Psychiatry

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Psychiatry CHARLOTTE HANLON  |  ABEBAW FEKADU

• General health professionals can safely and effectively deliver care to persons suffering from mental disorders using evidence-based guidelines.

their family: effective treatment of mental disorders is one way to alleviate poverty.6 Effective, culturally appropriate and affordable interventions exist that could help to treat distressing symptoms, and to rehabilitate and reintegrate persons with mental disorders into society. The problem is largely one of coverage: in many LAMICs, over 75% of persons with severe mental disorders never receive effective treatment during their lifetime.7 Given the dearth of specialist mental health professionals in LAMICs,8 task sharing with general healthcare professionals is one workable way to reduce this scandalous treatment gap. The WHO advocates that the care for priority mental disorders should be integrated into the primary and general healthcare system, with support from specialist mental health services.1 New evidencebased guidelines (the WHO mental health Gap Action Programme Implementation Guide; mhGAP-IG) exist to support this process and will form the basis of guidance given within this chapter.9

• The World Health Organization (WHO) has identified priority mental disorders for focused action and many LAMICs are scaling up mental health care.

Diagnosis and Epidemiology of ‘Priority’ Mental Disorders

KEY POINTS • Mental disorders are common across the world and associated with high levels of suffering and disability. • Physical and mental health are intertwined; comorbid mental disorders contribute to poorer prognosis, quality of life and survival in physical health conditions. • Mental disorders increase mortality through suicide, accidents and poorer physical health. • Stigma and discrimination mean that persons with mental disorders get worse health care. • Effective and affordable treatments for mental disorders are available for all countries of the world but awareness and implementation is low.

Introduction Mental disorders affect people in every country of the world. Despite this, psychiatry is often a marginalized and neglected specialty within low- and middle-income countries (LAMICs). There are, however, compelling reasons why action should be taken to provide better care for those with mental disorders. Mental disorders are common: 10–30% of people worldwide are estimated to be affected by a mental disorder over any 12-month period.1 Mental disorders cause immense suffering to the person, their family and the wider community. Often this suffering is compounded by the effects of stigma, discrimination and human rights abuses, all of which are exacerbated by a lack of access to known effective treatments. This situation has been described as a ‘global emergency on a par with the worst human rights scandals in the history of global health’2 and a ‘failure of humanity’.3 The public health argument recognizes that mortality alone is not an adequate measure of the adverse consequences of disease and illness. When disability is also taken into account, neuropsychiatric disorders top the list of the most disabling disorders worldwide.4 Even these figures ignore the substantial contribution of mental disorders to death by suicide (800 000 deaths/year, worldwide)5 and accidental death, and to poorer health outcomes when mental disorders are comorbid with a range of physical health conditions. There is, indeed, ‘no health without mental health’.5 Mental disorders also have important economic consequences for the person and

Mental disorders are diagnosed according to international, standardized criteria. The two most widely used diagnostic systems are the WHO’s International Classification of Disease, currently in its 10th revision (ICD-10)10 and the Diagnostic and Statistical Manual of Mental Disorders, version V (DSM-V).11 Both systems operationalize diagnosis by specifying constellations of symptoms and signs that appear to define a specific mental disorder and discriminate that disorder from other disorders. Review of the DSM has just been completed and review of the ICD is currently underway with the expectation that diagnostic criteria will become more closely aligned, although current differences are not substantial. The WHO recommends that general health workers focus their attention on selected ‘priority disorders’,1 namely the common mental disorders (CMDs), which include depression, anxiety and medically unexplained somatic symptoms, the severe mental disorders (SMD), which comprise the psychoses and bipolar disorder, as well as developmental and behavioural disorders in children and adolescents, dementia, and alcohol and drug use disorders. In addition, the cross-cutting issue of suicide and self-harm is prioritized for action. The estimated global prevalence of the WHO priority conditions is as follows:12 depression 1.9% in men, 3.2% in women; psychosis 0.4%; bipolar disorder 0.4%; child development disorders 1.0–3.0%;13 child behavioural disorders 10.0–20.0%; dementia 0.6% in the total population, ranging from 1.6% (sub-Saharan Africa) to 6.4% (USA) in those over 60 years;14 alcohol use disorders 2.8% in men, 0.5% in women; drug use disorders 0.4–4.0%. 1061

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It should be noted that the combined estimates of prevalence of SMD is conservative and likely to be closer to 2%.15,16 Crosscountry studies show a comparable prevalence of priority mental disorders in general population samples in LAMICs and high-income countries,17,18 although individual countries show some variation. In primary and general healthcare settings, the prevalence of depression is substantially higher than that found in the general population, with most countries in a WHO crosscountry study finding around 20–40% prevalence.19

Culture, Mental Health and Disorder Most diagnostic categorizations of mental disorder are based upon Western conceptualizations of mental health and illness. In the absence of gold standard tests for mental disorders, there is concern that mental pathology in non-Western cultures may be diagnosed where none truly exists; Kleinman’s so-called ‘category fallacy’.20 For example, it has been hypothesized that postnatal depression is a culture-bound disorder of the West, arising because of certain societal changes, including the dominance of biomedical management of childbirth and the alienation of women from important cultural rites of passage.21 Although plausible, the evidence accumulating from well-conducted, culturally sensitive studies in LAMICs rather supports the opposite: women in LAMICs appear to be at higher risk of postnatal depression, which is recognized within the culture and has public health relevance due to adverse effects on both mother and child.22 Some mental disorder categories are more controversial than others and the risk of category fallacy might vary across categories of mental disorder; higher for CMDs and lower for the SMD and dementia, whose manifestations appear less variable across cultures. Despite variation in presenting symptoms, however, the core syndromes of the WHO’s priority mental disorders appear to be present across cultures. Nonetheless, culture remains highly relevant to mental health and disorder in a number of ways. Cultural factors may affect vulnerability to mental disorder, the way that symptoms are expressed, detection by health professionals, the illness attribution of the person and their family, as well as the favoured help-seeking behaviour. For example, in South Asia, the societal pressure to deliver a boy baby has been shown to lead to increased levels of postnatal depression in women who give birth to girl babies.23

