- Email: [email protected]
Discussion of the updated WHO recommendations for mental, neurological, and substance use disorders
Comment
For more on a review of art therapy see Review Lancet Pyschiatry 2016; published online Aug 12. http://dx.doi.org/10.1016/ S2215-0366(16)30146-8
An artist to me is someone who is determined and committed to depict the world in a visual form, and be in a subjective dialogue with others as to what their art may mean. But that does not mean that the artist is able to define themselves or their art completely. People may try and define the artist by what they create, but because creativity is endless there are endless definitions that might be made. The artist’s job is to navigate through this and try and make people understand what creation is to them by reflecting on experiences and influences, making thoughts into material things. Art is not science, but the two are very closely linked because they are about who and what we are; art to me is discovery and openness. Art is material trying to discover the immaterial. Art is in the eye of the beholder, but art therapy is in the hands of the maker. If art is enjoyable, you will excel at it because you are enjoying it; if art is hard to make, this could still be a good thing. My art to me is my pain put into a painting. It is me trying to find out what the world is. It is trying to communicate to people when I cannot communicate with them; it is the overspill of life. It is hearing others’ opinions about it and trying to understand them as well. It is being part of life. It is having fun. It is being serious. It is taking on different personae. It is trying to be an artist of life—and we are all artists. People feel better when they create. When studying Art at university I became unwell several times and spent time making art in a therapeutic environment away from university. It helped occupy my mind and focus my energy. It passed time in a positive way and made my feelings and emotions less severe and made them objective, but could also be discussed outside of myself in a subjective way. When making art for other reasons I always find problems
doing this and it is a different way of thinking and making. When I create for myself it is therapeutic. It is my work at its most honest and vulnerable and maybe this makes it more communicative and universal. All art is of the artist and if what is created helps the artist understand in new ways, this can only be helpful for wellbeing, in my opinion. George Harding www.georgejharding.co.uk I declare no competing interests.
Studio, George Harding
Even if it’s nothing were something and its ok, George Harding
The meaning of art—and art therapy
Mauro Fermariello/Science Photo Library
Discussion of the updated WHO recommendations for mental, neurological, and substance use disorders WHO’s Mental Health Gap Action Programme (mhGAP) includes evidence-based guidance for the management of identified priority mental, neurological, and substance use conditions, and was launched in 2010.1 To remain relevant to current evidence, the mhGAP 1008
recommendations were updated in 2015, using the GRADE guideline development method.2 A guideline development group was responsible for updating the guidelines on the basis of a systematic appraisal of the evidence and considering the values and preferences www.thelancet.com/psychiatry Vol 3 November 2016
Comment
New abridged or updated recommendations
Strength
Antidepressant medication in comparison with psychological treatment for moderate-severe depressive disorder.
As first-line therapy, health-care providers might select psychological treatments (such as behavioural activation, cognitive behavioural therapy, or interpersonal psychotherapy) or antidepressant medication (such as selective serotonin reuptake inhibitors and tricyclic antidepressants).
Conditional
Comparative effectiveness of different formats of psychological treatments for depressive disorder.
Health-care providers can offer different treatment formats of WHO’s recommended, structured psychological interventions Conditional for adults and older adolescents with depressive disorder. Different treatment formats for consideration include (1) individual or group face-to-face psychological treatments, or both, delivered by professionals and supervised lay therapists, as well as (2) self-help psychological treatment.
Depression
Psychosis Role of depot antipsychotic medication in longterm antipsychotic treatment.
In people with psychotic disorders (including schizophrenia) requiring long-term antipsychotic treatment, depot antipsychotics can be offered instead of oral medications as part of a treatment plan.
Conditional
Antipsychotics and mood stabilisers (lithium, valproate, or carbamazepine) for maintenance treatment of bipolar disorder.
Lithium or valproate or certain second-generation antipsychotics (aripiprazole, olanzapine, paliperidone extended release, quetiapine, and risperidone long-acting injection release) can be offered for the maintenance treatment of bipolar disorder. If treatment with one of these drugs is not feasible, first-generation antipsychotics or carbamazepine can be used.
Conditional
Second-generation antipsychotic medications in psychotic disorders (including schizophrenia).
Second-generation antipsychotics (with the exception of clozapine, which is indicated for treatment-resistant psychosis) can be offered for the treatment of psychotic disorders (including schizophrenia).
Conditional
Pharmacological interventions in adolescents with psychotic disorders (including schizophrenia and bipolar disorder).
In adolescents with psychotic disorders (including schizophrenia and bipolar disorder), certain second-generation antipsychotic medications (aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone) can be offered as a treatment option under supervision of a specialist. If treatment with one of these drugs is not feasible, first-generation antipsychotics can be used under supervision of a specialist.
Conditional
Antiepileptic medications for management of acute convulsive seizures when no intravenous access is available.
When intravenous access is not available for the control of acute seizures in adults, non-parenteral routes of benzodiazepine administration should be used. Options include rectal diazepam, buccal or intranasal midazolam, rectal or intranasal lorazepam. The preference can be guided by availability, expertise, and social preference. Some benzodiazepines (lorazepam or midazolam) can be given by intramuscular route, which requires additional expertise. Intramuscular administration of diazepam is not recommended because of erratic absorption.
Strong
Antiepileptic medications for management of established status epilepticus.
Conditional In adults with established status epilepticus (ie, seizures persisting after two doses of benzodiazepines), either intravenous valproic acid, intravenous phenobarbital, or intravenous phenytoin can be used with appropriate monitoring. Intravenous valproic acid is preferred over intravenous phenobarbital or intravenous phenytoin because of its superior risk-benefit profile. When intravenous infusion might not be feasible, intramuscular phenobarbital remains an option, with appropriate monitoring. Phenytoin and valproic acid should not be given intramuscularly.
