

14. Loss of sexual interest or pleasure.

15. Poor appetite

16. Difficulty falling asleep and sleeping

17. Feeling hopeless about the future

18. Feeling blue

19. Feeling lonely

24
20. Thoughts of ending your life
21. Feeling of being trapped or caught

22. Worrying too much about things

23. Feeling no interest in things

24. Feeling everything is an effort

25. Feeling of worthlessness

The checklist needs to be translated to the local language by a bilingual translator.

Another translator (without contacting the first one) will translate back from the
local version to a new English version.
The mental health person in the field will compare both English versions (the
original and the new one produced via translation and back translation) and verify
which terms and expressions do not agree.
The whole team should meet and agree on the most simple and adequate terms,
the agreements should be incorporated in the local version scale.
The local version scale needs to be tested in a group of people from the same
social and educational level of the beneficiaries. Further changes and adaptations
will be made. It is very important that the final version has terms and expressions
of the local target population and not from the professionals working with MSF as
these usually come from higher social and educational strata of the society.
Cut off scores:

Although it needs to be revalidated locally (contact HQ for methodology), the
international cut off scores suggested are:
1,75 is the cut off score. It is calculated as follows:

0 points 1 2 3
All points in all questions are summed and the result is divided by 25. Therefore you
have the mean score.
Sum of points / 25 = mean score.
If greater than 1,75 it is highly likely that the person has severe psychological distress.
This diagnosis has to be corroborated by clinical impression.
25
Annex 3:
Basic psychiatric drugs kit for 250 patients for one month (with the most
frequent psychiatric diagnosis)
Oral:
Fluoxetine 20 mg: 3600 tablets
Clomipramine 25 mg: 3600 tablets
Amytriptiline 25 mg: 3600 tablets
Risperidone 2mg: 2500 tablets
Chlorpromazine 25 mg: 3000 tablets
Benzexhol 2mg: 6000 tablets
Biperidene 2 mg: 3000 tablets
Haloperidol 5 mg: 3000 tablets
Haloperidol 2mg: 1500 tablets
Clonazepam 2 mg: 3600 tablets
Carbamazepine 200 mg: 12 000 tablets
Carbamazepine 100 mg: 6000 tablets
Valproate 200 mg: 12 000 tablets
Lithium carbonate 300 mg: 6000 tablets
Diazepam 5 mg: 2000 tablets
Phenobarbital 100 mg: 2000 tablets
Phenobarbital 50 mg : 2000 tablets
Injectables:
Diazepam 2 ml : 50 amps
Haloperidol 2 mg : 50 amp
Prometazine 2 ml : 50 amp.
Extra (assess if needs are present) :
Lamotrigine and topiramate and phenytoin 100 mg (for epilepsy)

Valproate syrup (epilepsy in children)
26
Clozapine (resistant schizophrenia)
Fluphenazine (decanoate or enantate) injection, 25 mg in 1 ml ampole
Methadone (treatment of opioid dependence)
27
Annex 4:
Equivalence of different psychiatric drugs.
Approximate equivalence dosages have only be established for antipsychotics:
Chlorpromazine 100 mg/day equals:

Haloperidol 5 mg/day
Risperidone 2 mg/day
Olanzapine 5 mg/day
Quetiapine 75 mg/day
Ziprazidone 60 mg/day
Aripiprazole 7,5 mg/day
For substitution of antidepressants, it is recommended to reduce the dose of the

antidepressant by reducing one third of the dose every 2 days; a wash out period
of 2 days and then introduce the new antidepressant as recommended by the
dosage of the new antidepressant. This rule applies if the antidepressant being
reduced is a tryciclic with short half-life. If it is an SSRI as fluoxetine, a longer
wash out period (one-two weeks) is advisable as fluoxetine metabolites have long
half-life and strongly inhibit the cytocrome P450 2D6 increasing the serum levels
and chance of toxicity of the new antidepressant that will be prescribed. A
specialist is usually required.
For benzodiazepines, please contact psychiatrist in the country or HQ due to risk

of convulsive crisis during withdrawal of benzodiazepines.
No recommendation is given to mood stabilizers as our list contains the most

frequently used mood stabilizers.
28
Annex 5.
Profile of the most commonly used psychiatric drugs.
Antipsychotic medicines for severe mental disorders and people who are
confused, agitated or aggressive.
Low potency antipsychotic drugs: these drugs have a lower risk of side
effects.
Chlorpromazine:
Uses:
Helps sleep and is useful given at night for people with a psychosis and sleep
problems.
Dosage:
Start with 25 mg at night; increase up to 200-300 mg divided in two doses or one
dose at night.
Side effects: Stiffness, dryness of mouth, restlessness, drowsiness, dizziness,
weight gain, sudden jerky movements.(this drug poses low risk of acute dystonia)
High potency older antipsychotic drugs: these drugs have a higher risk of
side effects.
Haloperidol:
Uses:
Useful for severe agitation and is less sedative.
Dosage:
Start with 2,5 mg at night; increase up to 10 mg divided in two doses or one dose
at night.
Side effects: Stiffness, dryness of mouth, restlessness, drowsiness, dizziness,
weight gain, sudden jerky movements.
High potency newer antipsychotic drugs: these drugs have a lower risk of
side effects.
Risperidone:
Uses:
Potent drug, fewer side effects.
Dosage:
Start with 2 mg at night; increase up to 6-8 mg.
Side effects:
Drowsiness, restlessness, agitation.
Antidepressant medicines, for common mental disorders (panic attacks,