Mental Health and Physical Health Mind and body are inextricably linked. Mental disorders can be risk factors for physical disorders or may arise as a consequence of physical ill-health. In some cases, a common predisposition may underlie the occurrence of both conditions. All too often, mental disorders remain undetected, and therefore untreated, in general and primary healthcare settings. Findings from a recent comprehensive global review of the complex interrelationships between physical and mental ill-health will now be summarized in relation to physical conditions that command a high public health priority in LAMICs.5 CHRONIC COMMUNICABLE DISEASES The prevalence of HIV/AIDS is increased in persons with SMD in high-income countries, with mental disorder thought

to increase the risk of HIV infection. Findings from LAMICs are less clear. However, alcohol and drug use are associated with risky sexual behaviours,24 as well as direct risk of HIV transmission for injecting drug users, worldwide. There is strong evidence that the risk of CMDs is increased in persons with HIV/ AIDS, both in high-income countries25 and LAMICs.5 CMDs co-morbid with HIV have been associated with decreased helpseeking and uptake of treatment services for HIV/AIDS, poorer treatment adherence, more rapid disease progression, increased disability, poorer quality of life and increased mortality. Cognitive deficits and alcohol and drug use also adversely affect the outcome of HIV/AIDS. Similar consequences of undetected CMDs are also found in tuberculosis (TB), particularly in those suffering from multidrug resistant TB (MDR-TB). CHRONIC NON-COMMUNICABLE DISORDERS (NCDs) As reviewed by Prince and co-workers,5 CMDs increase the risk of a person developing hypertension, ischaemic heart disease and stroke, and may increase the risk of diabetes. The risk of diabetes is also raised substantially in persons with psychosis, related in part to lifestyle and the side-effects of medication. NCDs also increase the risk of developing CMDs, so that overall comorbidity between NCDs and mental disorders is high. CMDs comorbid with NCDs are associated with poorer prognosis, including higher risk of complications (e.g. diabetic retinopathy) and death. CMDs appear to worsen self-care, responsiveness to advice about lifestyle change and adherence to medication regimens that need to be sustained over a long period of time. CMDs have a large negative impact on overall health status and functioning, consistently greater in magnitude than that arising from the chronic and disabling diseases of diabetes, arthritis, angina and asthma.26 REPRODUCTIVE AND CHILD HEALTH In LAMICs, pregnant women appear to have an elevated risk of CMDs.27 Untreated CMD has been associated with poorer antenatal care attendance, increased use of alcohol and cigarettes, poorer weight gain during pregnancy and increased risk of preterm birth and low birth weight in high-income countries.28 To date in LAMICs, antenatal CMDs have been associated with prolonged labour, delayed initiation of breast-feeding29 and low birth weight.30,31 Although not appearing to be more prevalent than at other times in the life course, postnatal CMDs have been found to be associated with early cessation of breast-feeding; infant undernutrition;22 ill-health and decreased vaccine uptake;32 poorer cognitive development;33 and increased child mortality33 in LAMICs.

Aetiology Known aetiological mechanisms for specific priority mental disorders will be considered later. In this section, we introduce a widely used aetiological framework for conceptualizing possible reasons for the presence of a particular mental disorder in a particular person at a given moment in time; the so-called biopsychosocial formulation.34 The biopsychosocial approach recognizes that mental disorders often arise due to a



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TABLE 72.1 

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Example of Possible Biopsychosocial Framework for Psychosis

Biological Psychological Social

Predisposing

Precipitating

Perpetuating

Genetics/family history Developmental delay Migration

Cannabis use Conflict in the family Social isolation

Non-adherence with antipsychotic medication High expressed emotion within the family Stigma and discrimination

combination of biological, psychological and social factors, some leading to a vulnerability or resilience to mental disorders, others triggering the onset of the disorder, and perhaps others contributing to the maintenance of a mental disorder once started. Elucidating the contribution of these factors can be important in guiding appropriate management of mental disorders. See Table 72.1 for a possible biopsychosocial formulation of psychosis in an individual. In this case, the predisposing factors may give us important prognostic information, whereas the precipitating and perpetuating factors will be essential to address to maximize the person’s clinical and functional recovery from psychosis. Attributions for the causes of mental disorders vary widely across cultures and need to be understood by the healthcare workers. Even within cultures, marked individual variation in illness attribution is apparent, meaning that healthcare workers should take care not to make assumptions about an individual person’s illness model. Spiritual and supernatural explanations of mental disorder, e.g. due to the evil eye of an envious neighbour; bewitchment; spirit possession; influence from ancestral spirits; divine punishment for wrong-doing – are more commonly found in LAMICs, particular for SMD. Such illness models may guide help-seeking, affect the acceptability of interventions and contribute to non-adherence with biomedical treatments.

SCREENING AND DETECTION When a person presents to a general healthcare setting suffering from a CMD, the symptoms rarely fit neatly into the distinct diagnostic categories for a psychiatric disorder.35 With all patients, be attentive to emotional clues and non-verbal communication of distress. For example, does the person look sad or miserable, unduly worried, or preoccupied beyond what would be expected given their complaint? The presenting complaint may give some clue to psychosocial problems: a woman with multiple injuries may be a victim of intimate partner violence and at high risk of a CMD; a man who keeps getting injured in fights may have an alcohol problem. Other clues to underlying CMDs include nonspecific, vague or multiple complaints which do not easily map onto known illness. Forgetfulness is most often secondary to the difficulty in concentrating that comes with CMD, but in an older person it should raise the possibility of dementia. Psychotic illness is often indicated by behaviour or beliefs that are outside the norms of the society. COMMUNICATION AND PRIVACY The patient’s willingness to disclose emotional concerns will depend partly on the ability of the healthcare professional to Think about safety

General Principles of Assessment Psychiatric assessment follows the same structure as any medical assessment, with systematic exploration of signs and symptoms of disorder. Unlike other fields of medicine, assessment of mental disorder relies more heavily upon the person’s report of their experiences, collateral history from those in a good position to observe the development of disorder in the person, and the observations of the health worker during the interview. The health worker’s observations are collected systematically in a ‘mental state examination’, which looks at abnormalities of general appearance and behaviour, speech, mood, thoughts, perceptions, cognition and the patient’s level of awareness about their condition (insight). The health worker’s communication and observational skills are, therefore, of paramount importance in order to make a correct diagnosis.