Antiepileptic medications for adults and children with HIV.
In comparison with enzyme-inducing antiepileptic medications (phenobarbital, phenytoin, carbamazepine) or valproic acid, newer generation antiepileptic medications that are not hepatically metabolised (ie, leviteracetam, lacosamide, topiramate, gabapentin, and pregabalin) can be preferred for use in people with HIV on certain antiretroviral medications (protease inhibitors or non-nucleoside reverse-transcriptase inhibitors). If the treatment with newer generation antiepileptic medications is not feasible, valproic acid is preferred over the enzyme-inducing antiepileptic medications (phenobarbital, phenytoin, and carbamazepine).
Conditional
Antiepileptic medicines for medication-resistant convulsive epilepsy.
Certain newer antiepileptic medications (lamotrigine, levetiracetam, and topiramate) should be offered as add-on therapy in patients with medication-resistant convulsive epilepsy. The essential antiepileptic medications (carbamazepine, phenobarbital, phenytoin, and valproic acid) can be of benefit as add-on therapy in patients with medication-resistant convulsive epilepsy.
Conditional
Caregiver skills training for management of developmental disorders.
Caregiver skills training should be provided for management of children and adolescents with developmental disorders, including intellectual disabilities and pervasive developmental disorders (including autism).
Strong
Psychosocial interventions for treatment of behavioural disorders.
Behavioural interventions for children and adolescents, and caregiver skills training, can be offered for the treatment of behavioural disorders.
Conditional
Psychosocial interventions for treatment of emotional disorders.
Psychological interventions, such as cognitive behavioural therapy, interpersonal psychotherapy for children and adolescents, and caregiver skills training focused on their caregivers, can be offered for the treatment of emotional disorders.
Conditional
Effective strategies for detecting maltreatment of children and youth within the context of mental health and developmental assessment.
Health-care providers should be alert to the clinical features associated with child maltreatment and associated risk factors and assess for child maltreatment, without putting the child at increased risk.
Conditional
Community-based rehabilitation for adults with developmental disorders including intellectual disabilities and autism spectrum disorders.
Non-specialised health-care providers can offer supporting, collaborating, and facilitating referral to and from communitybased rehabilitation programmes, if available, for care of adults with developmental disorders, including intellectual disabilities and pervasive developmental disorders (including autism).
Conditional
Epilepsy
Mental disorders with childhood onset
(Table continues on next page)
of stakeholder groups and the practical issues of feasibility.3 We have listed the abridged recommendations and their strengths in the table. The strength of a recommendation expresses the degree to which www.thelancet.com/psychiatry Vol 3 November 2016
there was certainty in the balance between the desirable and undesirable consequences of implementing the recommendation. A strong recommendation was assigned when the evidence clearly supported that desirable outcomes outweigh undesirable consequences, 1009
Comment
New abridged or updated recommendations
Strength
Cholinesterase inhibitors and memantine for treatment of dementia.
Cholinesterase inhibitors and memantine can be offered for people with dementia in non-specialist health settings. The use of cholinesterase inhibitors should be focused upon those with mild to moderate Alzheimer’s disease, when almost all evidence is available. Memantine can be considered for those with moderate to severe Alzheimer’s disease and vascular dementia. Memantine should not be prescribed for dementia with Lewy bodies.
Conditional
Psychological therapies for people with dementia who have associated depression.
People with dementia and mild to moderate symptoms of depression can be offered psychological interventions (such as cognitive behavioural therapy, interpersonal therapy, structured counselling, and behavioural activation therapy) in nonspecialised health-care settings under supervision of a specialist.
Conditional
(Continued from previous page) Dementia
Oral nutrition supplementation or dietary education In people with dementia who are at risk of undernutrition, dietary advice aimed at food fortification should be tried first, and for caregivers for managing people with dementia at weight and nutritional status monitored. If nutritional status is not improved, then oral nutritional supplementation should risk for undernutrition or currently undernourished. be used (in the absence of any clinical contraindication) to achieve weight gain and restore nutritional status.
Strong
Nutritional interventions for people with dementia In people with either cognitive impairment or dementia, supplementation with nutrients, or use of Gingko biloba extracts or cognitive impairment. should not be considered to improve cognitive function, to reduce the risk of developing dementia, or to slow the progression of dementia once established. When feasible, dietary deficiencies should be investigated and monitored in those with dementia and appropriate supplementations should be provided.
Conditional
Alcohol-use disorders Baclofen for relapse prevention and management among people with alcohol dependence.
Baclofen can be offered to prevent relapse among people with alcohol dependence after detoxification.
Conditional
Drug-use disorders Psychosocial interventions for the management of Psychosocial interventions based on cognitive behavioural therapy or motivational enhancement therapy or family therapy cannabis dependence. can be offered for the management of cannabis dependence. Supervised dosing with a long-acting opioid medication for the management of prescription opioid dependence.
Conditional
When managing people who are dependent on strong prescription opioids (ie, morphine-like), physicians can switch to a long-acting opioid (such as methadone and buprenorphine), which can be taken once daily, with supervised dispensing if necessary, either for maintenance treatment or for detoxification.
Conditional
Implementation of suicide prevention programmes in school settings that include mental health awareness training and skills training can be offered to reduce suicide attempts and suicide deaths among adolescent students.
Conditional
Self-harm and suicide School-based interventions for reducing deaths from suicide and suicide attempts among young people.