depression, anxiety, obsessive-compulsive disorders, PTSD, medically
unexplained physical symptoms)
Amytriptiline:
Uses:
Common mental disorders as depression and anxiety as well as sleep problems
29
Dosage:
Start with 25 mg at night, increase in steps up to a minimum of 75 mg and a
maximum of 150 mg.
Side effects:
Drowsiness, dry mouth, dizziness, weight gain, blurred vision, constipation and
arrhythmia in people with previous history of cardiac disturbance or recent
myocardial infarction.
Imipramine:
Uses:
Same as with amytriptiline, but is also useful for bed wetting in children.
Dosage:
Same as with amytriptiline
Side effects:
Same as with amytriptiline but is less sedative.
Clomipramine:
Uses:
Same as with amytriptiline but is also useful for obsessive compulsive disorder
Dosage:
Same as with amytriptiline.
Side effects:
Same as with amytriptiline
Newer antidepressants (SSRI-selective serotonin reuptake inhibitors).
Fluoxetine:
Uses:
Common mental disorders as depression, anxiety, panic disorder, OCD,
generalized anxiety disorder and PTSD.
Dosage:
Start with 20 mg in the morning, increase by 20 mg on a 4 weeks interval up to 60
mg per day in the morning.
Side effects:
Nervousness, headaches, insomnia, fatigue, nausea, diarrhea, loss of appetite,
sexual impairment (most of the side effects appear at initiation of treatment and
will probably subside in one week period). For gastrointestinal symptoms,
antihemetics and fibre rich diet can be of help
Anti-anxiety and sleeping medicines. For short term use for anxiety problems
and sleep difficulties (these medicines must not be used for more than 4
weeks at a time to avoid dependence):
Diazepam
Uses:
For anxiety and difficulty sleeping, alcohol withdrawal and delirium tremens.
30
Dosages:
Start with 5 mg at night, increase up to 20 mg that can be divided in two doses.
Side effects:
Drowsiness, dizziness, dependence (if used for long periods), suppression of
breathing (in overdose).
Clonazepam
Uses:
Same as with diazepam but also useful for epilepsy.
Dosages:
Start with 0,5 mg at night, increase up to 2 mg that can be divided in two separate
dosages.
Medicines for manic-depressive disorder (mood stabilizers):
Lithium carbonate:
Uses:
For the control of manic-depressive disorder; avoid if serum levels cannot be
obtained or when the person is taking diuretics or presents diarrhea.
Dosage:
400-1200 mg a day given as a single dose; serum levels must be 0,6-1,2 mmol/l
Side effects:
Nausea, diarrhea, weight gain, increase thirst, interactions with non-steroid anti-
inflammatory drugs. Note that lithium can be very dangerous if taken in excess.
Sodium valproate:
Uses:
Same as with lithium but also for epilepsy.
Dosage:
Start with 400 mg divided in two doses (200 mg am and 200 mg pm). Increase by
200 mg on a weekly basis up to clinical response, side effects or 1200 mg per day.
Side effects:
Nausea, drowsiness, diarrhea, weight gain, tremor, jaundice, liver failure,
pancreatites.
Carbamazepine:
Uses:
Same as with lithium but also for epilepsy.
Dosages:
Start with 200 mg a day; increase over 2 weeks to 800 mg a day. If available,
serum levels should be in the range 8-12 mg/l.
Side effects:
Nausea, difficulty walking, constipation, sedation, serious allergic reactions,
hyponatremia. Sudden fall in blood count can occur.
31
Anticonvulsant medicines, for the control of epilepsy:
Phenobarbitone:
Uses:
For all types of epilepsy in adults.
Dosage:
2 mg/kg/day at night. (maximum of 100 mg at start). Increase progressively up to
6 mg/kg/day if necessary.
Side effects:
Drowsiness, restlessness, confusion.
Phenitoin:
Uses:
Dosage:
Start with 150 mg once daily; increase in steps up to 600 mg daily.
Side effects.
Nausea, tremor, dizziness, headaches.
Sodium valproate:
Uses:
Dosage:
Start with 600 mg per day divided in two doses. Increase 200 mg every 3 days up
to clinical response or side effects. In general the therapeutic dose is around 1000
to 2000 mg per day divided in two doses.
Side effects:
Nausea, drowsiness, diarrhea, weight gain, tremor.
Carbamazepine:
Uses:
For all types of epilepsy. (it is first choice for partial syndromes).
Dosage:
Start with 200 mg per day. Increase 200 mg each week up to therapeutic response
or side effects. (In general the therapeutic dose is around 800 to 1200 mg per day
that can be divided in 2 to 4 times per day).
Side effects:
Nausea, difficulty walking, constipation, sedation. Sudden fall in blood count can
occur.
Other medicines used for mental illness:
Procyclidine
Uses:
For side effects of antipsychotic drugs.(parkinsonial side effects as slowness,
rigidity, tremor, parkinsonial gait and cogwheel sign). For acute dystonia after
initiation of antipsychotics, IM administration is preferable)
32
Dosage.
2,5 mg twice daily; increase up to 5 mg three times daily.
Side effects:
Dry mouth, constipation blurred vision, urinary retention, confusion.
Benzhexol
Uses:
Same as with procyclidine.
Dosage:
1 mg once daily; increase up to 2,5 mg three times daily.
Side effects:
Benzhtropine:
Uses:
Same as procyclidine.
Dosage.
0,5 mg at night; increase up to 2 mg at night.
Biperidene:
Uses:
Same as procyclidine.
Dosage:
2 mg in the morning, increase up to 6 mg. (can be divided during the day)
Side effects:
Thiamine.
Uses:
For drinking problems and alcohol withdrawal.
Dosages:
20-50 mg three times daily.
Side effects:
Rarely reported.
33
Annex 6.
Treatment of most frequent mental disorders during acute emergencies.
Delirium, confusion and/or agitation (including alcohol abstinence/delirium

tremens):
People who are in confusional state should always be investigated for physical or
medical disorders that could be the cause of the confusion. Particular emphasis on
the investigation has to be done in the medically sick, the elder and children. Brain
and metabolic conditions are the main causes of confusional states. Aggressive or
agitated behavior can be an expression of a confusional state due to brain insult.
Main causes:
Side effects of medicines, withdrawal from alcohol (delirium tremens) or
sedatives or drug intoxication, brain illness as strokes, head injury and epilepsy,
AIDS and brain infections, drug overdose. In the tropics consider malaria,
trypanossomiasis, brucellosis and typhoid.
Treatment:
1. perform a physical examination and investigate the cause in order to rule
out a medical emergency.
2. place person in a private, calm and comfortable place with not many
external stimulus.
3. keep the patient (if possible) with relatives.
4. Give time and place orientation.
5. Restraining under close monitoring and observation can be an option in
very disrupted patients.
6. If the person is very agitated, administrate haloperidol 5 mg (2 mg in the
elder and persons who are sick or caquexic), by intramuscular injection. It
can be repeated up to 3 times per day, and after agitation subsides,
haloperidol can be prescribed orally 3 times per day at the same dose that
was used in IM injection but maximum dose of 10 mg per day.
Haloperidol will be removed gradually (2 mg every week) after condition
is medically stabilized and if medical explanation was found for the
confusional state. These medicines are palliatives and the most important
thing is to treat the cause.
7. Consider a referral to hospital in case of confusion as a sign of medical
emergency
8. Address the medical cause of the confusional state after the cause is
identified
To remember:
In tropical zones, confusion can be a sign of malaria, trypanossomiasis, brucellosis
and typhoid that needs to be immediately investigated and treated as other
infections diseases that can affect the brain. Opportunistic infections due to
HIV/AIDS have to be always ruled out.
34
Alcohol withdrawal and delirium tremens is constituted of confusion,
hallucinations, tremor and convulsive crisis and it usually starts 24 hours after the
person stops heavy alcohol consumption. Investigation of other medical
complications has to be done in all cases.
The treatment consists of:
Thiamine 100 mg intramuscular and daily oral intake of thiamine 50 mg tablets
for the period of one week plus folate 1 mg PO plus multivitamins. Give glucose
if signs of poor nutrition and fluids should be administrated.
During the alcohol withdrawal or delirium tremens administrate diazepam 10 mg
PO every hour until the patient calms down and the main symptoms disappear.
Up to a maximum of 30 mg per day. (monitoring respiratory function) if the
patient does not improve with 30 mg, he/she has to be referred to treatment center
or hospital.
For the next day, give the same dose of diazepam but divided in 3 times per day.
Then start reducing the dose of diazepam by 10 mg per day until it is totally
removed.
Alcohol or Drug dependence (the treatment of withdrawal and delirium