Keep calm Be polite and professional

Check ABC* and level of consciousness

Rule out organic causes requiring emergency intervention

Find out about the onset, course and duration of the disturbance

ACUTE BEHAVIOURAL DISTURBANCE If a person has acutely disturbed behaviour, they need to be seen straight away. A basic guideline for assessment is given in Figure 72.1. On occasion, the person may be too disturbed for an adequate physical examination to be carried out. Emergency tranquilization may then be required (Figure 72.2) but should not diminish the urgency of investigation of the underlying cause of disturbance.

See Box 72.1

Psychosis

Bipolar disorder

Sub-acute organic cause (Box 72.1)

*Airway, breathing and circulation Figure 72.1  Flowchart disturbance.

for

assessment

of

acute

behavioural

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Environmental manipulation • Quiet place • Night light • No dangerous objects • Increased nursing level

Organic underlying cause

Mental or behavioural disorder

Alcohol withdrawal

Elderly, Respiratory compromise, Hepatic/renal impairment Pregnant women

Other organic cause

Benzodiazepine e.g. Diazepam 10mg qds Thiamine 100mg po od

Haloperidol 2–5mg po/im

Offer ORAL treatment Haloperidol 5mg OR Chlorpromazine 75mg OR Olanzapine 10mg OR Risperidone 1-2mg AND/OR Diazepam 10mg

If not possible or ineffective after 30 minutes

Monitor temperature, pulse, blood pressure and respiratory rate If ineffective, refer for specialist advice

Parenteral treatment Haloperidol 5mg im OR Olanzapine 10mg im OR Lorazepam 1-2mg im OR Diazepam 10mg iv AND/OR Promethazine 50mg im

po = oral; im = intramuscular; iv = intravenous; qds = four times per day; od = once daily

make them feel comfortable to do so. This includes ensuring that the patient has privacy. Even in a busy clinic, it is crucial for health workers to try not to sound rushed. Important indicators of severe illness and risk may otherwise be missed, e.g. suicidal ideation. A non-judgemental and non-stigmatizing attitude will also encourage patients to be open about their difficulties. Closed questions should be avoided. For example, ‘You’re not feeling sad, are you?’ invites a ‘No’ response, even if the patient does have such feelings. RISK ASSESSMENT In any patient presenting with signs of mental disorder, and particularly in the case of a suicide attempt, it is essential for the health worker to assess the risk of suicide. Suicide risk is increased in CMDs, SMD and alcohol and drug use disorders. Asking about suicidal thoughts does not increase the risk of a person attempting suicide and for many, it will be a relief to share their distress. Be sensitive in your questioning, starting with more neutral questions, e.g. ‘Have you ever thought that

Figure 72.2  Management of acute behavioural disturbance. (Based on Taylor D, Paton C, Kapur S, editors. The Maudsley Prescribing Guidelines in Psychiatry, 11th ed. Chichester: Wiley-Blackwell; 2012.)

life was not worth living?’, and proceeding to ‘Have you ever thought of harming yourself in some way or trying to end your life?’. Past suicide attempts and current suicide plans or intent indicate high risk of suicide. Other important risk factors for completion of suicide include: chronic pain or a debilitating medical condition; presence of a priority mental disorder; social isolation; male sex; and unemployment. IDENTIFYING ORGANIC CAUSES OF MENTAL DISTURBANCE A number of general medical conditions can give rise to symptoms of mental disorder due to direct physiological consequences of the medical condition (Box 72.1). The underlying condition must be identified and treated.

General Principles of Management Just the process of being listened to by a health worker can be therapeutic and help to relieve some patients of their mental



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BOX 72.1  SOME OF THE ORGANIC CAUSES OF MENTAL DISTURBANCE • Non-infectious, CNS: Sub-dural haematoma, tumour, aneurysm, epilepsy (status epilepticus, post-ictal), severe hypertension, normal pressure hydrocephalus, head injury, multiple sclerosis, Parkinson’s disease • Metabolic/Endocrine: Hyper-/hypoglycaemia, hyper-/hypothyroidism, Addison’s disease, Cushing syndrome, hyper-/hypoparathyroidism, renal or hepatic disorders, Wilson’s disease, electrolyte derangement, vitamin deficiency (thiamine, vitamin B12, folate), porphyria • Infectious: Viral, e.g. HIV, HSV, Japanese encephalitis, rabies; bacterial, e.g. meningococcal meningitis, syphilis, typhoid fever, sepsis; mycobacterial, TB; parasitic, e.g. malaria, human African trypanosomiasis; mycotic, e.g. cryptococcosis • Cardiopulmonary: hypoxia, myocardial infarction, congestive cardiac failure • Systemic: systemic lupus erythematosus, vasculitis, anaemia • Exogenous Substances: • Alcohol or drug misuse • Prescribed medications: e.g. beta-blockers, methyldopa, reserpine, oral contraceptive pill, steroids, histamine-2 blockers, opiate analgesia, benzodiazepines, barbiturates, antimalarial drugs (especially mefloquine), antiretroviral therapies (e.g. efavirenz) • Poisoning: e.g. heavy metals (lead, mercury, organophosphates, manganese, arsenic). Adapted from Williams E, Shepherd S. Medical clearance of psychiatric patients. Emerg Med Clin North Am. May 2000; 18:2;193

TABLE 72.2 

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distress. The principles of management of mental disorders follow from the biopsychosocial assessment. In this section, we outline some common principles of interventions for priority mental disorders, divided into biological and psychosocial interventions. A summary of the WHO evidence-based guidelines is presented in Table 72.2. BIOLOGICAL INTERVENTIONS Physical Health and Nutritional Status Attending to the person’s physical as well as mental health needs is a necessary component of intervention. Self-neglect may have led to undernutrition and poorer general health status, which in turn may be contributing to worse mental health status. Prior to commencing psychotropic medications, a physical examination, measurement of blood pressure and pulse, and some basic laboratory investigations are usually required. For details, see Taylor and colleagues,36 but in summary: for antipsychotic medication, baseline full blood count, renal and hepatic function tests, prolactin level, plasma lipids, fasting blood glucose and, ideally, an ECG (mandatory for haloperidol) are recommended; with lithium, renal function and thyroid function tests are essential baseline investigations; and other mood-stabilizers require baseline hepatic function and full blood count.

