WHO Addresses Gaps in Mental Health Care Delivery and Quality

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The new, third edition of the World Health Organization's (WHO) Mental Health Gap Action Program (mhGAP) offers 30 updated and 18 new guidelines along with 90 previously issued for nonspecialist health workers in underresourced regions providing evidence-based treatment for mental, neurological and substance use (MNS) disorders.¹

“In 2010 when the mhGAP guideline was launched, MNS disorders caused 10.4% of GBD (Global Burden of Disease) as measured in disability-adjusted life-years and 28.5% of all years lived with disability,” observed Elaine Brohan, PhD, Department of Mental Health and Substance Use, WHO, Geneva Switzerland, and colleagues on the mhGAP guideline team.²

"When considered in the context of growing social and economic inequalities, conflicts, humanitarian emergencies, climate change, and public health emergencies, this continuing burden emphasizes the need for a strong focus on MNS disorders," Brohan and colleagues indicate.

The updated guidelines emphasize psychological interventions as the cornerstone of treatment and recommend a larger range of psychosocial approaches for depression, dementia, and stress-related conditions. Digitally delivered interventions are also highlighted in the new edition, with modules for conditions including substance use disorders, anxiety, stress-related conditions, and self-harm.

Recommendations for psychotropic medications have also been updated. Included for the first time is guidance for the antiepileptics levetiracetam and lacosamide; the antipsychotics quetiapine, aripiprazole, olanzapine, paliperidone, and long-acting forms of haloperidol and zuclopenthixol.

Combined psychosocial and pharmacological approaches are recommended for alcohol dependence, with guidance on incorporating acamprosate, disulfiram, and naltrexone into comprehensive support programs.

This edition of the mhGAP also cautions against particular interventions when the guideline team deems that potential risks outweigh potential benefit. For example, it advises against use of sodium valproate in women or girls of childbearing age, and prolonged use of benzodiazepines for generalized anxiety disorders (GAD) or panic disorders. It also warns of potential harms from pharmacological interventions in children and adolescents with anxiety disorders, and the use of antidepressants for children 12 years or younger with a depressive episode or disorder.

Selected Considerations with New Recommendations

Along with new recommendations on digitally delivered interventions for adults with alcohol use disorders, the mhGAP recommends that these not replace provision of other forms of interventions, and that there continue to be free and informed consent, safety, confidentiality, privacy, and security.

Regarding suicide attempts and self-harm, the mhGAP finds insufficient evidence to recommend media campaigns to raise awareness and sensitize the general public about suicide and its prevention. It does, however, recommend digital interventions based on such evidence-based programs as cognitive behavior therapy (CBT), dialectical behavior therapy, problem-solving therapy, and mindfulness programs.

Selective serotonin reuptake inhibitors (SSRIs) are the first line medications identified for panic disorder and GAD, with the guideline suggesting tricyclic antidepressants if SSRIs are not available. Brief, structured psychological interventions based on CBT are recommended for adults with GAD and/or panic disorder; and the mhGAP emphasizes that different delivery formats ranging from individual and group to digital online should be considered based on available resources.

In recommending antidepressants for moderate-to-severe depression, the mhGAP emphasizes that using the medicine alone should only be considered when psychological interventions are not available. It also cautions providers to monitor for adverse effects and consider individual preferences and tolerance.

For those caring for persons with psychosis or bipolar disorder, the mhGAP recommends supportive psychosocial interventions, including psychoeducation using problem-solving and cognitive-behavioral approaches for either the individual or family, as well as self-help interventions and mutual support groups. There should be respite programs for those caring for individuals with dementia, as well as psychosocial interventions including mindfulness-based interventions, multicomponent interventions, psychoeducation, psychotherapy, and counseling.

Medication for attention-deficit/hyperactivity disorder (ADHD) should be considered only when several conditions are met, including: the symptoms are causing significant impairment in at least 1 domain of functioning, after implementation of environmental modifications at school, home or other relevant settings. Structured physical exercise should be offered in treating ADHD to improve motor skills and functioning, including attention and executive functioning, and to reduce anxiety and disruptive behaviors.

"The widespread use of the mhGAP guideline has important implications, from clinical care to policy and system-wide change," Brohan and colleagues indicate. "mhGAP offers a framework to reinforce the commitment of health ministries and others, including mutisectoral stakeholders, to increase the allocation of financial and human resources for care of people living with MNS conditions and to increase access to key interventions in low-income and middle-income countries."

Dr Bender reports on medical innovations and advances in practice and edits presentations for news and professional education publications. He previously taught and mentored pharmacy and medical students, and he provided and managed pharmacy care and drug information services.

References

1. Mental Health Gap Action Programme (mhGAP) Guideline for Mental, Neurological and Substance Use Disorders, 3rd Edition. World Health Organization; 2023.

2. Brohan E, Chowdhary N, Dua T, et al. The WHO Mental Health Gap Action Programme for mental, neurological, and substance use conditions: the new and updated guideline recommendations. Lancet Psychiatry. 2024;11(2):155-158.