tremens was described under confusion and/or agitation):
Alcohol and some drugs are part of cultural habits of many cultures. The medical
practitioner should be concerned when people drink too much or use drugs in a
way that lead them to present behaviors that due to the excess use of alcohol or
drugs can lead to poor health in general including signs of mental health problems
including impairment in social and community life.
This section only describes the treatment strategies for alcohol abuse and
dependence as the diagnosis and treatment of other drugs related abuse and
dependence demands for more specialized care and are considered the job of the
specialist.
In general:
Man drink too much with high risk for their health if they drink more than 3
standard drinks per day.
Women drink too much if she drinks more than 2 standard drinks per day.
People drink too much when they have to drink in the morning when they wake
up.
People drink too much if they have one or more health or social problems related
to the drinking.
People with the criteria above should be advised by a medical practitioner

regarding harmful effects of alcohol and treatment should be offered. Patients can
be helped through motivational interviewing but the final decision to stop drinking
with or without the help of a medical practitioner relies on the patient.
Reasons for drinking too much:

Peer pressure
Times of stress
Depression
35
Development of dependence to alcohol where it is difficult to resist to the impulse
of drinking due to psychological and physical signs of withdrawal.
Treatment strategies (don’t forget about privacy, confidentiality and avoiding any
kind of moral judgment):
1. Discuss with patient (and if he/she aggress) with the family what is the
pattern of drinking, why the patient is worried about drinking and what are
the possible consequences of drinking.
2. Investigate and discuss with the patient what would be the consequences
of stopping drinking and try to understand if in the past the patient had
already succeeded in stopping drinking.
3. Look for medical consequences of drinking as: signs of alcohol withdrawal
as tremor, restlessness, nervousness and/or bruises, scars, signs of liver
disease as jaundice and signs of neurological impairment as poor balance
or speech problems. Treat immediately medical consequences.
4. In an acute emergency, the priority will be to try to stabilize the patient
who has problems with alcohol. Advice should be given to the patient in a
way that he/she could reduce or stop drinking alcohol.
5. The treatment consists in analyzing what are the triggers for alcohol
drinking and substituting these triggers with pro-social or positive
behavior. Positive reinforcement has to be given for changes in behavior
that reduce the amount of alcohol ingested.
6. Treatment for abstinence has to be offered (as described in alcohol
withdrawal and delirium tremens) in order to avoid progression of alcohol
abstinence to delirium tremens and the patient should stay at the health
clinic for close supervision and titration of diazepam dosage. The risk of
alcohol abstinence is greater if man drink more than 6 drinks a day and if
woman drink more than 4 drinks a day.
The same basic principles apply for the treatment of drug dependence. As the
treatment of drug dependence is considered a domain for specialists; during an
acute emergency, those patients should be referred to specialized services. If the
volume of cases is high or specialized services do not exist, MSF-CH will need to
have a specialized team (it should be discussed with HQ)
Psychosis:
Assuming that the possibility of an acute confusional state due to a medical

condition affecting the brain has been eliminated, a person with agitated behavior
and delusions and hallucinations has to be treated with antipsychotic medication if
the following symptoms are present:
• The patient is hearing voices or seeing things that do not exist and are not
culturally acceptable as a normal behavior by family members.
• The person has ideas that other people are persecuting her or trying to
harm her if family members do not explain this as reality.
36
• If the person presents strange, frightening or atypically impulsive behavior
or mood swings or lack of appropriate emotional response.
Remember that in some communities this behavior is considered normal vis-à-vis

cultural beliefs and community perceptions.
Treatment.
1. Rule out psychotic phenomena induced by drugs.
2. Assess for suicidal idea and intent (explained later)
3. Explain to patient and family that the phenomena is the result of brain
illness and there is appropriate treatment for that.
4. Encourage patient and ask the support of the family on the adherence to
the prescribed medication.
5. Advise family that patient needs to be supervised especially during the
first 2-3 weeks of treatment.
6. If risk to self (suicide or self harm)or risk to others (violent behavior), the
patient will have to be referred to hospitalization
7. Start treatment with haloperidol 5m at night and biperidene 2 mg at night
(to avoid risk of side effects during the initiation of antipsychotic therapy).
8. Educate the patient and family about possible side effects (extrapyramidal
side effects), and increase biperidene up to 6 mg per day in case of
extrapyramidal side effects.
9. On the second week, if behaviour is not improved, haloperidol can be
increased to 10 mg PO per day.
10. If severe side effects or fever refer to hospital.
11. Re-assessments have to be done on a weekly basis and if possible refer to
mental health team for long term planning and management of the
condition. Long term medication (at least one year) is usually the rule.
Assessment for risk of suicide and suicidal behavioral management:
Main reasons for suicidal ideas:

• Depression
• Alcohol and drug abuse
• Long term health problems
• Severe mental disorders (as psychosis)
And some social factors that can influence or interact with such disorders:
• Marital problems and marital violence
• Lack of basic needs including financial difficulties
• Human rights violations in refugee’s or IDP placements.
• Lost of loved ones
• Among teenagers, difficulties in the expression of their wishes or
desires mainly related to relationships with the opposite sex and
performance in school or sports.
37
A suicide assessment has to be made whenever there is a suspicion of depression
and immediately after a suicide attempt or a description of suicidal ideas. Patients
with psychosis should be assessed for suicidal ideation during consultations.
In that situation (in an environment where privacy and confidentiality can be

guaranteed), the assessment would consist of the following questions:
1. Does the patient have a plan?
2. Determine if patient has the means.
3. Find out if there is fixed time frame.
4. Is the family aware?
5. Has there been any attempt? How? Potentially lethal?
If patient has thoughts of suicide but also plan and the means, or attempts it with
lethal means, consider high risk.
If high risk, refer to hospitalization (when available) or arrange to stay with

family or friends (do not leave the patient alone) and advise the family on close
monitoring and observance of the patient 24 hours per day. The family should
put all means of suicide out of the reach of the patient (e.g. weapons, knifes,
ropes, poison, medicines).
The patient has to be seen on a regular basis by a medical practitioner and the
condition underlying the suicidal ideas has to be treated and followed up (e.g.
depression, psychosis) and psychological support to the patient and the family
has to be offered in conjunction.
Bereavement:
Bereavement should be managed by the mental health team following the

principles of psychological first aid.
It is important to take into consideration cultural rituals and practices that facilitate
the process of bereavement.
Mental health professionals should be concerned when:

• Signs of depression or suicidal ideas.
• Prolonged bereavement, taking more than 6 months.
• Marked change in person’s behavior and social interactions.
Treatment:
As described earlier, some of the techniques and areas that are focused in
psychological first aid can also be useful for bereavement. If there is a
superimposed mental illness or signs of severe psychological distress (e.g.
depression, PTSD symptoms, sleeping problems), it should be treated.
Progressive and guided return to normal daily activities and progressive exposure
to social interactions can have a benefit. Problem solving counseling and sharing
of concerns and emotional suffering can also help the person to feel alleviated.
38
Post Traumatic Stress Disorder:
Different accidents that put a person in extreme stress can have serious
psychological consequences.
During acute emergencies, people are exposed to a series of traumatic events and
it is known that war events can have long-term mental health effects.
It is considered that during the first months after a traumatic event, to present the
symptoms below can be considered normal as long as people maintain their
capacity to continue with the normal daily activities. If the possibility of
continuing daily activities is disrupted and there is clear deterioration in medical
or psychological status of a person, he/she should be treated even if it is during the
period of one month after a traumatic event. The symptoms below if happening
during the first months of the traumatic event are called Acute Stress Disorder. If
they persist at a significant level after one months period and are accompanied by
disruption in social, medical or psychological spheres of life, they should also be
treated and they are called PTSD:
Main PTSD characteristics:

• Relieving the traumatic event again: the person unintentionally relieves the
trauma through visions, of the incident, nightmares and flashbacks in
situations that are unexpected and are accompanied by high levels of
anxiety and suffering.
• Avoidance: the person avoids situations that could be a trigger to the
traumatic event. This can lead to extreme social isolation.
• Increased arousal: the person feels alert most of the time as if expecting to
react to an unknown event. Signs of anxiety and fear can happen suddenly
and the person can get easily scared with noises.
• Depression, multiple somatic complains, fatigue and problems to
concentrate are accompanying symptoms.
Treatment:
• Psychological first aid techniques.(already described and provided by
mental health team)
• Pharmacological therapy.
• Techniques of cognitive behavioral therapy.
As described before, psychotropic medication is reserved for cases where the

symptoms described above persist for more than one months after the traumatic
event and are accompanied by severe social and psychological suffering or
medical complications (e.g. loosing weight, chronic sleep problems, etc).
If the symptoms are very pervasive during the first months of the traumatic event,
psychotropic medicines should also be prescribed.
Psychopharmacological treatment:
Fluoxetine 20 mg PO: one tablet in the morning.
If the symptoms do not improve or the improvement is poor, fluoxetine can be
increase to 40 mg after 4 weeks and again up to 60 mgs after 8 weeks of the
initiation of the treatment.
39
Information to the patient about the disease, its nature, and the description of the
pharmacological treatment and its possible side effects has to be done before
starting treatment.
The same treatment applies if there is co morbidity with depression.
Techniques of cognitive behavioral treatment:

Although very effective, some considerations have to be taken before using them
in an acute emergency. The main technique is called exposure where patients are
gradually (step by step according to pre-established hierarchy according to levels
of anxiety) guided to think or confront the traumatic situation in order to habituate
to high anxiety levels and extinguish the PTSD symptomatology. As the events
are still happening during an acute emergency, these techniques should only be
used for chronic cases after the events that provoked the PTSD symptoms are not
more a risk to the patient and only if clear acceptance and consent by the patient.
During the acute emergency, we mainly use:
• Stimulation of re-establishment of daily activities.
• Encouraging the re-establishment of a social support system and sharing
difficulties and experiences with others.
• Guarantee and support access to social and medical needs.
Depression:
The diagnosis of depression and its adequate treatment poses real challenges in
periods of acute emergencies. It is clear that lots of symptoms of depression can
be considered as a normal reaction in periods of mass population displacement
and violence but it is also clear that we most of the times miss the opportunity to
make a diagnosis of depression and give the appropriate treatment to the patient.
Although symptoms of depression can be considered as a normal reaction to
stressful events, the prolongation of symptoms for a period longer than one
months, the lack of improvement of depressive symptoms after psychological first
aid and the lack of capacity of a person with symptoms of depression to perform
daily activities as performed previously should sign an alert for the need of
specific treatment of depression.
In developing countries, depression is usually masked by multiple unspecified
somatic complains, therefore all patients with these symptoms have to be screened
for the diagnosis of depression. Patients with chronic sleep problems and
complains of fatigue also have to be screened for the diagnosis of depression.
For the patients with the symptoms described above a further screening has to be
made.
In general 2 questions have to be asked:

1. Have you lost interest/pleasure in things and activities that you usually
enjoy?
2. Do you feel that you have less energy than usual?
If one of them is positive, further assessment has to be made and the following
symptoms investigated:
Depression symptoms:
40
1. Continuous disturbed sleep
2. Loss or increase in appetite
3. Poor capacity to concentrate
4. Lethargy or moves slowly
5. Decreased sexual drive
6. Loss of self-confidence or esteem
7. Thoughts of suicide or death
8. Persistent guilty feelings
For patients with fatigue consider also anemia, lack of exercise, sleep
problems, malaria, HIV/AIDS and tuberculosis.
If a patient has 5 or more symptoms that persist for more than 2 weeks despite
psychological first aid and the symptoms impair the capacity of the patient to
perform daily activities (functioning), the patient has to be treated for
depression.
Treatment:
1. Exclude past history of bipolar disorder by asking for periods where the
patient felt accelerated, disinhibited, did not feel the necessity to sleep and
had ideas of grandiosity. If these symptoms were present, the patient will
need treatment for a possible bipolar disorder with mood stabilizers as
lithium, sodium valproate or carbamazepine.
2. Otherwise treat with amytriptiline 25 mg PO: start with 50 mg at night and
keep it for one week. After one week increase to 75 mg at night. After one
week increase to 100 mg at night. If after one month of treatment there is
inadequate response, keep 100 mg at night and introduce 50 mg in the
morning. Anticholonergic side effects (constipation, blurred vision, dry
mouth) should be monitored at each consultation and increase dose slowly
if side effects disturb the patient.
Avoid amytriptiline in patients with history of any cardiac disease or arritmia
or signs of glaucoma (high intraocular pressure) at the moment of the medical
consultation. If patient does not tolerate amytriptiline, fluoxetine can be used
the same way as it is used for PTSD.
For patients older than 60 years old or weighting less than 40 kg, divide all
dosages described below by half.
3. In parallel, counseling and patient education regarding the diagnosis and
treatment of depression has to be offered to all patient with a diagnosis of
depression. The main points on counseling patients with depression is
described below:
a. Explain that the symptoms are part of an illness called depression
b. Explain that depression is common and effective treatment is
available.
c. Give a description of how antidepressants work, the time it takes to
work (in general two weeks) and the main side effects that are
expected.
d. Work with the patient on an analysis of the main stressors that the
patient is facing at the moment. Make a priority in terms of which
stressors are bigger and which stressors are smaller. Work with the
patient on a practical level in order to make him/her reflect in
41
different possibilities of solving the problem. In parallel make a list
of positive and negative things in life. Give positive reinforcement
on the positive things and stimulate the patient to engage more time
in the positive things in a way to expand positive activities on
patient’s daily life. Practice this exercise with the patient in each
consultation always focusing in different stressors and ways to
overcome it.
For patients with less than 5 symptoms of depression:

1. Only offer counseling as described on item d. But if symptoms 1, 2 or 7
are present, consider the prescription of antidepressants as described
above.
For patients without other symptoms but with sleep problems:

1. Teach sleep hygiene techniques as relaxation exercises, avoidance of
caffeine and other stimulants at night and induction of pleasant and
positive thoughts at time of sleeping and neutralization of negative and
ruminating ideas.
2. If necessary prescribe amytriptiline 25 mg PO. 1 tablet one hour before
going to bed.
Patients on first episode of depression should be kept on antidepressant for 6

months, if depression is completely resolved, the dose can be slowly decreased
during 2 months period. If symptoms come back, re-introduce the same dose that
had effect and keep for another 6 months.
Patients that already had previous episode of depression should be kept on
antidepressant for the period of one year and then slow reduction of dose as for
patients that are kept for 6 months.
Always assess for suicidal ideas and if present refer to suicide assessment and
management.
Management of behavioral problems in patients with mental retardation.
Patients with mental retardation or developmental problems can present

behavioral difficulties during periods of acute emergency mainly due to loss, or
abrupt change in environment and routines.
The main symptoms can be agitation, refusal to eat, insomnia and aggression.
In people with mental retardation, more than other persons, it is fundamental to

investigate other medical causes that can be responsible for the behavioral change.
Pain, infections, sudden interruption of medication has to be excluded.
Treatment:
1. Investigate medical causes that can be responsible for the behavioral
change.
2. Orient the family and patient to establish clear routine as much as possible
as it was before the acute crisis
42
3. If only problem is sleep difficulties, amytriptiline 25 mg PO can be
prescribe one hour before sleep time. If there is also agitation during the
day, chlorpromazine 25 mg PO can be prescribed one tablet in the morning
and one tablet at night.
43
Annex 7:
Children’s developmental milestones.
Milestone Age at which most Suspect mental

children achieve this retardation if
milestone milestone is delayed
beyond…
Responds to 1-3 months 4th month
name/voice
Smile at others 1-4 months 6 month
Holds head steady 2-6 months 6 month
Sits without support 5-10 months 12th month
Stands without support 9-14 months 18th month
Walks well 10-20 months 20th month
Talks in 2-3 word 16-30 months 3rd year
sentences
Eats/drinks by self 2-3 years 4th year
Can tell own name 2-3 years 4th year
Is toilet trained 3-4 years 4th year
Avoids simple hazards 3-4 years 4th year
44
Annex 8
Children in psychological distress during acute emergencies.
Although the main signs and symptoms of distress that children can present during
an acute emergency were described before as well as the basis of the therapeutic
support, we believe that it is important to clearly describe what would be the
intervention and what would be the approach of MSF-CH.
The approach is divided in two levels:

• Protection and access to psychosocial care: UNICEF has the mandate to
coordinate these activities and they mainly rely on all aspects of protection
for children during acute emergencies and access to psychosocial services
(e.g. family unit). Psychosocial services include activities where routines
are normalized and children have the possibility to have an environment
where they can perform activities adequate to their developmental stage
and the main activities is guided playing. All children in an acute
emergency will benefit from these activities as they can reduce symptoms
of distress and probably prevent the development of higher levels of
distress. MSF-CH in general does not perform those activities but actively
liaise with agencies that perform such activities in order to serve as a
referral service for children presenting higher levels of distress (as
described before). MSF-CH should instruct other agencies performing
these activities on how to recognize and refer to MSF-CH children
presenting higher levels of distress and lacking the capacity to function as
before.
• Children that present higher levels of distress have to be seen by the
mental health team. Child and family can be seen together in order to
better understand the reasons for the stress in an individual child.
Psychological first aid adapted to children has to be offered to the child
and the family as in general, children in high levels of distress are usually
children where the family environment and the capacity of parents to
provide emotional support is disrupted or children who witnessed or
suffered high levels of violence.
45
Annex 9
Psychological First Aid
The manual from the national center for PTSD is provided in annex as a reference
guideline.
Annex 10.
Monitoring forms (client files)
46
1. Client Code: Client Address: 2. Age: 3. Sex:
Adult form 0. F
Date___/___/__
Client name: 4. Marital status: 1. M
Psy:_________ 0. Single:
1. Married:
2. Divorced:
3. Widowed:
5. Current status: 6. Religion: 7. Education Level: 8.Financial Support:
0. Displaced: 0.Sunni muslin: 0.No education: 0.Family self support:
1.Shia muslin: 1.Primary:
1. Non displaced: 2.Christian: 2.Secondary: 1.Dependent on
3.University: external aid:
Name of Doctor/psychiatric Name of Person to Contact if 9.Where does he/she sleep?
Service: Necessary: 0.With parents
1.With relatives
2.With neighbours
3.In a shelter
4.On the street
10. Syndromic diagnosis:

0. Acute psychological distress: 1. Chronic psychiatric disorder:
2. Other: Which: ___________________________
11. Traumatic event (HTS): (has the client experienced any of the following events)
Lack of shelter (sleeping in the open) Combat physical injury

Lack of food or water Imprisonment
Sickness without med. care Forced labour
Confiscation of property Extortion/robbery
Destruction of property Forced to hide
Combat situation (shelling, sniper fire, Kidnapped
grenade/missile attacks)
Used as human shield Forced separation from family
Evacuation under dangerous situation Forced to find or bury bodies
Beating to the body Your house was searched by someone
Rape Confined at home because of danger
Other sexual abuse/humiliation Prevented from burying someone
Torture Forced to harm someone you like
Disappearance of relative Disappearance of friend
Friend Kidnapped Relative Kidnapped
Serious physical injury on relative Serious physical injury on friend
Witnessing killings Witnessing rape
Witnessing someone being humiliated Witnessing torture
Witnessing beatings 12. Number of people in household that died (by
11. Score: _______ combat injury): _________
13. Number of people in household that died (by 14. Number of household members that client
disease): _________ does not know where they are: _______
15. PTSD (TSQ): 15. Score:_______

1. Upsetting thought or memories of the event coming 2. Upsetting dreams of the event
to your mind against your will
3. Acting/feeling as if the event is happening again 4. Feeling upset by reminders of event
5. Bodily reactions when reminded of the event 6. Difficulty falling/staying asleep
(shaking, heart pounding, etc)
7. Irritability/outbursts of anger 8. Difficulty concentrating
9. Heightened awareness of potential dangers of 10. Being jumpy or startled at something unexpected
potential dangers to yourself or others
47
16. Mental Health Status (HSC) : 1 never 2 sometimes 3 usually 4 all the time
Suddenly scared for no reason 1 2 3 4 Crying easily 1 2 3 4
Feeling fearful 1 2 3 4 Loss of sexual interest or pleasure. 1 2 3 4
Faintness, dizziness or weakness 1 2 3 4 Poor appetite 1 2 3 4
Nervousness or shaking inside. 1 2 3 4 Difficulty falling asleep and sleeping 1 2 3 4
Heart pounding or racing 1 2 3 4 Feeling hopeless about the future 1 2 3 4
Trembling 1 2 3 4 Feeling blue 1 2 3 4
Feeling tense or keyed up 1 2 3 4 Feeling lonely 1 2 3 4
Headaches 1 2 3 4 Thoughts of ending your life 1 2 3 4
Spells of terror or panic 1 2 3 4 Feeling of being trapped or caught 1 2 3 4
Feeling restless, can’t sit still 1 2 3 4 Worrying too much about things 1 2 3 4
Feeling low in energy 1 2 3 4 Feeling no interest in things 1 2 3 4
Blaming yourself for things 1 2 3 4 Feeling everything is an effort 1 2 3 4
Feeling of worthlessness 1 2 3 4
16. Score: _______
17. Psychosis (SRQ) 1 yes 0 no Feels that you are more important than other people
Feels some one wants to harm you (not war related) Hear voices
Feels other people are interfering with your thoughts
Have convulsion/epileptic seizures
17. Score: _______
18. Substance abuse 1 yes 0 no You wanted to stop drinking/using drugs but you could not
stop
Someone told you that you are drinking/using drugs too Fights or arrest because of alcohol/other drugs
much
Has difficulties at work/daily activities due to
alcohol/other drugs
Feels or believes that you are using alcohol/other drugs too Which drugs:
much ___________________________________
18. Score: ______________
19. Functioning (SF-36):

1. Your health/mental health is: 0. Excellent
1. Very good
2. Good
3. Fair
4. Poor
2. To what extend your health/mental health 0. Not at all
problems interfere with normal social activities 1. Slightly
(daily activities; cooking; cleaning; care for the 2. Moderately
family; care for children; interaction with family, 3. Quite a bit
friends, community; hygiene) 4. Extremely
3. How much of the time has your health/mental 0. None of the time
health problems interfered with your social 1. A little of the time
activities (daily activities; cooking; cleaning; care 2. Some of the time
for the family; care for children; interaction with 3. Most of the time
family, friends, community; hygiene) 4. All of the time
19. Score (total): _________
20. Consultation: 1 2 3 4 5 6 7 8 (9) Default (10) Died
48
Client code: _____________
Consultation number: ______

Date: _______/________/________
Psy: _________________
Diagnosis:_________________________________________________________
Treatment
plan :_____________________________________________________________
__________________________________________________________________
__________________________________________________________________
___________________________________________________________
Overview of Mental Health status:
16. Score :
17. Score :
18. Score :
19. Score :
_____________________________________________________________________
Date: _______/________/________
Psy: _________________
Diagnosis:_________________________________________________________
Treatment
plan :_____________________________________________________________
__________________________________________________________________
__________________________________________________________________
___________________________________________________________
16. Score :
17. Score :
18. Score :
19. Score :
49
1. Client Code: Client Address: 2. Age: 3. Sex:
Child form 0. F
Date___/___/__
Client name: 4. Marital status: 1. M
Psy:_________ 0. Single:
1. Married:
2. Divorced:
3. Widowed:
5. Current status: 6. Religion: 7. Education Level: 8.Financial Support:
0. Displaced: 0.Sunni muslin: 0.No education: 0.Family self support:
1.Shia muslin: 1.Primary:
1. Non displaced: 2.Christian: 2.Secondary: 1.Dependent on
3.University: external aid:
Name of Doctor/psychiatric Name of Person to Contact if 9.Where does he/she sleep?
Service: Necessary: 0.With parents
1.With relatives
2.With neighbours
3.In a shelter
4.On the street
10. Syndromic diagnosis:

0. Acute psychological distress: 1. Chronic psychiatric disorder:
2. Other: Which: ___________________________
11. Traumatic event (HTS): (has the client experienced any of the following events)
Lack of shelter (sleeping in the open) Combat physical injury