Summary of Evidence-Based Treatment Approaches for Priority Mental Disorders Treated in General Healthcare Settings

COMMON APPROACH FOR ALL PRIORITY DISORDERS BIO Monitoring of physical health and medication side-effects PSYSOC Psychoeducation Risk management Family/carer support Regular follow-up DEPRESSION AND ANXIETY BIO Antidepressants   Tricyclic (e.g. amitriptyline)   Selective serotonin reuptake inhibitor (e.g. fluoxetine) Short-term anxiolytic medication   Diazepam PSYSOC Addressing current psychosocial stressors Reactivate social networks Structured physical activity   If available, can also consider: behavioural activation, cognitive behavioural therapy, interpersonal therapy, problem-solving therapy, relaxation training PSYCHOSIS BIO

PSYSOC

Antipsychotics   High-potency first-generation antipsychotics (FGAs) (e.g. haloperidol, trifluoperazine)   Low-potency FGAs (e.g. chlorpromazine)   Second-generation antipsychotics (SGAs) (e.g. risperidone, olanzapine)   Second-line only antipsychotic medication (clozapine)   Depot medication (e.g. fluphenazine) Anticholinergic medication   Biperiden, benzhexol Community-based rehabilitation Continued on following page

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Summary of Evidence-Based Treatment Approaches for Priority Mental Disorders Treated in General Healthcare Settings—cont’d

BIPOLAR DISORDER BIO Acute mania   Antipsychotics (FGA or SGA) and/or mood-stabilizer (lithium, valproate or carbamazepine)   Consider short-term benzodiazepine (diazepam) Depressive relapse   Mood-stabilizer alone or in combination with antidepressant Prevention of relapse   Mood-stabilizers (lithium, valproate or second-line carbamazepine) PSYSOC Reactivate social networks Rehabilitation DEMENTIA BIO

PSYSOC

Reduce cardiovascular risk factors, where relevant Treat associated physical conditions For behavioural and psychological symptoms associated with imminent risk and not responding to psychosocial approach, consider low-dose haloperidol/atypical antipsychotic   If specialist supervision and support is available and specific diagnosis of Alzheimer’s disease, anticholinesterases may be appropriate Sensitive communication of assessment findings Psychosocial interventions for cognitive symptoms and functioning Promote independence, functioning and mobility Manage behavioural and psychological symptoms

CHILD DEVELOPMENTAL DISORDERS BIO Manage nutrition problems and medical conditions, e.g. epilepsy PSYSOC Advice to teachers Community-based rehabilitation Promoting and protecting human rights   If available, consider parent skills training CHILD BEHAVIOURAL PROBLEMS BIO If specialist supervision and support is available and specific diagnosis of hyperkinetic disorder present, consider methylphenidate PSYSOC Advice to teachers   If available, consider parent skills training, cognitive behavioural therapy, social skills training and problem-solving for family issues ALCOHOL USE DISORDERS BIO Alcohol intoxication   Supportive treatment and observation   Exclude methanol poisoning Alcohol withdrawal if dependent   Diazepam   Thiamine   Hydration   Haloperidol for psychotic symptoms Alcohol dependence   Planned withdrawal as above   Relapse prevention If specialist supervision and support is available, acamprosate, naltrexone or disulfiram may be considered PSYSOC Brief intervention Self-help groups Attend to social problems, e.g. housing and employment   If available, consider family therapy, cognitive behavioural therapy, problem-solving therapy, motivational enhancement therapy, contingency management therapy DRUG USE DISORDERS BIO Sedative overdose   Naloxone if opioid Stimulant overdose   Diazepam   Short-term antipsychotics Manage physical complications of intravenous drug use Opioid withdrawal   Supportive treatment, e.g. antiemetic   With specialist support, reducing dose of methadone, buprenorphine, clonidine or lofexidine PSYSOC Brief intervention Self-help groups Attend to social problems Harm-reduction strategies From World Health Organization. Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) for mental, neurological and substance use disorders in non-specialized health settings. Geneva: WHO; 2010.

Psychotropic Medications Medication is recommended in the treatment of several priority conditions, although the effectiveness often depends on accompanying psychosocial support. Where the patient lacks insight into their condition, they may be ambivalent about taking medication. Psychoeducation (below), including honest information about side-effects, and a flexible, but supportive approach can help. Patients will often need encouragement to continue medication, even when they feel well. Response to medication needs to be reviewed. Health workers should not be tempted to prescribe placebo medication or ineffective treatments. Evidence-based treatments do exist. PSYCHOSOCIAL Psychoeducation Explaining to patients and family/care givers about the nature of the mental disorder and the availability of interventions can help to instil hope and reduce the stigma associated with the condition. Providing information can empower families and patients to maximize self-help strategies to bring about symptom relief and rehabilitation. Risk Management If a risk to the patient, or to others, is identified, then appropriate steps need to be taken to minimize the risk of harm. Management strategies may include referral for in-patient psychiatric care, continuous monitoring by family members and appropriate treatment for the underlying condition. Family/Care Giver Support The psychological impact of caring for a person with a mental disorder puts care givers at increased risk of developing mental disorders, particularly CMDs or alcohol or drug use disorders. Provide support through listening, giving information and screening for mental disorders where indicated. Regular Follow-Up Scheduling regular appointments allows monitoring of the patient’s mental state, response to medication and problems with side-effects. In addition, regular follow-up fulfils an important supportive function, helping to motivate and engage the patient and give encouragement to the care givers.