Table: New abridged or updated WHO Mental Health Gap Action Programme recommendations on mental, neurological, and substance use disorders for priority conditions
and conditional was used for recommendations when degrees of uncertainty were present. Out of 23 new or updated recommendations, three were rated as strong. For the control of acute seizures in adults, WHO strongly recommends the use of nonparenteral routes of benzodiazepine administration when intravenous access is not available. A second strong recommendation refers to the provision of caregiver skills training for the management of children and adolescents with developmental disorders, including intellectual disabilities and pervasive developmental disorders. Finally, in people with dementia who are at risk of undernutrition, WHO strongly recommends dietary advice aimed at food fortification and oral nutritional supplementation, if nutritional status has not improved. Another update refers to the introduction of conditional recommendations for the use of secondgeneration antipsychotics for both maintenance treatment of bipolar disorder, as well as in the treatment of schizophrenia and related psychotic 1010
disorders. In individuals with moderate-to-severe depression, challenging questions that were addressed by the updated WHO guidelines included the comparative effectiveness of antidepressants versus psychological interventions, and the effectiveness of different forms of psychological treatments. Depression within the context of dementia was also addressed, as was the use of cholinesterase inhibitors and memantine in individuals with dementia. Additional updates for the guidelines include those regarding the management of status epilepticus, the choice of antiepileptic medications for adults and children with HIV, and add-on therapy for medicationresistant convulsive epilepsy. In the area of mental disorders of childhood onset, updated WHO recommendations provide guidance on psychosocial interventions for the treatment of behavioural and emotional disorders, on effective strategies for detecting maltreatment of children within the context of mental health and developmental assessment, and on community-based rehabilitation www.thelancet.com/psychiatry Vol 3 November 2016
Comment
for adults with developmental disorders. New recommendations were also issued regarding baclofen for the prevention of relapse among people with alcohol dependence after detoxification, and regarding the role of psychosocial interventions for the management of people with cannabis dependence. Finally, for the prevention of self-harm, WHO guidelines recommend the implementation of suicide prevention programmes in school settings. The first edition of the mhGAP guidelines has been used by more than 80 countries and translated into more than 20 languages through an integrated intervention package of programmes over the past 5 years. This package includes the mhGAP Intervention Guide, a set of clinical protocols based on the evidence-based guidelines that assist non-specialist health-care providers in low-income and middle-income countries to directly translate recommendations into practice.1 These mhGAP guidelines are key features in the development of mental health action plans by these countries. The widespread use of mhGAP has important implications, from direct clinical care to policy and system-wide changes. For example, adaptation and contextualisation exercises make the WHO guidelines relevant and appropriate to the local health system,4–7 and these have directly informed the 2015 updates by highlighting common issues of feasibility or gaps in the 2010 materials. The guidelines also affect other health systems’ strengthening efforts—for example, their influence on the WHO model list of essential medicines. The two new additions to the model essential medicines list are buccal midazolam in the core list for control of acute seizures, and intravenous valproic acid in the complementary list for the management of status epilepticus.8 However, despite the widespread use of the mhGAP programme, very few research studies exist that directly assess the use of mhGAP guidelines in the field.9 The few studies done show that the programme is most useful in enhancing capacity for individual conditions, but that the entire programme (ie, all the identified priority conditions) has limited uptake.9,10 Monitoring and assessment were quite cumbersome and a built-in, more effective (potentially electronic or web-based, or remote monitoring) system is needed.10,11 Other programmes showed the use of mhGAP in direct training, such as in Ethiopia where it www.thelancet.com/psychiatry Vol 3 November 2016
was incorporated into the educational programme for child psychiatry.7 In Nepal, it was used as a training tool as part of a larger mental health package.5 As updated mhGAP guidelines will be used in many countries, it is essential that evidence of their effect is generated. Direct feedback on facilitators and barriers to the use of the guidelines, adherence to recommendations, and patient outcomes are important to inform improvement at the provider level, as well as at the larger programmatic and country levels. Implementation research is required to enhance our knowledge on how mhGAP can be scaled up to improve mental health care. *Tarun Dua, Corrado Barbui, Archana A Patel, Elizabeth Centeno Tablante, Graham Thornicroft, Shekhar Saxena, WHO’s mhGAP Guideline team† Department of Mental Health and Substance Abuse, World Health Organization, Geneva CH-1211, Switzerland (TD, ECT, SS); Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (CB); Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA (AAP); and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK (GT) [email protected] †WHO’s mhGAP Guideline team (development group) Sophia Achab, Emiliano Albanese (WHO Collaborating Centre, University of Geneva/Hôpitaux Universitaires de Genève, Geneva, Switzerland); Robert Ali (Drug and Alcohol Services South Australia (DASSA), WHO Collaborating Centre for the Treatment of Drug and Alcohol Problems, University of Adelaide, Adelaide, Australia); Corrado Barbui (Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy); Vladimir Carli (National Centre for Suicide Research and Prevention of Mental lll-Health, Karolinska Institute, Stockholm, Sweden); Sudipto Chatterjee (Parivartan Trust and Sangath, Goa, India); Pim Cuijpers (Vrije University, Amsterdam, Netherlands); Kolou Simliwa Dassa (Ministry of Health, Lomé, Togo); Christopher Dowrick, Atif Rahman (Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK); Julian Eaton (CBM International, Lomé, Togo; London School of Hygiene and Tropical Medicine, London, UK); Asma Humayun (Meditrina Health Care, Islamabad, Pakistan); Gabriel Ivbijaro (Wood Street Medical Centre, London, UK); Nathalie Jette (Hotchkiss Brain Institute and O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada); Charles Newton (Kenya Medical Research Institute, Kilifi, Kenya); Olayinka Omigbodun (Centre for Child and Adolescent Mental Health, University College Hospital, Ibadan, Nigeria); Akwasi Osei (Ministry of Health Ghana, Accra, Ghana); Alfredo Pemjean (Department of Mental Health, Ministry of Health, Santiago, Chile; Faculty of Medicine, University Diego Portales, Santiago, Chile); Graham Thornicroft (chair), Martin Prince (Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK); Richard Rawson (University of California at Los Angeles Integrated Substance Abuse Programs, California, LA, USA); Pratap Sharan (All India Institute of Medical Sciences, New Delhi, India); Vandad Sharifi (Tehran University of Medical Sciences, Tehran, Iran); Lakshmi Vijayakumar (SNEHA Suicide Prevention Centre, Chennai, India); Inka Weissbecker (International Medical Corps, Washington, DC, USA); and Zhao Min (Shanghai Mental Health Centre, Shanghai Jiao Tong University School of Medicine, Shanghai, China). WHO Secretariat: Nicolas Clark, Tarun Dua, Alexandra Fleischmann,
1011
Comment
Melissa Harper, Archana A Patel, Shekhar Saxena, Chiara Servili, Elizabeth Centeno Tablante, Mark van Ommeren, Mohammad Taghi Yasamy.
3
GT is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King’s College London Foundation Trust. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health. GT acknowledges financial support from the Department of Health via the NIHR Biomedical Research Centre and Dementia Unit awarded to South London and Maudsley NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust. GT is supported by the European Union Seventh Framework Programme (FP7/2007–2013) Emerald project. NC, TD, AF, CS, MvO, and SS are staff members of WHO, while MH and ECT are consultants with WHO. MTY was a WHO staff member at the time of the mhGAP guidelines update. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of WHO. All other authors have no competing interests.
4
1
2
Dua T, Barbui C, Clark N, et al. Evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries: summary of WHO recommendations. PLoS Med 2011; 8: e1001122. Barbui C, Dua T, van Ommeren M, et al. Challenges in developing evidence-based recommendations using the GRADE approach: the case of mental, neurological, and substance use disorders. PLoS Med 2010; 7: e1000322.
5 6
7
8 9
10
11
Barbui C, Dua T, Harper M, Centeno Tablante E, Thornicroft G, Saxena S. Use of GRADE to update WHO recommendations on MNS. Lancet Psychiatry 2015: 2: 1054–56. Abdulmalik J, Kola L, Fadahunsi W, et al. Country contextualization of the mental health gap action programme intervention guide: a case study from Nigeria. PLoS Med 2013; 10: e1001501. Jha A, Sapkota N. Dementia assessment and management protocol for doctors in Nepal. JNMA J Nepal Med Assoc 2013; 52: 292–98. Katchanov J, Birbeck GL. Epilepsy care guidelines for low- and middle- income countries: from WHO mental health GAP to national programs. BMC Med 2012; 10: 107. Tesfaye M, Abera M, Gruber-Frank C, Frank R. The development of a model of training in child psychiatry for non-physician clinicians in Ethiopia. Child Adolesc Psychiatry Ment Health 2014; 8: 6. WHO. 19th WHO model list of essential medicines. Geneva: World Health Organization, 2015. Saraceno B, van Ommeren M, Batniji R, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007; 370: 1164–74. Gureje O, Abdulmalik J, Kola L, Musa E, Yasamy MT, Adebayo K. Integrating mental health into primary care in Nigeria: report of a demonstration project using the mental health gap action programme intervention guide. BMC Health Serv Res 2015; 15: 242. Tol WA, Purgato M, Bass JK, Galappatti A, Eaton W. Mental health and psychosocial support in humanitarian settings: a public mental health perspective. Epidemiol Psychiatr Sci 2015; 24: 484–94.
What is mindfulness-based therapy good for? What exactly is mindfulness meditation good for? For whom and how does it work? Can it have adverse effects? A cursory glance at the mental health literature suggests that it can help with almost anything, but a deeper look reveals contradictory findings. How good is the evidence for its benefits? A major meta-analysis1 of 163 studies focusing on psychological variables suggests that mindfulness has a range of positive effects on mental health, such as changes in stress and negative emotions. A closer inspection, however, reveals that most of the studies had methodological limitations (less than 10% used an active control group) and, most surprising, there seems to be no consistent longitudinal effect— meditating for a greater length of time is not associated with better psychological outcomes. This lack of a longitudinal effect has been confirmed by a meta-analysis2 of brain imaging studies: although mindfulness practice leads to structural brain changes, these changes are confined to the first weeks of practice. Evidence concerning the use of mindfulness-based interventions for recurrent depression is more promising: across nine clinical trials, individuals who received a cognitive-based mindfulness-based intervention had a lower chance of relapse within 1012
60 weeks of follow-up.3 Yet, a mindfulness intervention was not more helpful than other forms of mental health training, and the only study that tried to tease apart the effect of the meditation element from the psychoeducation training didn’t find the meditation practice to be more effective than treatment as usual.4 Another meta-analysis5 of 47 randomised clinical trials on the use of mindfulness-based interventions for mental health problems confirmed moderate evidence of improved results for depression, as well as anxiety. However, for variables one would expect mindfulness to have a strong effect on, such as stress and positive mood, there were only weak effects. Turning to the second question: for whom and how does mindfulness work? The answer to this question is precarious and messy. There has been very little research on individual differences in mindfulness, probably because of an assumption that this technique develops a kind of self-awareness capacity that is innate to all individuals. There are, however, indications that individuals with certain personality characteristics (openness to experience and agreeableness) will use mindfulness more frequently,6 and that mindfulness-based interventions are more effective for recurrent depression with patients who have suffered childhood trauma and www.thelancet.com/psychiatry Vol 3 November 2016
For more on a review of art therapy see Review Lancet Pyschiatry 2016; published online Aug 12. http://dx.doi.org/10.1016/ S2215-0366(16)30146-8
An artist to me is someone who is determined and committed to depict the world in a visual form, and be in a subjective dialogue with others as to what their art may mean. But that does not mean that the artist is able to define themselves or their art completely. People may try and define the artist by what they create, but because creativity is endless there are endless definitions that might be made. The artist’s job is to navigate through this and try and make people understand what creation is to them by reflecting on experiences and influences, making thoughts into material things. Art is not science, but the two are very closely linked because they are about who and what we are; art to me is discovery and openness. Art is material trying to discover the immaterial. Art is in the eye of the beholder, but art therapy is in the hands of the maker. If art is enjoyable, you will excel at it because you are enjoying it; if art is hard to make, this could still be a good thing. My art to me is my pain put into a painting. It is me trying to find out what the world is. It is trying to communicate to people when I cannot communicate with them; it is the overspill of life. It is hearing others’ opinions about it and trying to understand them as well. It is being part of life. It is having fun. It is being serious. It is taking on different personae. It is trying to be an artist of life—and we are all artists. People feel better when they create. When studying Art at university I became unwell several times and spent time making art in a therapeutic environment away from university. It helped occupy my mind and focus my energy. It passed time in a positive way and made my feelings and emotions less severe and made them objective, but could also be discussed outside of myself in a subjective way. When making art for other reasons I always find problems
doing this and it is a different way of thinking and making. When I create for myself it is therapeutic. It is my work at its most honest and vulnerable and maybe this makes it more communicative and universal. All art is of the artist and if what is created helps the artist understand in new ways, this can only be helpful for wellbeing, in my opinion. George Harding www.georgejharding.co.uk I declare no competing interests.
Studio, George Harding
Even if it’s nothing were something and its ok, George Harding
The meaning of art—and art therapy
Mauro Fermariello/Science Photo Library
Discussion of the updated WHO recommendations for mental, neurological, and substance use disorders WHO’s Mental Health Gap Action Programme (mhGAP) includes evidence-based guidance for the management of identified priority mental, neurological, and substance use conditions, and was launched in 2010.1 To remain relevant to current evidence, the mhGAP 1008
recommendations were updated in 2015, using the GRADE guideline development method.2 A guideline development group was responsible for updating the guidelines on the basis of a systematic appraisal of the evidence and considering the values and preferences www.thelancet.com/psychiatry Vol 3 November 2016
Comment
New abridged or updated recommendations
Strength
Antidepressant medication in comparison with psychological treatment for moderate-severe depressive disorder.
As first-line therapy, health-care providers might select psychological treatments (such as behavioural activation, cognitive behavioural therapy, or interpersonal psychotherapy) or antidepressant medication (such as selective serotonin reuptake inhibitors and tricyclic antidepressants).
Conditional
Comparative effectiveness of different formats of psychological treatments for depressive disorder.
Health-care providers can offer different treatment formats of WHO’s recommended, structured psychological interventions Conditional for adults and older adolescents with depressive disorder. Different treatment formats for consideration include (1) individual or group face-to-face psychological treatments, or both, delivered by professionals and supervised lay therapists, as well as (2) self-help psychological treatment.
Depression
Psychosis Role of depot antipsychotic medication in longterm antipsychotic treatment.
In people with psychotic disorders (including schizophrenia) requiring long-term antipsychotic treatment, depot antipsychotics can be offered instead of oral medications as part of a treatment plan.
Conditional
Antipsychotics and mood stabilisers (lithium, valproate, or carbamazepine) for maintenance treatment of bipolar disorder.
Lithium or valproate or certain second-generation antipsychotics (aripiprazole, olanzapine, paliperidone extended release, quetiapine, and risperidone long-acting injection release) can be offered for the maintenance treatment of bipolar disorder. If treatment with one of these drugs is not feasible, first-generation antipsychotics or carbamazepine can be used.
Conditional
Second-generation antipsychotic medications in psychotic disorders (including schizophrenia).
Second-generation antipsychotics (with the exception of clozapine, which is indicated for treatment-resistant psychosis) can be offered for the treatment of psychotic disorders (including schizophrenia).
Conditional
Pharmacological interventions in adolescents with psychotic disorders (including schizophrenia and bipolar disorder).
In adolescents with psychotic disorders (including schizophrenia and bipolar disorder), certain second-generation antipsychotic medications (aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone) can be offered as a treatment option under supervision of a specialist. If treatment with one of these drugs is not feasible, first-generation antipsychotics can be used under supervision of a specialist.
Conditional
Antiepileptic medications for management of acute convulsive seizures when no intravenous access is available.
When intravenous access is not available for the control of acute seizures in adults, non-parenteral routes of benzodiazepine administration should be used. Options include rectal diazepam, buccal or intranasal midazolam, rectal or intranasal lorazepam. The preference can be guided by availability, expertise, and social preference. Some benzodiazepines (lorazepam or midazolam) can be given by intramuscular route, which requires additional expertise. Intramuscular administration of diazepam is not recommended because of erratic absorption.
Strong
Antiepileptic medications for management of established status epilepticus.
Conditional In adults with established status epilepticus (ie, seizures persisting after two doses of benzodiazepines), either intravenous valproic acid, intravenous phenobarbital, or intravenous phenytoin can be used with appropriate monitoring. Intravenous valproic acid is preferred over intravenous phenobarbital or intravenous phenytoin because of its superior risk-benefit profile. When intravenous infusion might not be feasible, intramuscular phenobarbital remains an option, with appropriate monitoring. Phenytoin and valproic acid should not be given intramuscularly.
Antiepileptic medications for adults and children with HIV.
In comparison with enzyme-inducing antiepileptic medications (phenobarbital, phenytoin, carbamazepine) or valproic acid, newer generation antiepileptic medications that are not hepatically metabolised (ie, leviteracetam, lacosamide, topiramate, gabapentin, and pregabalin) can be preferred for use in people with HIV on certain antiretroviral medications (protease inhibitors or non-nucleoside reverse-transcriptase inhibitors). If the treatment with newer generation antiepileptic medications is not feasible, valproic acid is preferred over the enzyme-inducing antiepileptic medications (phenobarbital, phenytoin, and carbamazepine).
Conditional
Antiepileptic medicines for medication-resistant convulsive epilepsy.
Certain newer antiepileptic medications (lamotrigine, levetiracetam, and topiramate) should be offered as add-on therapy in patients with medication-resistant convulsive epilepsy. The essential antiepileptic medications (carbamazepine, phenobarbital, phenytoin, and valproic acid) can be of benefit as add-on therapy in patients with medication-resistant convulsive epilepsy.
Conditional
Caregiver skills training for management of developmental disorders.
Caregiver skills training should be provided for management of children and adolescents with developmental disorders, including intellectual disabilities and pervasive developmental disorders (including autism).
Strong
Psychosocial interventions for treatment of behavioural disorders.
Behavioural interventions for children and adolescents, and caregiver skills training, can be offered for the treatment of behavioural disorders.
Conditional
Psychosocial interventions for treatment of emotional disorders.
Psychological interventions, such as cognitive behavioural therapy, interpersonal psychotherapy for children and adolescents, and caregiver skills training focused on their caregivers, can be offered for the treatment of emotional disorders.
Conditional
Effective strategies for detecting maltreatment of children and youth within the context of mental health and developmental assessment.
Health-care providers should be alert to the clinical features associated with child maltreatment and associated risk factors and assess for child maltreatment, without putting the child at increased risk.
Conditional
Community-based rehabilitation for adults with developmental disorders including intellectual disabilities and autism spectrum disorders.
Non-specialised health-care providers can offer supporting, collaborating, and facilitating referral to and from communitybased rehabilitation programmes, if available, for care of adults with developmental disorders, including intellectual disabilities and pervasive developmental disorders (including autism).
Conditional
Epilepsy
Mental disorders with childhood onset
(Table continues on next page)
of stakeholder groups and the practical issues of feasibility.3 We have listed the abridged recommendations and their strengths in the table. The strength of a recommendation expresses the degree to which www.thelancet.com/psychiatry Vol 3 November 2016
there was certainty in the balance between the desirable and undesirable consequences of implementing the recommendation. A strong recommendation was assigned when the evidence clearly supported that desirable outcomes outweigh undesirable consequences, 1009
Comment
New abridged or updated recommendations
Strength
Cholinesterase inhibitors and memantine for treatment of dementia.
Cholinesterase inhibitors and memantine can be offered for people with dementia in non-specialist health settings. The use of cholinesterase inhibitors should be focused upon those with mild to moderate Alzheimer’s disease, when almost all evidence is available. Memantine can be considered for those with moderate to severe Alzheimer’s disease and vascular dementia. Memantine should not be prescribed for dementia with Lewy bodies.
Conditional
Psychological therapies for people with dementia who have associated depression.
People with dementia and mild to moderate symptoms of depression can be offered psychological interventions (such as cognitive behavioural therapy, interpersonal therapy, structured counselling, and behavioural activation therapy) in nonspecialised health-care settings under supervision of a specialist.
Conditional
(Continued from previous page) Dementia
Oral nutrition supplementation or dietary education In people with dementia who are at risk of undernutrition, dietary advice aimed at food fortification should be tried first, and for caregivers for managing people with dementia at weight and nutritional status monitored. If nutritional status is not improved, then oral nutritional supplementation should risk for undernutrition or currently undernourished. be used (in the absence of any clinical contraindication) to achieve weight gain and restore nutritional status.
Strong
Nutritional interventions for people with dementia In people with either cognitive impairment or dementia, supplementation with nutrients, or use of Gingko biloba extracts or cognitive impairment. should not be considered to improve cognitive function, to reduce the risk of developing dementia, or to slow the progression of dementia once established. When feasible, dietary deficiencies should be investigated and monitored in those with dementia and appropriate supplementations should be provided.
Conditional
Alcohol-use disorders Baclofen for relapse prevention and management among people with alcohol dependence.
Baclofen can be offered to prevent relapse among people with alcohol dependence after detoxification.
Conditional
Drug-use disorders Psychosocial interventions for the management of Psychosocial interventions based on cognitive behavioural therapy or motivational enhancement therapy or family therapy cannabis dependence. can be offered for the management of cannabis dependence. Supervised dosing with a long-acting opioid medication for the management of prescription opioid dependence.
Conditional
When managing people who are dependent on strong prescription opioids (ie, morphine-like), physicians can switch to a long-acting opioid (such as methadone and buprenorphine), which can be taken once daily, with supervised dispensing if necessary, either for maintenance treatment or for detoxification.
Conditional
Implementation of suicide prevention programmes in school settings that include mental health awareness training and skills training can be offered to reduce suicide attempts and suicide deaths among adolescent students.
Conditional
Self-harm and suicide School-based interventions for reducing deaths from suicide and suicide attempts among young people.
Table: New abridged or updated WHO Mental Health Gap Action Programme recommendations on mental, neurological, and substance use disorders for priority conditions
and conditional was used for recommendations when degrees of uncertainty were present. Out of 23 new or updated recommendations, three were rated as strong. For the control of acute seizures in adults, WHO strongly recommends the use of nonparenteral routes of benzodiazepine administration when intravenous access is not available. A second strong recommendation refers to the provision of caregiver skills training for the management of children and adolescents with developmental disorders, including intellectual disabilities and pervasive developmental disorders. Finally, in people with dementia who are at risk of undernutrition, WHO strongly recommends dietary advice aimed at food fortification and oral nutritional supplementation, if nutritional status has not improved. Another update refers to the introduction of conditional recommendations for the use of secondgeneration antipsychotics for both maintenance treatment of bipolar disorder, as well as in the treatment of schizophrenia and related psychotic 1010
disorders. In individuals with moderate-to-severe depression, challenging questions that were addressed by the updated WHO guidelines included the comparative effectiveness of antidepressants versus psychological interventions, and the effectiveness of different forms of psychological treatments. Depression within the context of dementia was also addressed, as was the use of cholinesterase inhibitors and memantine in individuals with dementia. Additional updates for the guidelines include those regarding the management of status epilepticus, the choice of antiepileptic medications for adults and children with HIV, and add-on therapy for medicationresistant convulsive epilepsy. In the area of mental disorders of childhood onset, updated WHO recommendations provide guidance on psychosocial interventions for the treatment of behavioural and emotional disorders, on effective strategies for detecting maltreatment of children within the context of mental health and developmental assessment, and on community-based rehabilitation www.thelancet.com/psychiatry Vol 3 November 2016
Comment
for adults with developmental disorders. New recommendations were also issued regarding baclofen for the prevention of relapse among people with alcohol dependence after detoxification, and regarding the role of psychosocial interventions for the management of people with cannabis dependence. Finally, for the prevention of self-harm, WHO guidelines recommend the implementation of suicide prevention programmes in school settings. The first edition of the mhGAP guidelines has been used by more than 80 countries and translated into more than 20 languages through an integrated intervention package of programmes over the past 5 years. This package includes the mhGAP Intervention Guide, a set of clinical protocols based on the evidence-based guidelines that assist non-specialist health-care providers in low-income and middle-income countries to directly translate recommendations into practice.1 These mhGAP guidelines are key features in the development of mental health action plans by these countries. The widespread use of mhGAP has important implications, from direct clinical care to policy and system-wide changes. For example, adaptation and contextualisation exercises make the WHO guidelines relevant and appropriate to the local health system,4–7 and these have directly informed the 2015 updates by highlighting common issues of feasibility or gaps in the 2010 materials. The guidelines also affect other health systems’ strengthening efforts—for example, their influence on the WHO model list of essential medicines. The two new additions to the model essential medicines list are buccal midazolam in the core list for control of acute seizures, and intravenous valproic acid in the complementary list for the management of status epilepticus.8 However, despite the widespread use of the mhGAP programme, very few research studies exist that directly assess the use of mhGAP guidelines in the field.9 The few studies done show that the programme is most useful in enhancing capacity for individual conditions, but that the entire programme (ie, all the identified priority conditions) has limited uptake.9,10 Monitoring and assessment were quite cumbersome and a built-in, more effective (potentially electronic or web-based, or remote monitoring) system is needed.10,11 Other programmes showed the use of mhGAP in direct training, such as in Ethiopia where it www.thelancet.com/psychiatry Vol 3 November 2016
was incorporated into the educational programme for child psychiatry.7 In Nepal, it was used as a training tool as part of a larger mental health package.5 As updated mhGAP guidelines will be used in many countries, it is essential that evidence of their effect is generated. Direct feedback on facilitators and barriers to the use of the guidelines, adherence to recommendations, and patient outcomes are important to inform improvement at the provider level, as well as at the larger programmatic and country levels. Implementation research is required to enhance our knowledge on how mhGAP can be scaled up to improve mental health care. *Tarun Dua, Corrado Barbui, Archana A Patel, Elizabeth Centeno Tablante, Graham Thornicroft, Shekhar Saxena, WHO’s mhGAP Guideline team† Department of Mental Health and Substance Abuse, World Health Organization, Geneva CH-1211, Switzerland (TD, ECT, SS); Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy (CB); Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA (AAP); and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK (GT) [email protected] †WHO’s mhGAP Guideline team (development group) Sophia Achab, Emiliano Albanese (WHO Collaborating Centre, University of Geneva/Hôpitaux Universitaires de Genève, Geneva, Switzerland); Robert Ali (Drug and Alcohol Services South Australia (DASSA), WHO Collaborating Centre for the Treatment of Drug and Alcohol Problems, University of Adelaide, Adelaide, Australia); Corrado Barbui (Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy); Vladimir Carli (National Centre for Suicide Research and Prevention of Mental lll-Health, Karolinska Institute, Stockholm, Sweden); Sudipto Chatterjee (Parivartan Trust and Sangath, Goa, India); Pim Cuijpers (Vrije University, Amsterdam, Netherlands); Kolou Simliwa Dassa (Ministry of Health, Lomé, Togo); Christopher Dowrick, Atif Rahman (Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK); Julian Eaton (CBM International, Lomé, Togo; London School of Hygiene and Tropical Medicine, London, UK); Asma Humayun (Meditrina Health Care, Islamabad, Pakistan); Gabriel Ivbijaro (Wood Street Medical Centre, London, UK); Nathalie Jette (Hotchkiss Brain Institute and O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada); Charles Newton (Kenya Medical Research Institute, Kilifi, Kenya); Olayinka Omigbodun (Centre for Child and Adolescent Mental Health, University College Hospital, Ibadan, Nigeria); Akwasi Osei (Ministry of Health Ghana, Accra, Ghana); Alfredo Pemjean (Department of Mental Health, Ministry of Health, Santiago, Chile; Faculty of Medicine, University Diego Portales, Santiago, Chile); Graham Thornicroft (chair), Martin Prince (Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK); Richard Rawson (University of California at Los Angeles Integrated Substance Abuse Programs, California, LA, USA); Pratap Sharan (All India Institute of Medical Sciences, New Delhi, India); Vandad Sharifi (Tehran University of Medical Sciences, Tehran, Iran); Lakshmi Vijayakumar (SNEHA Suicide Prevention Centre, Chennai, India); Inka Weissbecker (International Medical Corps, Washington, DC, USA); and Zhao Min (Shanghai Mental Health Centre, Shanghai Jiao Tong University School of Medicine, Shanghai, China). WHO Secretariat: Nicolas Clark, Tarun Dua, Alexandra Fleischmann,
1011
Comment
Melissa Harper, Archana A Patel, Shekhar Saxena, Chiara Servili, Elizabeth Centeno Tablante, Mark van Ommeren, Mohammad Taghi Yasamy.
3
GT is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King’s College London Foundation Trust. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health. GT acknowledges financial support from the Department of Health via the NIHR Biomedical Research Centre and Dementia Unit awarded to South London and Maudsley NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust. GT is supported by the European Union Seventh Framework Programme (FP7/2007–2013) Emerald project. NC, TD, AF, CS, MvO, and SS are staff members of WHO, while MH and ECT are consultants with WHO. MTY was a WHO staff member at the time of the mhGAP guidelines update. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of WHO. All other authors have no competing interests.
4
1
2
Dua T, Barbui C, Clark N, et al. Evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries: summary of WHO recommendations. PLoS Med 2011; 8: e1001122. Barbui C, Dua T, van Ommeren M, et al. Challenges in developing evidence-based recommendations using the GRADE approach: the case of mental, neurological, and substance use disorders. PLoS Med 2010; 7: e1000322.
5 6
7
8 9
10
11
Barbui C, Dua T, Harper M, Centeno Tablante E, Thornicroft G, Saxena S. Use of GRADE to update WHO recommendations on MNS. Lancet Psychiatry 2015: 2: 1054–56. Abdulmalik J, Kola L, Fadahunsi W, et al. Country contextualization of the mental health gap action programme intervention guide: a case study from Nigeria. PLoS Med 2013; 10: e1001501. Jha A, Sapkota N. Dementia assessment and management protocol for doctors in Nepal. JNMA J Nepal Med Assoc 2013; 52: 292–98. Katchanov J, Birbeck GL. Epilepsy care guidelines for low- and middle- income countries: from WHO mental health GAP to national programs. BMC Med 2012; 10: 107. Tesfaye M, Abera M, Gruber-Frank C, Frank R. The development of a model of training in child psychiatry for non-physician clinicians in Ethiopia. Child Adolesc Psychiatry Ment Health 2014; 8: 6. WHO. 19th WHO model list of essential medicines. Geneva: World Health Organization, 2015. Saraceno B, van Ommeren M, Batniji R, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007; 370: 1164–74. Gureje O, Abdulmalik J, Kola L, Musa E, Yasamy MT, Adebayo K. Integrating mental health into primary care in Nigeria: report of a demonstration project using the mental health gap action programme intervention guide. BMC Health Serv Res 2015; 15: 242. Tol WA, Purgato M, Bass JK, Galappatti A, Eaton W. Mental health and psychosocial support in humanitarian settings: a public mental health perspective. Epidemiol Psychiatr Sci 2015; 24: 484–94.
What is mindfulness-based therapy good for? What exactly is mindfulness meditation good for? For whom and how does it work? Can it have adverse effects? A cursory glance at the mental health literature suggests that it can help with almost anything, but a deeper look reveals contradictory findings. How good is the evidence for its benefits? A major meta-analysis1 of 163 studies focusing on psychological variables suggests that mindfulness has a range of positive effects on mental health, such as changes in stress and negative emotions. A closer inspection, however, reveals that most of the studies had methodological limitations (less than 10% used an active control group) and, most surprising, there seems to be no consistent longitudinal effect— meditating for a greater length of time is not associated with better psychological outcomes. This lack of a longitudinal effect has been confirmed by a meta-analysis2 of brain imaging studies: although mindfulness practice leads to structural brain changes, these changes are confined to the first weeks of practice. Evidence concerning the use of mindfulness-based interventions for recurrent depression is more promising: across nine clinical trials, individuals who received a cognitive-based mindfulness-based intervention had a lower chance of relapse within 1012
60 weeks of follow-up.3 Yet, a mindfulness intervention was not more helpful than other forms of mental health training, and the only study that tried to tease apart the effect of the meditation element from the psychoeducation training didn’t find the meditation practice to be more effective than treatment as usual.4 Another meta-analysis5 of 47 randomised clinical trials on the use of mindfulness-based interventions for mental health problems confirmed moderate evidence of improved results for depression, as well as anxiety. However, for variables one would expect mindfulness to have a strong effect on, such as stress and positive mood, there were only weak effects. Turning to the second question: for whom and how does mindfulness work? The answer to this question is precarious and messy. There has been very little research on individual differences in mindfulness, probably because of an assumption that this technique develops a kind of self-awareness capacity that is innate to all individuals. There are, however, indications that individuals with certain personality characteristics (openness to experience and agreeableness) will use mindfulness more frequently,6 and that mindfulness-based interventions are more effective for recurrent depression with patients who have suffered childhood trauma and www.thelancet.com/psychiatry Vol 3 November 2016