Lack of food or water Imprisonment
Sickness without med. care Forced labour
Confiscation of property Extortion/robbery
Destruction of property Forced to hide
Combat situation (shelling, sniper fire, Kidnapped
grenade/missile attacks)
Used as human shield Forced separation from family
Evacuation under dangerous situation Forced to find or bury bodies
Beating to the body Your house was searched by someone
Rape Confined at home because of danger
Other sexual abuse/humiliation Prevented from burying someone
Torture Forced to harm someone you like
Disappearance of relative Disappearance of friend
Friend Kidnapped Relative Kidnapped
Serious physical injury on relative Serious physical injury on friend
Witnessing killings Witnessing rape
Witnessing someone being humiliated Witnessing torture
Witnessing beatings 12. Number of people in household that died (by
11. Score: _______ combat injury): _________
13. Number of people in household that died (by 14. Number of household members that client
disease): _________ does not know where they are: _______
15. PTSD (TSQ): 15. Score:_______

1. Upsetting thought or memories of the event coming 2. Upsetting dreams of the event
to your mind against your will
3. Acting/feeling as if the event is happening again 4. Feeling upset by reminders of event
5. Bodily reactions when reminded of the event 6. Difficulty falling/staying asleep
(shaking, heart pounding, etc)
7. Irritability/outbursts of anger 8. Difficulty concentrating
9. Heightened awareness of potential dangers of 10. Being jumpy or startled at something unexpected
potential dangers to yourself or others
50
Children’s psychological distress presentation:
16. Ages 0-5 Score_______
Helplessness and passivity Yes No
Generalised fear Yes No
Lack of verbalisation (e.g. selective Yes No
mutism, repetitive nonverbal traumatic
play)
Sleep disturbances (insomnia, night Yes No
terrors, nightmares)
Anxious attachment (e.g. clinging, not Yes No
wanting to be away from attachment
figures)
Regressive symptoms (thumb-sucking, Yes No
bedwetting, baby-talk)
17. Ages 6-12 Score_______

Specific fears triggered by traumatic Yes No
reminders
Impaired concentration and learning Yes No
Sleep disturbances (insomnia, bad Yes No
dreams, enuresis)
Altered and inconsistent behaviour (e.g. Yes No
unusually aggressive and restless
behaviour)
Somatic complains-headaches, stomach- Yes No
aches, dizziness.
18. Ages 13 and up Score______
Detachment, isolation. Yes No
Acting out behaviour (e.g. using alcohol, Yes No
drugs, sexual acting out)
Life threatening re-enactment, self Yes No
destructive or accident prone behaviour
Abrupt shifts in interpersonal Yes No
relationships
19. Total Score:________
20. Consultation: 1 2 3 4 5 6 7 8 (9) Default (10) Died
51
Client code: _____________

Date: _______/________/________
Psy: _________________
Diagnosis:_________________________________________________________
Treatment
plan :_____________________________________________________________
__________________________________________________________________
__________________________________________________________________
___________________________________________________________
16. Score :
17. Score :
18. Score :
19. Score :
_____________________________________________________________________
Date: _______/________/________
Psy: _________________
Diagnosis:_________________________________________________________
Treatment
plan :_____________________________________________________________
__________________________________________________________________
__________________________________________________________________
___________________________________________________________
16. Score :
17. Score :
18. Score :
19. Score :
52
Annex 11.
Terms of reference for mental Health Coordinator in Acute Emergencies
Terms of Reference:
Position: Mental Health Coordinator Emergencies
Background. Psychiatrist or psychologist.
Duties:
SOCIAL CARE: ( to guarantee that other agencies are implementing
what is described below)
• People have access to an ongoing reliable flow of credible information on
the emergency and associated relief efforts.
• Normal cultural and religious events are maintained or re-established
(including grieving rituals by relevant spiritual and religious practitioners).
People are able to conduct funeral ceremonies.
• When necessary, a tracing service is established to reunite people and
families.
• Where people are displaced, shelter is organized with the aim of keeping
family members and communities together. The community is consulted
regarding decisions on where to locate religious places, schools, water
points and sanitation facilities. The design of camps for displaced persons
includes recreational and cultural space
• People are offered sessions where stress reactions are explained as
normal reaction to the events and the ones needing further support are
advised to be referred to mental health teams.
PSYCHOLOGICAL AND PSYCHIATRIC CARE: (that would be MSF-CH

main role).
To set up MH services that addresses the following areas:
• Individuals experiencing acute mental distress after exposure to traumatic
stressors have access to psychological first aid at MSF-CH health
services.
• Care for urgent psychiatric complaints are available through the MSF-CH
medical care system. Essential psychiatric medications, consistent with
the Essential Drug List, are available at MSF-CH medical care facilities.
• Individuals with pre-existing psychiatric disorders continue to receive
relevant treatment. Harmful, sudden discontinuation of medications is
avoided.
PSYCHIATRIC HOSPITAL: (that would be MSF-CH role)

1. Patients at psychiatric institutions should be protected and
access to basic need and continuity of medication guaranteed.
• Basic needs (including medication) of patients in custodial psychiatric
hospitals are addressed.
All details on implementing mental health services in acute emergencies are