Common Mental Disorders PATHOGENESIS A modest contribution of genetic factors to the aetiology of depression is supported by twin and adoption studies.37,38 The best evidence to date is of a gene–environment interaction between a polymorphism in the promoter region of the serotonin transporter gene and child maltreatment.39 Other factors have also been implicated in the aetiology of CMDs, including: poverty; stressful experiences (e.g. death of a loved one, unemployment, marriage/divorce); female gender; increasing age; physical ill-health, especially if associated with chronic pain and disability; and alcohol or drug use.35 Disability associated with

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poor physical health appears to explain most of the prevalence of depression in later life.5 CLINICAL FEATURES AND DIAGNOSIS Medically unexplained somatic symptoms are the commonest way that people express mental distress worldwide and are often culture-specific. For example, in many sub-Saharan African settings, somatic complaints may take the form of burning or crawling sensations on the head or body. Somatic symptoms are a manifestation of underlying depression or anxiety in about two-thirds of cases.40 However, on direct enquiry, the classic features of depression and anxiety (see below) are usually straightforward to elicit. Somatic symptoms may also communicate subconsciously understood distress, e.g. the woman who presents with medically unexplained genital pain following sexual assault. The cardinal features of depression in Western settings are sad mood and loss of interest or enjoyment of life’s usual pleasures. In the young and the old, irritability may predominate over sadness. Other features are also present, including: somatic symptoms (loss of appetite, weight loss, sleep disturbance, loss of libido) and cognitive symptoms (hopelessness, worthlessness, poor self-esteem, suicidal ideation, unjustified guilt, impaired concentration and memory). General aches and pains, headache and constipation are also frequently seen. In situations of precarious survival, moderate levels of poor energy and motivation may be overcome due to necessity and not manifest as impaired functioning. Where communal religious beliefs prevail, there are often strong societal sanctions against admitting feelings of worthlessness or suicidal ideation. Sensitivity is required. In such settings, irritability, somatic symptoms and feelings that one is being punished for perceived wrong-doing can be pointers to an underlying depression. Anxiety is characterized by persistent worry or fear, out of proportion to the level of threat or difficulties faced, and associated with impairment. In anxiety, physiological effects of noradrenaline and adrenaline lead to somatic symptoms such as palpitations, shortness of breath, light-headedness, tremor and chest tightness. Other physical consequences of anxiety include muscle aches and headache secondary to tension, diarrhoea, nausea and stomach discomfort. Isolated CMD symptoms are experienced by most people within the general population. To be considered an illness, symptoms should be present most of the time, enduring (present for more than 2 weeks) and should not occur in the immediate aftermath of bereavement or be directly attributable to a general medical condition or medication side-effect (see Box 72.1). Furthermore, impairment should be present, in terms of relationships, work and/or daily functioning. Life difficulties may make CMDs understandable, but not all people with psychosocial problems develop CMDs – the key is to look for symptoms that the person or their associates consider to be excessive or out of keeping with their usual reactions. MANAGEMENT AND TREATMENT Somatic Symptoms Where the presentation is predominantly somatic, it is important to carry out a proper medical investigation. If screens for comorbid anxiety, depression, alcohol or drug use are negative, the main principles of management for somatic symptoms are

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as follows: (1) gain the patient’s trust; (2) facilitate a shift in the patient’s understanding of the causes of their symptoms from medical to psychosocial; (3) minimize disability and restore functioning; and (4) minimize the adverse effects of multiple visits to healthcare providers in terms of cost and receiving ineffective/potentially harmful investigations and treatments. Gaining the patient’s trust requires listening sympathetically to all of their symptoms and investigating them appropriately, but not excessively. Shifting the patient’s model of illness is a greater challenge. Avoid confrontation and statements such as, ‘it is all in your head’, or ‘there is nothing really wrong with you’. Ask about psychosocial stressors and discuss with the patient how these may link to their symptoms. Give examples of how the close links between mind and body could give rise to symptoms: ‘when you worry a lot, your muscles become tense and that can lead to headache’. In longstanding cases, a pragmatic approach may be required, admitting that there is no medical intervention for the person’s symptoms, but that the person will feel better if they can distract themselves by doing some activities. Regular follow-up appointments and a trusting health worker–patient relationship help to reduce ‘doctor-shopping’ and the associated harms. Low-dose tricyclic antidepressant (e.g. amitriptyline 25 mg at night) can help with chronic pain. Depression and Anxiety Where depression and/or anxiety disorders are present, evidence-based treatment protocols (Table 72.2) should be followed. If an antidepressant is prescribed, psychoeducation involves explaining that the medication takes 3–6 weeks before having a noticeable effect. Side-effects are usually transient and tolerable. Address psychosocial stressors by asking the patient about difficulties in their life and listening with compassion. People with CMD may feel overwhelmed by even relatively small difficulties. Reactivating social networks, by asking the person about the people who have supported them in the past and encouraging them to resume contact, can be one way to bolster coping with psychosocial stressors. Behavioural activation may be helpful, e.g. encouraging the person to structure their day, spend some time outside the house and try to do things that previously held meaning for them. PREVENTION There is preliminary evidence that targeted and universal depression primary prevention programmes are effective in reducing the incidence of depression in children and adolescents.41 A population-based approach to primary prevention of CMDs across the age span, e.g. by reducing social risk factors such as poverty, has been advocated, but little explored, to-date.42 Psychological but not antidepressant therapy may prevent depression post-stroke.43

Psychotic Disorders In its simplest form, psychosis is a symptom rather than a disorder, but even in isolation, psychosis symptoms indicate a potentially severe problem. Psychosis may occur de novo (primary psychotic disorder) or as a secondary manifestation of other disorders (e.g. secondary to mood disorders, general medical conditions or alcohol or drug use). Schizophrenia is the prototypical example of primary psychosis. In this section,

schizophrenia will be discussed in detail with reference to other psychotic disorders where relevant. EPIDEMIOLOGY Almost all psychotic disorders affect both men and women equally. These disorders start early in life, most between 15 and 45 years of age, and tend to follow a chronic course, meaning that psychoses make a disproportionate contribution to population disease burden. Historically, the prognosis of schizophrenia was thought to be better in LAMICs44 but recent studies have challenged this finding.45–47 PATHOGENESIS Imaging studies of untreated persons with schizophrenia have identified characteristic structural brain changes. The ‘neurodevelopmental’ model of schizophrenia, whereby developmental genes and early neurological insults (e.g. secondary to obstetric complications) are hypothesized to interact and bring about psychosis, has been expanded to incorporate the role of later environmental insults (e.g. chronic social adversity and drug use).48 This multifactorial model of schizophrenia is hypothesized to bring about dopamine dysfunction within the brain as a final common pathway.49 Other neurotransmitter abnormalities, e.g. serotonin and glutamate, have also been implicated.50 CLINICAL FEATURES There are three main symptom dimensions of schizophrenia: positive, negative and general symptoms.51 Positive and general symptoms occur predominantly during an acute episode of schizophrenia. Positive symptoms include delusions, hallucinations, psychomotor disturbance, such as agitated behaviour and formal thought disorder. Delusions are defined as fixed, false beliefs that are not shared by people of the same educational and cultural background. Delusional beliefs are most commonly persecutory but referential delusions and grandiose delusions are also common. Hallucinations, referring to perceptions without external stimuli in any of the sensory modalities, are most often auditory. Impairment in reality testing is probably the key psychopathological feature of psychosis, in which the affected person has lost a fundamental ability to distinguish between reality and fantasy. The negative symptoms of schizophrenia relate to loss of functions necessary for relating with the external world. The person tends to be withdrawn and in their own world, with reduced affective expression or blunted affect, and markedly reduced verbal output, which is considered to be an expression of a reduced ability to think (alogia). ICD-10 requires the occurrence of characteristic symptoms for at least 1 month for a diagnosis of schizophrenia.52 The main differential diagnoses of schizophrenia are other psychotic disorders: schizoaffective disorder, delusional disorder and acute and transient psychotic disorders. In schizoaffective disorder, psychotic episodes are associated with clear mood episodes that may be depressive or manic in nature. In delusional disorder, there are systematized delusions in the absence of persistent hallucinations or other psychotic symptoms. In acute and transient psychotic disorders, ‘delusions, hallucinations, incomprehensible or incoherent speech, or any combination of these’ develop over a maximum of 2 weeks.52

TREATMENT AND MANAGEMENT The WHO’s evidence-based guidelines (Table 72.2) mean that treatment for psychosis can begin in primary or general healthcare settings, with appropriate review by specialist mental health workers if the person does not respond to first-line interventions. Whenever possible, persons with psychosis should be managed in the community. The WHO guidelines assume that only first-generation antipsychotics will be available in most LAMICs. The typical effective dose of haloperidol is 3–20 mg, although doses above 10 mg rarely bring extra benefit but carry a high risk of serious extrapyramidal side effects (EPSE), including Parkinsonian symptoms, dystonia, dyskinesia and akathisia. Secondgeneration antipsychotic medications have an equal efficacy to the older medications and may be better tolerated, although they can also have troublesome side effects. PREVENTION There are no established primary prevention strategies. There is an accepted link between duration of untreated psychosis (DUP) and poor outcome. Therefore, secondary prevention strategies to reduce DUP are important. Community rehabilitation and recovery strategies, as well as prevention of relapse through maintenance treatment, are also important strategies to reduce the impact of the disorder on functioning.

Bipolar Disorder Bipolar disorder (BD) is a recurrent condition characterized by episodes of severe fluctuation in mood.

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behaviour, overspending and reckless decision-making are additional behavioural symptoms. Optimism and selfconfidence generally gives way to grandiosity and grandiose delusions. The depressive phase of the illness shares similar symptoms to that of a depressive disorder. Reversal of biological symptoms (increased appetite and weight, hypersomnia and mood reactivity) and excessive tiredness, so-called leaden paralysis, are said to be more characteristic of a bipolar depression. TREATMENT AND MANAGEMENT The treatment of BD may be viewed in three phases: acute, continuation and maintenance. See Table 72.2 for evidencebased guidelines. Treatment invariably requires medication but psychosocial interventions will also be required. Medication options for an acute episode of mania include mood stabilizers or antipsychotic medications. All these drugs require careful monitoring, but lithium requires the most intensive monitoring because of its narrow therapeutic margin and potential renal toxicity and neurotoxicity. Continuation treatment is the treatment phase that follows the achievement of remission and lasts about 6 months. Almost 90% of persons with a first episode of mania will experience relapse. Therefore, maintenance treatment is required. Often longer-term management of BD requires specialist input or the input of a practitioner with a special interest in mental health. In particular, management of the depressive phase of the illness can be complicated. It is important that the affected person and care givers are educated about the illness. The person needs to be advised to modify their lifestyle and maintain routine, e.g. in terms of dietary and sleep habits. PREVENTION

EPIDEMIOLOGY The mean age of onset of BD is 21 years and the disorder affects both men and women equally. In primary care settings, up to 10% of patients may have a bipolar spectrum condition.53 Comorbidity with substance abuse and anxiety disorders is in the order of 50–60%.15

Prevention should be considered in terms of prevention of relapse and recurrence as described above. This should extend to addressing issues of substance abuse, careful physical health monitoring and monitoring for risk of suicide, which can affect up to 15% of patients.

Dementia

PATHOGENESIS

EPIDEMIOLOGY

Genetic factors are important in BD: the risk of BD in monozygotic twins is 40–70%, while in dizygotic twins and all other 1st degree relatives it is 5–10%.38 However, the mode of inheritance is complex, mediated by multiple genes of small effect. Neuroimaging studies show an increase in size and reduction in glucose utilization in the amygdala and basal ganglia.54 Grey matter volume appears to be reduced in the subgenual prefrontal cortex. Neuropsychological tests have shown impairment in memory and concentration during illness episodes that also persist after recovery.

After the age of 65 years, the prevalence of dementia doubles every 5 years.55 Diagnosis of dementia remains a challenge in non-Western settings with low levels of educational attainment, leading to probable underestimation of prevalence.56 Almost 60% of persons with dementia are found in LAMICs, projected to increase to 71% by 2040.14 Dementia is highly burdensome, for the affected person as well as for care givers.57 Early diagnosis and evidence-based interventions can help to alleviate this burden, even in LAMICs.57 Alzheimer’s disease (AD) accounts for the majority of confirmed diagnoses of dementia at postmortem (over 50%), followed by vascular dementia (25%), dementia with Lewy bodies (15%) and other dementias including frontotemporal dementias (5%).58

CLINICAL FEATURES The central feature of mania is severely elated or irritable mood lasting for at least a week. Associated behavioural and cognitive symptoms include increased energy and hyperactivity, ranging from semi-purposeful activity to disruptive and restless behaviour. Disinhibition, with increased sexual energy, excessive socializing and over-talkativeness, indiscrete and inappropriate

PATHOGENESIS Most is known about the pathogenesis of AD.55,59 Around 70% of the risk of AD is attributable to genetic factors, with

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dominant transmission of genetic mutations explaining about 5% of cases (mostly early-onset AD), and multiple, interacting genes of small effect increasing the risk of late-onset AD.59 Of the latter, polymorphisms of the gene encoding apolipoprotein E are associated with the biggest increased risk.59 The core pathological findings in AD are amyloid plaques and neurofibrillary tangles, which are associated with neurotoxicity and neuronal death. There is substantial overlap in the pathological changes seen in AD and vascular dementia.55,59 In HIV-associated dementia (HAD), neurotoxicity due to direct effects of HIV infection, coupled with indirect effects due to neurotoxins from infected or immune-activated mi­­ croglia or macrophages are implicated in the pathogenesis.60 Even following the introduction of highly active antiretroviral therapy, HAD remains an important feature of AIDS.60,61 CLINICAL FEATURES Dementia is characterized by global, chronic and progressive cognitive decline (affecting memory, orientation, speech and language), which is associated with impaired functioning; e.g. in the activities of daily living such as washing, dressing, eating and personal hygiene. The presenting complaint for dementia, particularly AD, is often forgetfulness, but can also be depressed mood or deteriorating social behaviour, emotional control and motivation or symptoms of psychosis.9,58 The affected person may not appreciate the symptoms of the disease and so a detailed history from a reliable informant is also necessary. Other forms of dementia have some distinguishing features, although there is much overlap in the clinical picture. In vascular dementia, the classical presentation is with executive dysfunction rather than forgetfulness, and the disease follows a stepwise progression, which may even be associated with periods of improvement or stabilization of symptoms.58 In Lewy body dementia, motor symptoms and visual hallucinations may be prominent, associated with sensitivity to antipsychotic medication.58 In frontotemporal dementias, personality and behavioural changes are often the first manifestations of disorder, with onset usually before 60 years of age. In HIV-associated dementia, a sub-cortical picture of deficits is often seen, characterized by mental and motor slowing, poor attention and memory, apathy, reduced emotional responsivity and social withdrawal.61 TREATMENT AND MANAGEMENT The first priority is to exclude delirium and screen for potentially reversible causes of cognitive decline, including severe depression (see Box 72.1). Clinical features favouring delirium rather than dementia include an abrupt and recent onset, worsening at night-time and disorientation to time and place. Three simple cognitive screening tests for dementia are: testing memory by asking the person to repeat three common words immediately and after 5 minutes (memory), assessing orien­ tation to time and place, and asking the person to point to parts of the body and explain their function (language skills).9 Principles of intervention are outlined in Table 72.2.9 Supporting care givers also brings benefits to the patient, including delaying institutionalization.62 Although rare, challenging behaviours in the affected person may provoke abusive practices from others.

PREVENTION A recent expert consensus panel using data from systematic reviews of the best available evidence concluded that there were insufficient data to guide preventive interventions for dementia at the current time.63 However, tackling probable lifestyle risk factors for dementia, e.g. by increasing physical activity, improving diet and stopping smoking, would in any case bring other health benefits.59 Increasing cognitive reserve through cognitive activities is a promising disorder-specific intervention to reduce the risk of dementia.59

Alcohol and Drug (‘Substance’) Use Disorders EPIDEMIOLOGY Alcohol consumption alone is associated with an estimated 3.8% of all global deaths and 4.6% of global disability-adjusted life-years (DALYs).64 Worldwide, around 15.3 million persons are estimated to suffer from drug use disorders.65 Many more use illicit substances: in 2008, an estimated 155–250 million persons worldwide used drugs, mostly cannabis, followed by amphetamine-type stimulants, cocaine and opioids.65 As well as adverse health effects, the social costs of illicit drugs are high, estimated to be around 2% of GDP in countries, where this has been measured.66 Patterns of alcohol and drug use vary across countries and over time, but new fashions can quickly spread due to global interconnectedness. Drug use is expanding particularly fast in LAMICs, e.g. heroin use in East Africa.65 CLINICAL FEATURES Alcohol and drug use disorders include the syndromes of dependence and harmful use10 or abuse.11 Dependence is less common but more severe and is characterized by a strong desire or compulsion to take the substance, difficulty controlling the substance misuse, physiological or psychological withdrawal, escalating intake due to tolerance to the effects, continuing to use the substance despite obvious harm, dominance of the substance use over all aspects of life, and fast reinstatement of the substance use to previous levels following a period of abstinence.52 Harmful use occurs when a person’s substance use is associated with clear physical, interpersonal, social or legal harm. In general healthcare settings, alcohol and substance use disorders commonly present with trauma, secondary to accidents or violence, or physical consequences of the substance use (e.g. acute pancreatitis in binge-drinkers, hepatic impairment in persons with alcohol dependence, blood-borne disorders such as HIV and abscesses in injecting drug users). Healthcare workers therefore have an opportunity to identify a group of persons who are at high risk of complications from substance use. TREATMENT AND MANAGEMENT Emergency interventions may be required for acute intoxication or withdrawal (Table 72.2). In the majority of cases, safe withdrawal from alcohol and/or benzodiazepines requires active medical management in order to minimize the risk of seizures, delirium and death. Although not life-threatening,

opiate withdrawal is unpleasant and symptomatic treatment of symptoms is helpful. For all substances, the process of withdrawal is the easy part; the true challenge lies in remaining abstinent. To achieve this goal, psychosocial support and rehabilitation are the mainstays of intervention. Self-help groups, e.g. alcoholics anonymous or narcotics anonymous, where available, can also be highly beneficial for some individuals. PREVENTION For legally available substances such as alcohol, successful primary prevention strategies involve reducing access, e.g. through price regulation or reducing opening hours of retail outlets selling alcohol.67 Alcohol-related harm is directly related to the per-capita consumption in a country.64 Secondary prevention measures include legislation to stop drink-driving and individual-based brief psychological interventions for persons identified to be ‘at-risk’. In persons with harmful use of alcohol, this simple intervention has been shown to reduce alcohol intake.68 Providing injecting drug users with sterile needles and swapping injectors onto long-term use of oral opiate substitutes, e.g. methadone, can reduce injecting behaviour and the harms associated with injecting, particularly transmission of blood-borne diseases.69

Child Mental Health Problems The WHO’s mhGAP-IG provides specific guidelines for the detection and management of: (a) developmental disorders and (b) behavioural disorders in children.9 CMDs and substance use disorders are also problems for children and adolescents, but covered in the general sections with specific advice for when these conditions occur in young people. EPIDEMIOLOGY Mental health and developmental problems are a leading cause of disability in the child and adolescent age group.70 Timing of risk factor exposure can be usefully divided into preconceptional, perinatal, infancy or early childhood, school age and adolescence, superimposed upon lifelong risk factors such as genetic predisposition, physical health problems, mental health problems within care givers, problems in the care-giving environment, exposure to harmful substances or toxins, and exposure to violence, abuse or neglect.71 CLINICAL FEATURES AND DIAGNOSIS Developmental disorders encompass the categories of intellectual disability (formerly known as mental retardation) and pervasive developmental disorders, including autism. Intellectual disability (ID) is characterized by delays in broad domains of development, including cognitive, social, language and motor development, which are associated with impaired functioning in activities of daily living. Care needs to be taken when applying intelligence quotient tests from other cultures in order to make a diagnosis of ID; comparison to other children and evaluation of adaptive functioning are usually better indicators of developmental delay. Pervasive developmental disorders (PDD) are indicated by more specific deficits in social behaviour, communication and language, together with a narrowed range of activities or interests that are often carried out repetitively. ID

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is also present in about two-thirds. Investigations need to exclude visual or auditory impairment, impoverished psychosocial stimulation within the home and maternal depression, all of which can lead to apparent developmental delay in the child. Epilepsy and co-morbid priority mental disorders, especially depression and psychosis, are more common in children with developmental disorders and can lead to episodic behavioural disturbance or deterioration in functioning. The presentation of these comorbid conditions will often be atypical, requiring a high index of suspicion in clinicians and greater reliance upon observable symptoms, e.g. appetite and weight loss in depression. Behavioural disorders in children include attention deficit hyperactivity disorder (ADHD) and conduct disorder. The main features of ADHD are: (a) difficulty maintaining attention, e.g. getting distracted in the middle of activities and leaving things undone, and (b) an increased level of activity, shown as excessive restlessness, fidgeting, noisiness and talkativeness. For ADHD to be present, these symptoms must have started before the age of 6 years, have persisted for more than 6 months and be causing difficulties in more than one setting, e.g. at school and in the home. Conduct disorder manifests as severe temper tantrums, persistent disobedience and antisocial acts that go far beyond normal naughtiness or rebellious behaviour, e.g. bullying others, stealing, setting fires, cruelty to animals; destruction of property; lying; and running away from home. To be considered a disorder, these behavioural problems should have been present for at least 6 months and lead to difficulties in several domains of life. TREATMENT AND MANAGEMENT See the WHO’s mhGAP guidance for treatment of developmental and behavioural conditions,9 summarized in Table 72.2. Simple tips for general health workers to provide support and psychoeducation to care givers of children with developmental disorders are provided in freely downloadable training materials being piloted in Ethiopia, see: http://labspace.open.ac.uk/ mod/oucontent/view.php?id=451962&direct=1. Brief psychosocial interventions can be highly effective in improving behavioural disorders in children, but care givers and teachers will need clear guidance and support to enable them to implement changes. Consistently rewarding good behaviour yields better results than punishing bad behaviour. Withdrawal of treats or attention, e.g. using a strategy of ‘timeout’, can also be effective. PREVENTION A public health approach to the primary prevention of ID is required, including: improving nutrition; reducing infections (including rubella, HIV and toxoplasmosis) and alcohol consumption in pregnant women; improving obstetric care; and reducing the risk of central nervous system infections (including malaria, epidemic meningitis, HIV, and measles); head injury; malnutrition (stunting, iodine- and irondeficiency); and exposure to environmental pollutants (e.g. arsenic and lead) in infants and young children.72 Maternal depression, particularly in the postnatal period, is an important and remediable risk factor for onset and maintenance of poorer development and both emotional and behavioural disorders in children.73

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Post-humanitarian Crises Increasingly, mental health interventions are being included in the standard responses to humanitarian crises.74 Although this is largely a welcome development and provides opportunities for improving mental health care in previously underserved communities (e.g. see: http://internationalmedicalcorps.org/ page.aspx?pid=313), there is also the potential for inappropriate targeting of scarce resources to culturally insensitive, ineffective or even harmful interventions.74 To avoid such outcomes, sound guidance has been issued by an inter-agency taskforce of experts in the field.75 There are two main mental health issues post-humanitarian crisis: (1) (re-)establishing protection and

treatment for those with known SMD and (2) responding to any trauma-related mental health problems. In both cases, it is critical not to neglect the basic needs of food, shelter and safety. Much mental distress will be alleviated by attending to these necessities. For mental distress arising due to the crisis, the need for cultural sensitivity is paramount. Giving time and allowing society to heal its wounds collectively may be most helpful in the longer term. Indeed, immediate ‘debriefing’ of traumatized persons has been found to increase, not decrease, subsequent development of mental disorders.76 However, severe or persistent reactions may need immediate intervention, following the WHO’s mhGAP9 or IASC guidelines.75

REFERENCES 5. Prince M, Patel V, Saxena S, et al. Global mental health 1: no health without mental health. Lancet 2007;370:859–77. 9. WHO. Mental Health Gap Action Programme Implementation Guide (mhGAP-IG) for mental, neurological and substance use disorders in non-specialized health settings. Geneva: World Health Organization; 2010.

12. WHO. The world health report 2001. Mental health: new understanding, new hope. Geneva: WHO; 2001. 71. Kieling C, Baker-Henningham H, Belfer M, et al. Child and adolescent mental health worldwide: evidence for action. Lancet 2011;378(9801): 1515–25.

75. Inter-Agency Standing Committee (IASC). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC; 2007.

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73. Grace SL, Evindar A, Stewart DE. The effect of postpartum depression on child cognitive development and behavior: A review and critical analysis of the literature. Arch Womens Ment Health 2003;6:263–74. 74. van Ommeren M, Barbui C, de Jong K, et al. If you could only choose five psychotropic medicines: updating the Interagency Emergency Health Kit. PLoS Medicine 2011;8(5):e1001030. 75. Inter-Agency Standing Committee (IASC). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC; 2007. 76. Rose SC, Bisson J, Churchill R, et al. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2002;(2):CD000560.