described in Draft MSF-CH Mental Health in Acute Emergencies guidelines.
53
Annex 12.
Log frame (objectives, activities, indicators)
General Objective.
To respond to mental health needs of people affected by high levels of violence
during the acute emergency.
Specific objective 1:
To respond to mental health needs of people with acute stress syndrome.
Activities:
1. to train medical staff on the recognition and referral of acute stress
syndrome to the mental health team.
2. to measure the prevalence of mental health problems via putting in place a
monitoring system to measure the prevalence of mental health problems
among OPD consultations.
3. to set up a mental health team that can provide psychological first aid to
people with acute stress syndrome.
4. to create a monitoring system to describe symptom profile and
functionality of patient with acute stress syndrome.(done by MH team)
Indicators:
1. # %OPD medical staff trained on recognition and referral of mental health
problems (acute stress syndromes included). Target 100%
2. monitoring system describing prevalence of mental health problems at
OPD in place. (standard data base in place)
3. mental health team operational.
4. # % patients with acute stress syndrome treated by MH team (provision of
psychological first aid). Target 100% of patients referred.
5. # % of monitoring forms filled by MH team. Target 100%
To respond to psychiatric needs of patients with previous or new onset psychiatric
disorders.
Activities:
1. to train medical staff at OPD in the recognition and referral to MH team of
patients with psychiatric problems according to MSF-CH guidelines.
2. to capacitate mental health team to assess and give a recommendation
regarding psychiatric problem.
3. to capacitate medical staff to treat psychiatric condition according to MSF-
CH guidelines.
4. to have an essential list of psychiatric drugs according to MSF-CH
guidelines.
54
Indicators:
1. #% medical staff trained on recognition of psychiatric problems. Target
100%.
2. mental health team capacitated of doing assessment and recommendation
regarding psychiatric problem.
3. medical staff prescribing psychiatric treatment according to MSF-CH
guidelines.
4. Psychiatric drugs are part of medical kits during acute emergencies.
5. #% of people with psychiatric problems treated according to MSF-CH
guidelines. Target 100%.
To guarantee basic needs and medicines to patients staying in psychiatric
facilities/institutions. (if existing)
Activities:
1. To identify basic needs and medication needs of patients living in
psychiatric facilities/institutions
2. Proactively respond to basic needs and medication needs of psychiatric
patients staying in psychiatric facilities/institutions in areas of acute
emergencies.
Indicators:
1. # % of psychiatric facilities/institutions have continuous support in terms
of basic needs and medication. Target 100%.
To provide psychological support to staff working in acute emergency.
Activities:
1. set up (preferentially external) a system where staff can have assess to
psychological support during acute emergency.
Indicators.
1. psychological care for staff is in place.
55
Annex 13 Monthly Report Template:
Project:
Date: from_____ to ______.
Professional.
1. General Narrative:
Describe the context and general observations and developments in the project with
emphasis on implementation of mental health services. Describe the status of
psychiatric institutions during acute emergency.
2. Data OPD:
Put in the table below, the proportion of patients with mental health problems that
come for OPD consultations; this data can be extracted from general morbidity data.
Number of cases
Physical Health conditions 00 (00%)
Mental Health conditions 00 (00%)
Total OPD Consultations 00 (00%)
Describe and compare with previous data collection.
3. Data MH team:
Put in the table, the differentiation between Acute Psychological Distress and
Psychiatric condition (new psychiatric disorder, old psychiatric disorder stable or
deteriorated) from all cases that are seen by the Mental Health Team.
Under 15 yr old Over 15 yr old

Male Female Male Female Total
Acute
Psychological
Distress % % % % %
Psychiatric
Condition % % % % %
Other % % % % %
Epilepsy % % % % %
Total % % % % %
Describe and compare with previous data collection.
4. Conclusions and recommendations:
56
References:
1. Medecins sans Frontieres Clinical and Therapeutical guidelines 7th edition
2006
2. Where there is no psychiatrist. A mental health care manual. Vikram Patel
3. Integrated Management of Adolescent and Adult Illness WHO November
2004
4. Mental Health & HIV/AIDS Therapy Series. Psychiatric care in anti-retroviral
therapy. WHO.
5. MSF-Holland Mental Health Guidelines: a mental health handbook for
implementing mental health programs in areas of armed conflict.
6. Essential drugs in Psychiatry. WHO Geneva
7. Mental health and conflict Florence Baingana, Ian bannon and Rachel Thomas
February 2005
8. Sphere guidelines. Humanitarian Charter and minimum standarts in disaster
response.
9. Mental Health and Psychosocial protection and support for adults and children
affected by the middle east crisis. Inter agency technical advice for the current
Lebanon emergency.
57

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Acute Emergencies and Mental Health: the

implementation of mental health services for

Médecins Sans Frontières-Suisse

Draft 1 . Only for internal use. Please do not distribute.

2.1 Mental health morbidity in acute emergencies:

Table 1: Proportion of cases of mental health problems * in OPD Mobile Clinic

Distribution of MH cases according to syndromic

3. The recognition of patients presenting at medical consultation with a possible

3.1 Patients with an acute onset of psychological distress (Acute Psychological

Some particular vulnerable groups are at higher risk of developing acute

People at higher risk of developing severe psychological distress in an acute

Most frequent presentation of medically unexplained somatic symptoms (if no

Another possibility is to use some symptoms of the Hopkins Symptom Checklist in

If no explanation for the patient’s complains after proper medical assessment,

1. Suddenly scared for no reason

2. Faintness, dizziness or weakness

3. Nervousness or shaking inside.

4. Heart pounding or racing

6. Feeling tense or keyed up

8. Spells of terror or panic

10. Blaming yourself for things

11. Crying easily

12. Poor appetite

13. Difficulty falling asleep and sleeping

14. Thoughts of ending your life

Children’s psychological distress presentation:

At medical consultation (or from other referrals):

If one of previous options is positive, refer to mental health team

Mental Health team assessment

• New case of acute • Previous history of

If one of previous is positive :

When to integrate mental health care in acute emergencies:

In general parents play a crucial role in the re-establishing of normal behavior

3.2. Patients with a psychiatric disorder or in use of psychotropic medication

• Patient with previous history of psychiatric disorder and stable on treatment:

• Patient with previous history of psychiatric disorder and presenting

Chlomipramine can be increased by 50mg every week until the dose of

• For patients on benzodiazepines:

• Patients with psychotic syndromes (bipolar disorder and schizophrenic

Chlorpromazine (if there are hallucinations or delusions) can be increased by

Risperidone (if there are hallucinations or delusions) can be increased by 2 mg

Carbamazepine (for patients with bipolar disorder) can be increase by 200 mg

Lithium carbonate (for patients with bipolar disorder) should never be

* Higher doses can be prescribed by specialists in psychiatry.

• Patient with a new psychiatric disorder in need of psychiatric treatment:

The following description aims to help in diagnosing patients that might be

Patients with strange and disruptive behaviour:

ASK ABOUT ALCOHOL OR DRUG WITHDRAWAL OR INTOXICATION

ASK ABOUT PSYCHOTIC SYMPTOMS

ASK ABOUT RECENT DEPRESSED MOOD

ASK ABOUT RECENT TRAGIC EVENTS

RULE OUT A DEFINITE PHYSICAL ILLNESS

IF NO PHYSICAL ILLNESS OR IMPROVEMENT ON USUAL

ASK ABOUT SYMPTOMS OF DEPRESSION OR ANXIETY

TREAT FOR DEPRESSION OR ANXIETY

ASK RELEVANT QUESTIONS ABOUT DRINKING AND/OR DRUG USE

IF ANY POSITIVE ANSWERS

BINGE DRINKING OR OTHER

TAKE A CAREFUL HISTORY OF DEVELOPMENT

ASK ABOUT BEHAVIOUR AT ACCOMODATION CENTER AND

General Mental Health Indicators:

For purposes of operational and human resources planning 3 set of indicators

2. At Mental Health Team level: