GHM 202 – Session 2: Priority disorders

Aims
To introduce seven mental, neurological, and substance use disorders commonly prioritised in the
field of global mental health.

Learning objectives
By the end of this session you should be able to:
 Describe the typical symptoms for seven priority mental, neurological, and substance use
disorders.
 Compare and contrast the symptoms, treatment, and management of three priority
disorders: depression, schizophrenia and epilepsy.
 Critically assess the systems of classification used for the diagnosis of mental disorders,
including trade-offs between utility and validity.

Essential readings
 Gureje O & Stein D (2014). Disorders, diagnosis and classification. In: Patel V, Minas H,
Cohen A & Prince M (eds.) Global mental health: Principles and practice. Oxford: Oxford
University Press.

Recommended readings
 World Health Organization (2016). mhGAP intervention guide for mental, neurological and
substance use disorders in non-specialized health settings: Mental health gap action
programme (mhGAP) – version 2.0. Geneva: World Health Organization.

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GHM 202 – Session 2: Priority disorders

Session outline
Aims....................................................................................................................................................1
Learning objectives.............................................................................................................................1
Essential readings..............................................................................................................................1
Recommended readings....................................................................................................................1
Session outline...................................................................................................................................2
Instructions.........................................................................................................................................3
1. Introduction.....................................................................................................................................3
2. Classifying disorders......................................................................................................................4
3. Priority disorders.............................................................................................................................6
4. Depression.....................................................................................................................................9
5. Psychoses....................................................................................................................................11
6. Epilepsy........................................................................................................................................15
7. Summary......................................................................................................................................16
8. Integrating activity.........................................................................................................................18
9. References...................................................................................................................................19

10. Answers to activities...............................................................................................................................21

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GHM 202 – Session 2: Priority disorders

Instructions
In this session you should first work through the different screens and spend time on the various
activities and exercises. This should take you about two hours. You will also be required to do any
required reading, as indicated. This should take you roughly an additional two hours.
You should then complete the integrating activity, referring to the readings as necessary. This
should take you about three hours.
Finally, you should spend a further two hours on self-study covering the supplementary reading
and any others from the references section as necessary.

1. Introduction
The term ‘global mental health’ reflects the field’s broad remit, which includes mental disorders,
substance use disorders, and many neurological disorders, such as dementia and epilepsy. 1 In the
context of severe resource limitations—which we will discuss at length in the session ‘Resources
for mental health’—it is necessary to define clear priorities within the field.
Several priority disorders have been identified by the World Health Organisation (WHO) mental
health Gap Action Programme (mhGAP), taking into consideration the burden of disease,
vulnerability to human rights violations, and economic burden (WHO, 2016c). As you may recall
from the session ‘Emergence of global mental health’, the goal of mhGAP was to develop an
evidence-based package of care for delivery by non-specialist health workers in order to increase
service coverage in low-resource settings. Though mhGAP did not intend to define key priorities of
the global mental health agenda, per se, these disorders have become de facto priorities for the
field.
At this early stage of the module, it is important to familiarise yourself with these priority disorders.
You will encounter many of them in subsequent sessions—for example, in the session ‘Suicide’.
First, we will explain how these disorders are classified, as well as the limitations of the systems
used for classification. Then, we will review common presentations of the seven priority disorders
covered in the mhGAP Intervention Guide (mhGAP-IG). Finally, we will examine three of these
priority disorders in greater detail.

1
Please note that throughout this module we use the term ‘mental, neurological, and substance use (MNS)
conditions’, but, in this session, we use the term ‘mental disorder’ because the major classification systems (DSM-5
(APA, 2013) and ICD-10 (WHO, 1993)) use the term ‘disorder’.

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GHM 202 – Session 2: Priority disorders

2. Classifying disorders
The field of global mental health relies on standardised classifications of disorders—typically the
Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD),
which will be further described later in this section—for many purposes. Without a classification
system, there would be no universal language in which to describe the prevalence or burden of
mental, neurological, and substance use (MNS) disorders, define clear study criteria, or write
guidelines for indicated treatment.
However, given the lack of clear biomarkers for most MNS disorders, classification is ‘not a precise
science’ (Gureje & Stein, 2014). As we will discuss further in the session on ‘Culture and critiques
of global mental health’, our systems of classification and the ways in which they are applied—for
example, to make a diagnosis—are shaped by culture and context, which are constantly in flux.
Consider, for example, that homosexuality was described as a pathology in the DSM until 1973
(Drescher, 2015). Hysterical neurosis—thought to be a product of a ‘wandering womb’ in Plato’s
time—was removed from the DSM around the same time (Tasca et al, 2012). Such examples
highlight the mutability of existing classification systems and call into question the nature—and
perhaps even the existence—of mental disorders.
Some believe that diagnostics are inherently values-based, and definitions of disorders often do
not translate across cultures that hold very different values (Gureje & Stein, 2014). Others believe
that the core features of mental disorders can be identified across cultures, but because
descriptions of symptoms are subjective and shaped by the local context, diagnostic tools and
techniques must be cross-culturally validated [Box 1].
The required reading for this session, by Oye Gureje and Dan Stein (Gureje & Stein, 2014),
introduces these and other issues that will be discussed at length in the session on ‘Culture and
critiques of mental health’.
Box 1. Diversity in the conceptualisation of mental health: Examples from South Sudan
and Ethiopia
As we will discuss further in ‘Culture and critiques of mental health’, there is remarkable diversity
in how mental health is understood within and between countries. Consider the case of South
Sudan, where there have been recorded three distinct syndromes in each of two districts (the
western district of Kwajeni Payam and southern district of Yei). The symptoms, causes and
potential treatments of each of these six syndromes are distinct and rooted in local
conceptualisations of mental health. Although there are some similarities with international
psychiatric classifications which could allow them to be clumped into “conditions related to
severe behavioural disturbances”, “conditions related to sadness and social withdrawal”, and
“conditions related to psychotrauma” (Ventevogel et al, 2013), it is an imperfect fit.
Unsurprisingly, these differences are also observable in the screening tools used to detect MNS
conditions and consequently, the epidemiological studies that seek to document the distribution

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of MNS conditions. In the case of Ethiopia, the Composite International Diagnostic Survey
(CIDI), largely based on the DSM, is recommended as a reliable and valid tool for comparing
prevalence across different settings and cultures. However, when used among the Borana
community, not a single case of psychosis was detected (Beyero et al, 2004). In a follow-up
study, researchers explored local concepts and understandings of severe mental illness, and
then asked key informants to identify community members that were “marata” (literal translation
“mad” or “madness”). When interviewed by psychiatrists, 75% of identified individuals met DSM
criteria for a disorder, the majority of which were psychotic disorders. The key difference
between methods was that the local understanding of severe mental illness focused on overt
behavioural symptoms while the CIDI focuses primarily on the presence of delusions and
hallucinations, which often go underreported (Shibre et al, 2010; Cohen et al, 2016).

2.1. ICD and DSM

As mentioned, the two classification systems most widely used in international contexts are the
WHO’s ICD (WHO, 2010) and the American Psychiatric Association’s DSM (APA, 2013). The ICD,
used by the WHO to gather most health-related data from member nations, provides
internationally recognised standards for the diagnosis of mental disorders. The DSM, a national
classification system for the United States, is also used internationally, often in research contexts.
Notably, several other national systems of classification have been developed, including the
Chinese Classification of Mental Disorders and the Cuban Glossary of Psychiatry, both of which
acknowledge specific cultural and contextual differences in the manifestation of disorders while
aligning largely to ICD classifications (Lee, 1996; Otero-Ojeda, 2002).

2.2. Clinical utility versus diagnostic validity

The challenge of standardising diagnoses across sociocultural settings has generally favoured the
clinical utility of diagnostic criteria over scientific validity, where ‘validity’ entails the precise
categorisation of disorders into distinct, bounded definitions—an impossible task due to the current
lack of biomarkers for mental disorders (Kendell & Jablensky, 2003). Conversely, clinical utility of
diagnostic criteria, unconcerned with aetiology, pathology, or other components of disorder
classification for validity, seeks to provide vital information regarding the prognosis, treatment, and
general disorder management (clinically and personally) for an individual with a given diagnosis.
Without precise biological markers, diagnostic criteria are most useful with regard to
‘communication’ and ‘implementation’ of diagnosis in clinical settings, ie clinical utility (Reed,
2010). Furthermore, clinical utility of diagnostic criteria is essential to providing appropriate
treatment and managing care, especially in under-resourced settings.
Notably, the orientation of disorder classifications in the ICD and DSM differ: where ICD
classifications strive for clinical utility, DSM classifications emphasise diagnostic validity
(Gureje & Stein, 2014). For example, the DSM-5 describes ‘delusions, hallucinations,

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disorganised thinking (speech), grossly disorganised or abnormal motor behaviour

(including catatonia), and negative symptoms’ (APA, 2013), while the ICD-10 also
includes ‘thought insertion’, ‘thought echo’, ‘thought broadcasting’, and ‘influence or
passivity’ in its description of schizophrenia (WHO, 2010). Conversely, the mhGAP
Intervention Guide (mhGAP-IG) does not define ‘schizophrenia’ at all; the mhGAP-IG
must categorise disorders and describe common symptoms in more general terms that
can be easily understood by non-specialists whose main objective is to provide relatively
low-intensity treatment. To describe schizophrenia and other related disorders, the
mhGAP-IG uses ‘psychosis’ as a general term, along with ‘bipolar disorder’.

Activity 1: Critical thinking

In 2010, while the DSM-5 was undergoing revision, the US National Public Radio (NPR)
released a story about the unintended consequences of seemingly minor changes to our
systems of classification. Listen to the story or read the transcript online.
http://www.npr.org/2010/12/29/132407384/whats-a-mental-disorder-even-experts-cant-
agree
In no more than three concise paragraphs, compare and contrast the perspectives of Allen
Frances, an editor of DSM-IV, and William Carpenter, who was working on DSM-5 at the
time that this story was released, regarding the addition of new diagnoses to the DSM. Try
to draw on the concepts of clinical utility and diagnostic validity discussed in Section 2.
Upload your response to Moodle, then check it against the model answer provided at the
end of the session notes.

3. Priority disorders
As we discussed in the session ‘Emergence of global mental health’, the burden of MNS disorders
can be described in a number of different ways—for example, in terms of morbidity, mortality,
economic costs, or risk of human rights violations. Arguably, these measures should be the basis
by which we prioritise certain disorders over others.
Using these criteria, the WHO mhGAP has designated seven disorder categories as priorities for
treatment and management in low-resource settings. (WHO, 2008, 2016c):
 Depression
 Psychoses
 Epilepsy
 Child and adolescent mental and behavioural disorders
 Dementia
 Disorders due to substance use
 Self-harm / suicide

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GHM 202 – Session 2: Priority disorders

The mhGAP-IG also includes a module on ‘other significant mental health complaints’, to help
guide providers on what to do when someone presents with symptoms that do not fit any of these
seven categories.
The mhGAP-IG includes detailed information on the diagnosis and management of each of the
seven priority disorders. For reference, we have included a table that summarises the common
presentations of these disorders as described in the mhGAP-IG, below.
We will discuss three of these priority disorders more in-depth in this session: depression,
psychosis, and epilepsy. We will describe the burden, symptoms, and functional disability
associated with each disorder, as well as treatment and management strategies. Again, the
discussion of these three disorders is largely based on mhGAP-IG so as to provide the least
technical (while still clinically accurate) descriptions.
The required reading by Oye Gureje and Dan Stein (Gureje & Stein, 2014) provides a helpful
overview, but you may also wish to refer to the mhGAP-IG to learn more about the disorders that
are not covered in detail in this session.
Condition Common presentation
Depression  Multiple persistent physical symptoms with no clear cause
 Low energy, fatigue, sleep problems
 Persistent sadness or depressed mood, anxiety
 Loss of interest or pleasure in activities that are normally pleasurable
Psychoses  Marked behavioural changes; neglecting usual responsibilities related to
work, school, domestic or social activities
 Agitated, aggressive behaviour, decreased or increased activity
 Fixed false beliefs not shared by others in the person’s culture
 Hearing voices or seeing things that are not there
 Lack of realisation that one is having mental health problems
Epilepsy  Convulsive movement or fits/seizures
 During the convulsion: loss of consciousness or impaired consciousness,
stiffness, rigidity, tongue bite, injury, incontinence of urine or faeces
 After the convulsion: fatigue, drowsiness, sleepiness, confusion, abnormal
behaviour, headache, muscle aches, or weakness on one side of the
body
Child and Child/adolescent being seen for physical complaints or a general health
adolescent assessment who has:
mental and  Problem with development, emotions or behaviour (eg inattention, over-
behavioural activity, or repeated defiant, disobedient and aggressive behaviour)
disorders  Risk factors such as malnutrition, abuse and/or neglect, frequent illness,
chronic diseases (eg HIV/AIDS or history of difficult birth)

Carer with concerns about the child/adolescent’s:

 Difficulty keeping up with peers or carrying out daily activities considered
normal for age

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GHM 202 – Session 2: Priority disorders

 Behaviour (eg too active, aggressive, having frequent and/or severe

tantrums, wanting to be alone too much, refusing to do regular activities or
go to school)

Teacher with concerns about a child/adolescent

 eg easily distracted, disruptive in class, often getting into trouble, difficulty
completing school work

Community health or social services worker with concerns about a

child/adolescent
 eg rule- or law-breaking behaviour, physical aggression at home or in the
community
Dementia  Decline or problems with memory (severe forgetfulness) and orientation
(awareness of time, place and person) Mood or behavioural problems
such as apathy (appearing uninterested) or irritability
 Loss of emotional control (easily upset, irritable or tearful)
 Difficulties in carrying out usual work, domestic or social activities
Disorders  Appearing affected by alcohol or other substance (eg smell of alcohol,
due to slurred speech, sedated, erratic behaviour)
substance  Signs and symptoms of acute behavioural effects, withdrawal features or
use effects of prolonged use
 Deterioration of social functioning (ie difficulties at work or home, unkempt
appearance)
 Signs of chronic liver disease (abnormal liver enzymes), jaundiced
(yellow) skin and eyes, palpable and tender liver edge (in early liver
disease), ascites (distended abdomen is filled with fluid), spider naevi
(spider-like blood vessels visible on the surface of the skin), and altered
mental status (hepatic encephalopathy)
 Problems with balance, walking, coordinated movements, and nystagmus
 Extreme hopelessness and despair
 Current thoughts, plan or act of self-harm/ suicide, or history thereof
 Any of the other priority conditions, chronic pain, or extreme emotional
distress
 Incidental findings: macrocytic anaemia, low platelet count, elevated
mean corpuscular volume (MCV)
 Emergency presentation due to substance withdrawal, overdose, or
intoxication. Person may appear sedated, overstimulated, agitated,
anxious or confused
 Persons with disorders due to substance use may not report any
problems with substance use. Look for:
– Recurrent requests for psychoactive medications including analgesics
– Injuries
– Infections associated with intravenous drug use (HIV/AIDS, Hepatitis C
Self-harm /  Extreme hopelessness and despair
suicide  Current thoughts, plan or act of self-harm/ suicide, or history thereof

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 Any of the other priority conditions, chronic pain, or extreme emotional

distress

Activity 2: Critical thinking

Scholars have argued that dementia, compared to other non-communicable diseases, has 4
been relatively under-prioritised (Prince et al, 2008)—particularly in low- and middle-income
countries (LMICs). Why might dementia be considered a more urgent priority now than in it
.
was in the past? If you don’t know much about dementia already, you might find it useful to D
read this fact sheet from the WHO, before formulating a response:
http://www.who.int/mediacentre/factsheets/fs362/en/. e
Write a concise, single-paragraph argument, then upload your response to Moodle. When p
you're finished, you can check your response with the model answer provided at the end of
the session notes. r
e
ssion
Depression is generally characterised by low mood or feelings of sadness, loss of interest and
enjoyment, and low energy and fatigue (WHO, 2019). Depression is one of the most significant
contributors to the global burden of disease, affecting more than 264 million people of all ages
globally (Lancet Global Health Metrics, 2018). Depression can be co-morbid with a number of
other mental disorders (eg dementia, intellectual disabilities) as well as physical health conditions
(eg HIV/AIDS, cancer). The mhGAP-IG prioritises diagnosis of and care for moderate-severe
depression (including management of depressive episodes of bipolar disorder), while several
forms of depression are classified in the ICD-10 and the DSM-5, eg recurrent depressive disorder,
dysthymia, and premenstrual dysphoric disorder.

4.1. Symptoms and functioning

Clinical features of depression identified in the mhGAP-IG include core symptoms—low mood and
loss of interest or pleasure in activities—and additional symptoms such as changes in sleep,
changes in appetite and weight, fatigue or reduced energy, loss of concentration, feelings of guilt
and worthlessness, and suicidal ideation. The mhGAP-IG suggests that presence of at least one
core symptom (low mood or loss of interest) and ‘several’ additional symptoms for at least two
weeks, coupled with ‘considerable difficulty with daily functioning’ is suggestive of a depressive
episode. Notably, the mhGAP-IG does not further specify parameters of diagnosis at this stage;
the mhGAP-IG does further clarify that current symptoms of depression are not associated with
bipolar disorder or bereavement.
Moderate-severe depression interferes with an individual’s ability to work and participate in family
life and social activities; this ‘considerable difficulty in functioning’ is used as the benchmark for
assessing severity in the mhGAP-IG. In some cases, depression can lead to suicidal thoughts or

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actions. Depression often presents with symptoms of anxiety and other medically unexplained
somatic symptoms, and can be co-morbid with other conditions, especially substance abuse
disorders that may involve individuals ‘self-medicating’ with alcohol or drug use (Bolton et al,
2009).

4.2. Intervention packages

Management of depression can include both psychosocial and pharmacological interventions. A
number of psychosocial interventions are recommended:

 Psychoeducation
 Psychological therapies
 Social network reactivation
 Promotion of functioning in activities of daily life

Pharmacological treatments, ie antidepressants, may also be included in an individual’s treatment.

Several classes of antidepressants are available; efficacy and tolerability of different medications
can vary by individual, and certain types of antidepressants are contraindicated in individuals with
comorbid conditions. Amitriptyline and fluoxetine are included in the WHO’s list of essential
medicines for the treatment of depressive disorders (WHO, 2017).

Activity 3: Check your understanding

Four different types of psychosocial interventions for depression are numbered in bold; beneath
these intervention types, several examples of interventions are listed. Select the two most
relevant examples that correspond with each intervention (you should use each lettered
example only once), then check your answers with the end of the session notes.
1. Psychoeducation
2. Psychological therapy
3. Social network reactivation
4. Promotion of functioning

a. Setting a consistent sleep schedule

b. Participating in community activities
c. Explaining that a mental disorder is not a character flaw
d. Interpersonal therapy
e. Cognitive behavioural therapy
f. Discussing treatment options
g. Creating an exercise plan
h. Scheduling a weekly family dinner

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5. Psychoses
Psychosis is a term used to describe a group of symptoms characterised by:
‘Distorted thoughts and perceptions, as well as disturbed emotions and behaviours.
Incoherent or irrelevant speech may also be present. Symptoms such as
hallucinations–hearing voices, or seeing things that are not there; delusions–fixed,
false beliefs; severe abnormalities of behaviour–disorganised behaviour, agitation,
excitement, inactivity, or hyperactivity; disturbances of emotion–marked apathy, or
disconnect between reported emotion and observed affect, such as facial expression
and body language, may also be detected’ (WHO, 2016c).
Chronic conditions such as schizophrenia2 cause psychosis. The mhGAP-IG (2008) includes
management of bipolar disorder3 in its module on psychosis, as episodes of mania attributable to
bipolar disorder can include psychotic symptoms. Schizophrenia affects an estimated 20 million
people globally, while bipolar disorder affects an estimated 45 million people worldwide (Lancet
Global Health Metrics, 2018). Though the overall percentage of the global population affected by
psychosis is small in comparison to those experiencing depression, untreated psychosis can be
severely disabling, and individuals with psychosis can be especially vulnerable to human rights
violations, such as detention, chaining, and other abuses.

5.1. Symptoms and functioning

The mhGAP-IG lists several ‘common presentations of psychoses’ that may be used to assess
whether an individual is experiencing the disorder (WHO, 2010):

 Hallucinations (‘hearing voices or seeing things that are not there’)

 Delusions (‘fixed false beliefs not shared by others in the person’s culture’)
 Poor insight into the nature or presence of disorder
 Significant changes in behaviour (poor hygiene or ‘neglecting usual responsibilities’)

Individuals presenting with hallucinations, delusions, or disorganised behaviour (eg talking or

laughing to oneself, or unkempt appearance) should be considered for a diagnosis of psychosis.
Psychosis can also include disordered thought, such as ‘thoughts being “inserted or withdrawn”
from the patient’s mind by “external influences”’ (Gureje & Stein, 2014).
If an individual presents with any of these symptoms, further assessment should be made to
distinguish psychosis from a manic episode of bipolar disorder, symptoms of which include:
 Increased activity and energy

2
Schizophrenia is characterised by severe disruptions in thinking and perceptions, and can include positive symptoms
(eg delusions or hallucinations) and negative symptoms (eg social withdrawal, loss of motivation), and is often
accompanied by disorganised thoughts and incoherent speech.
3
Bipolar disorder is a condition in which individuals experience extreme shifts in mood and energy, cycling between
mania and depression.

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GHM 202 – Session 2: Priority disorders

 Talkativeness or rapid speech

 Decreased need for sleep
 Elevated mood
 Reckless behaviour (eg excessive spending)
 Feelings of grandiosity
 Socially inappropriate behaviour

Untreated psychosis can be especially debilitating because its symptoms can interfere significantly
with an individual’s ability to perform duties related to work, family, or social commitments.
Changes in the behaviour, conduct, and appearance of individuals with persistent psychosis are
often stigmatised, exacerbating existing difficulties with functioning and social integration. This
stigmatisation can also ostracise families of individuals with psychosis. (For more detail, refer to
the session ‘Human rights and stigma’.)

Activity 4
Part A: Fill-in-the-blank
Symptoms associated with either a depressive disorder or schizophrenia are listed. Without
looking at a diagnostic manual, try to match the symptoms with the correct diagnosis. Write
either ‘S’ for schizophrenia or ‘D’ for depressive disorder, next to each symptom. Before moving
on to Part B, check your answers with the end of the session notes.
1. low mood or sadness
2. feeling guilt-ridden
3. having no motivation or interest in things
4. poor ability to understand and use information finding it difficult to make decisions
5. delusions (false beliefs)
6. not getting any enjoyment out of life
7. feeling anxious or worried
8. having suicidal thoughts or thoughts of harming oneself
9. change in appetite or weight
10. lack of ability to begin or sustain planned activities
11. constipation
12. lack of affect (appearing emotionless)
13. unexplained aches and pains
14. lack of interest in sex
15. changes to menstrual cycle
16. disturbed sleep
17. hallucinations (eg hearing voices or seeing things that do not exist)
18. feeling tearful
19. feeling irritable and intolerant of others
20. lack of energy
21. feeling hopeless and helpless
22. socially withdrawn

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23. poor hygiene

24. talking to oneself
25. having low self-esteem
26. bizarre behaviour
27. disorganised speech
28. moving or speaking more slowly than usual
29. agitated movements
30. lack of pleasure
31. lack of concentration

Part B: Short answer

In all likelihood, you did not attribute all 31 of these symptoms to the correct disorder. Even if
you are a trained clinician, you may have struggled to select just one disorder for some of these
symptoms. What does this exercise tell us about the challenges of diagnosing a mental
disorder? Write a concise, single-paragraph response, upload it to Moodle, then compare your
response to the model answer provided at the end of the session notes.

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5.2. Intervention packages

Like depression, care for individuals with psychosis includes both psychosocial and
pharmacological interventions.
For both psychosis and bipolar disorder, psychosocial interventions are similar:

 Psychoeducation (for individuals and their carers)

 Stress reduction
 Social network reactivation
 Promotion of functioning in activities of daily life (eg facilitation of participation in economic
activities, life skills training, or support in obtaining housing and other necessities
 Advice for families and carers (eg ‘do not try to convince the person that his or her beliefs or
experiences are false or not real’) (WHO, 2019)

Pharmacological interventions vary based on diagnosis; psychosis can be treated with

antipsychotics in either injectable or tablet forms, and bipolar disorder can be treated with lithium,
carbamazepine, valproate, or antipsychotics. Notably, lithium should be prescribed only when
clinical and laboratory monitoring are available to monitor side effects, and therefore is not
commonly offered in low-resource settings. The WHO’s list of essential medicines includes lithium,
carbamazepine, and valproate for the treatment of bipolar disorder and chlorpromazine,
haloperidol, risperidone, and fluphenazine for the treatment of psychosis (WHO, 2017)

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Activity 5: Check your understanding

Watch 01:45-03:50 of the video ‘Our Stories: Living and Coping with Schizophrenia’, produced
for the COPSI (Community care for People with Schizophrenia in India) project, in which a
woman living with schizophrenia and her family describe the symptoms she experienced:
https://www.youtube.com/watch?v=VBFeStQJtJo. Then answer the following questions.
When you’re finished, check the answers at the back of the session notes.
1. Did she report any symptoms of psychosis? If so, which ones?
a. Hallucinations
b. Delusions
c. Poor insight into the nature or presence of disorder
d. Significant changes in behaviour (poor hygiene or ‘neglecting usual
responsibilities’)
e. None (she didn’t report any of these symptoms)

2. Did she report any additional symptoms of bipolar disorder? If so, which ones?
a. Increased activity and energy
b. Talkativeness or rapid speech
c. Decreased need for sleep
d. Elevated mood
e. Reckless behaviour
f. Feelings of grandiosity
g. Socially inappropriate behaviour
h. None (she did not report any of these symptoms)

3. How might her treatment differ if she is ultimately diagnosed with bipolar disorder as
opposed to schizophrenia or another psychotic disorder? Write a short (one-sentence)
answer.

4. Does the ICD-10 (http://www.icd10data.com/ICD10CM/Codes/F01-F99 ) classify bipolar

disorder with psychotic disorders like schizophrenia?

5. Why might a non-specialist provider be better served by the mhGAP-IG, as opposed to

ICD-10, if this woman were to present to his or her clinic?

6. Epilepsy
Epilepsy is a neurological disorder characterised by recurrent seizures. While it may surprise
some that epilepsy is included as a priority disorder in the field of global mental health, it is
important to note that epilepsy is not understood to be a neurological or ‘physical’ disorder in all
cultures. Epilepsy is often seen as a disorder of the mind, and is stigmatised like other mental

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disorders. An estimated 50 million people live with epilepsy globally (WHO, 2019). Again, while this
figure is comparatively small when considering the prevalence of depression globally (264 million
people), epilepsy is the most common neurological condition globally, in which the risk of
premature death can be up to three times higher compared to the general population (WHO,
2019). Left untreated, epilepsy is severely disabling, especially due to injuries sustained from
seizures.

6.1. Symptoms and functioning

The critical feature of epilepsy is seizure. During a convulsion, an individual may lose
consciousness, experience stiffness or rigidity of muscles, sustain injury (eg from falling), or
experience incontinence. Common symptoms following a seizure include drowsiness, fatigue,
confusion, headache and muscle aches, or weakness on one side of the body. The mhGAP-IG
specifies that only convulsions lasting longer than one to two minutes should be considered for
diagnosis of epilepsy. Importantly, experiencing a single seizure over the life course does not
constitute a diagnosis of epilepsy (WHO, 2019) The mhGAP-IG narrows the definition of epilepsy
(for the purpose of initiating treatment) to those individuals who have experienced two or more
seizures within the past year.
Functioning for individuals with untreated epilepsy varies; epilepsy can be severely disabling,
especially in cases of daily (or more frequent) convulsions. Seizures can lead to severe injury, eg
burns, fractures, or bruising. Epilepsy is also associated with other mental disorders, especially
anxiety and depression (WHO, 2019) . Epilepsy is especially stigmatised when believed to be the
result of spirits or witchcraft, or to be contagious.
Activity 6: Critical thinking
In her TED talk, activist Sitawa Wafula gives a first-hand account of her experience with
epilepsy, which motivated her to create Kenya’s first free support line for people with MNS
disorders. Watch the video, then explain, in a short paragraph, how Wafulu’s experiences with
epilepsy might overlap with others’ experiences of mental disorders in Kenya. Compare your
response with the model answer provided at the end of the session notes.
https://www.ted.com/talks/sitawa_wafula_why_i_speak_up_about_living_with_epilepsy

6.2. Intervention packages

Under appropriate and regular care, epilepsy can be effectively managed with psychosocial and
pharmacological interventions. Psychosocial interventions for epilepsy include psychoeducation,
especially to explain the causes of disorder (‘excess electrical activity in the brain’) and that the
disorder can be controlled with antiepileptic medication. Additional information should be provided
to carers regarding proper management of a convulsion, including when and how to seek further

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GHM 202 – Session 2: Priority disorders

medical care. A number of pharmacological interventions are available for epilepsy including
phenobarbital, carbamazepine, phenytoin, and valproate (WHO, 2017).
Note that several side effects are possible with each of these medications, ranging in severity from
drowsiness to liver failure; the mhGAP-IG includes descriptions of potential side effects of each
recommended medication. The medications also have guidelines about when they should or
should not be used when treating certain populations, eg children, individuals living with HIV, and
pregnant or lactating women.
Activity 7: Multiple choice
Psychotropic drugs can have many side effects—ranging from minor inconveniences like dry
mouth (a common side effect), to rare, but potentially fatal conditions, such as blood dyscrasia
(a potential side effect of clozapine). How can non-specialist intervention guidelines like mhGAP
reduce the risk of unnecessarily exposing people to potentially dangerous side effects of
psychotropic drugs? Check your answer with the end of the session notes.
a. By specifying the clinical and laboratory monitoring requirements which must be in place
before certain high-risk drugs can be prescribed
b. By recommending psychosocial interventions as a first-line of defence, as much as possible
c. By supporting non-specialists to effectively distinguish between various MNS disorders,
particularly between those that do require medication in most cases, and those that do not
d. All of the above

7. Summary
Although the systems available to us for the classification of MNS disorders are not perfect, they
are necessary. mhGAP-IG aims to maximise clinical utility in its categorisation of seven priority
disorders—though it is important to remember that mhGAP-IG is a set of treatment guidelines, not
diagnostic tools. The categorisations used by the ICD and DSM, in contrast, have significant
implications for research, policy and practice, and must maintain a higher standard of scientific
validity.
One very obvious way in which mhGAP-IG differs from ICD-10 and DSM-5 is its focus on just
seven priority disorders. While the field of global mental health encompasses many more
conditions, it is helpful to establish priorities in the context of severe resource limitations, which we
will discuss further in the session ‘Resources for mental health’. The WHO set these priorities by
assessing the burden imposed by each disorder in a number of different ways. mhGAP aims to
dramatically expand mental health service coverage in LMICs by equipping non-specialists to
recognise and treat these priority disorders.
It is not possible for us to discuss every MNS disorder—or indeed, every priority disorder—at
length in a single session. We have deliberately kept the notes for this session brief so that those

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GHM 202 – Session 2: Priority disorders

of you who are not clinicians can devote sufficient time and energy to self-study. Use the essential
and recommended readings to familiarise yourself with the seven priority disorders, their
symptoms, impact on functioning, and treatment. In the process, ask yourself the following three
questions:
 Why is this disorder considered a priority?
 How might the presentation, treatment, and management of this disorder vary across
cultures and contexts?
 What unique challenges might this disorder present in terms of the implementation and
scale-up of mental health services?

These are important questions that preoccupy many of us who work in the field of global mental
health, and will be revisited in subsequent sessions of this module.

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GHM 202 – Session 2: Priority disorders

8. Integrating activity
Fill in the Blank/Short Answer
It is unlikely that any country will ever achieve 100% service coverage for MNS disorders;
inevitably, some cases will go untreated. However, it is useful to set targets for coverage, in
order to aid in planning for mental health services. Below is an incomplete table from a WHO
report that set targets for coverage of mhGAP conditions based on a review of the literature and
expert consultation (Sheffler et al, 2011). Using the targets provided for other conditions as
benchmarks, make a guess of the targets for depression, psychosis, and epilepsy, respectively.
Then in a few sentences, explain what informed your guesswork. Upload your answers to
Moodle and then check the model answer at the end of session notes.

Condition Target Coverage %

Depression
Psychosis
Epilepsy
Child and Adolescent Conditions 20%
Dementia 80%
Substance Use 25% for alcohol, 50% for other drugs
Suicide 80%

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GHM 202 – Session 2: Priority disorders

9. References
9.1. Cited references and sources
APA (2013). Diagnostic and statistical manual of mental disorders : DSM-5, Washington, D.C., American
Psychiatric Association.

Beyero T, Alem A, Kebede D, Shibre T, Desta M, Deyessa N (2004). Mental disorders among the Borana
semi-nomadic community in Southern Ethiopia. World Psychiatry, 3, 110.

Bolton JM, Robinson J & Sareen J (2009). Self-medication of mood disorders with alcohol and drugs in the
national epidemiologic survey on alcohol and related conditions. J Affect Disord, 115, 367-75.

Cohen A, Padmavati R, Hibben M, Oyewusi S, John S, Esan O, Patel V, Weiss H, Murray R, Hutchinson G,
Gureje O (2016). Concepts of madness in diverse settings: a qualitative study from the INTREPID project.
BMC Psychiatry, 16, 388.

Drescher J (2015). Out of DSM: Depathologizing homosexuality. Behavioral Sciences, 5, 565-575.

Gureje O & Stein D (2014). Disorders, diagnosis and classification. In: Patel V, Minas H, Cohen A & Prince
M (eds.) Global mental health: Principles and practice. Oxford: Oxford University Press. pp 27-40.

Kendell R & Jablensky A (2003). Distinguishing between the validity and utility of psychiatric diagnoses. Am
J Psychiatry, 160, 4-12.

Lee S (1996). Cultures in psychiatric nosology: The ccmd-2 and international classification of mental
disorders. Culture, Medicine & Psychiatry, 20, 421-472.

Otero-Ojeda AA (2002). Third cuban glossary of psychiatry (gc-3): Key features and contributions.
Psychopathology, 35, 181-4.

Prince M, Acosta D, Albanese E, Arizaga R, Ferri CP, Guerra M, . . . Wortmann M (2008). Ageing and
dementia in low and middle income countries-using research to engage with public and policy makers. Int
Rev Psychiatry, 20, 332-43.

Reed GM (2010). Toward ICD-11: Improving the clinical utility of who’s international classification of mental
disorders. Prof Psychol Res Pract, 41, 457 - 464.

Scheffler RM, Bruckner TA, Fulton BD, Yoon J, Shen G, Chisholm D, Morriss J, Dal Poz MR, Saxena S
(2011). Human resources for mental health: workforce shortages in low- and middle-income countries,
Geneva, World Health Organization.

Shibre T, Teferra S, Morgan C, Alem A (2010). Exploring the apparent absence of psychosis amongst the
Borana pastorialist community of Southern Ethiopia, World Psychiatry, 9, 98-102.

Tasca C, Rapetti M, Carta MG & Fadda B (2012). Women and hysteria in the history of mental health. Clin
Pract Epidemiol Ment Health, 8, 110-119.

Ventevogel P, Jordans M, Reis R, de Jong J (2013). Madness or sadness? Local concepts of mental illness
in four conflict-affected African communities, Conflict and Health, 7, 3.

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GHM 202 – Session 2: Priority disorders

WHO (1993). The ICD-10 classification of mental disorders and behavioural disorders: Diagnostic criteria
for research, Geneva, World Health Organization Annex 2.

WHO (2008). mhGAP: Mental health gap action programme: Scaling up care for mental, neurological and
substance use disorders, Geneva, World Health Organization.

WHO (2010). International statistical classification of diseases and related health problems 10th revision
(ICD-10). Geneva: World Health Organization.

WHO (2017). 20th WHO model list of essential medicines (August 2017). Geneva: World Health
Organization.

WHO (2017). Fact sheet: Epilepsy [Online]. Available:

https://www.who.int/en/news-room/fact-sheets/detail/epilepsy [Accessed 2020].

WHO (2019b). Fact sheet: Mental disorders [Online]. Available:

http://www.who.int/mediacentre/factsheets/fs396/en/ [Accessed 2020].

WHO (2016c). mhGAP intervention guide for mental, neurological and substance use disorders in non-
specialized health settings: Mental health gap action programme (mhGAP) – version 2.0. Geneva: World
Health Organization.

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GHM 202 – Session 2: Priority disorders

10. Answers to activities

10.1. Activity 1
In no more than three concise paragraphs, compare and contrast the perspectives of Allen
Frances, an editor of DSM-IV, and William Carpenter, who was working on DSM-5 at the
time that this story was released, regarding the addition of new diagnoses to the DSM.
Both Allen Frances and William Carpenter recognise that the decision to add a new
diagnosis to the DSM can have major consequences. However, they differ in their
valuation of the risks versus benefits.
Frances is advocating to restrict the number of diagnoses included in DSM-5. Using
the example of Asperger’s syndrome in the US, he argues that the classification of
disorders is highly political, and that the consequences are difficult to control. While
he does not doubt the scientific validity of Asperger’s syndrome, he believes that
children are receiving this diagnosis because it provides access to educational
resources that might not otherwise be available—not necessarily because the
diagnosis is clinically relevant.
Carpenter, on the other hand, is actually advocating for the DSM to be revised in
such a way as to recognise earlier stages of psychosis. By maximising the scientific
validity of the DSM, it is more likely that this category of individuals will be
recognised, and that targeted interventions will be developed and tested. There might
not be much clinical utility to diagnosis at this point, but perhaps there would be
down the line, if research efforts were successful.

10.2. Activity 2
Why might dementia be considered a more urgent priority now than in it was in the past?
With the dramatic increase in life expectancy in recent years—particularly in LMICs—the
burden of chronic diseases increases. Conditions that manifest in later life, including
most dementias, might be vanishingly rare in a population where the life expectancy is
very short. Even in comparison to many other chronic diseases, such as diabetes or
cardiovascular disease, dementia is very disabling. The cost of care is high, as is the
opportunity cost to caregivers who may leave the workforce in order to provide care at
home. In addition, the risk of elder abuse, combined with the risk of abuse that people
living with MNS disorders experience generally, increases the vulnerability of older
people.

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GHM 202 – Session 2: Priority disorders

10.3. Activity 3
Select the two most relevant examples that correspond with each intervention.
1. Psychoeducation: C, F
2. Psychological therapy: D, E
3. Social network reactivation: B, H
4. Promotion of functioning: A, G

a. Setting a consistent sleep schedule

b. Participating in community activities
c. Explaining that a mental disorder is not a character flaw
d. Interpersonal therapy
e. Cognitive behavioural therapy
f. Discussing treatment options
g. Creating an exercise plan
h. Scheduling a weekly family dinner

10.4. Activity 4
Part A: Fill-in-the-blank
Without looking at a diagnostic manual, try to match the symptoms with the correct diagnosis.
Write either ‘S’ for schizophrenia or ‘D’ for depressive disorder, next to each symptom.
1. low mood or sadness: D
2. feeling guilt-ridden: D
3. having no motivation or interest in things: D
4. poor ability to understand and use information finding it difficult to make decisions: D
5. delusions (false beliefs): S
6. not getting any enjoyment out of life: D
7. feeling anxious or worried: D
8. having suicidal thoughts or thoughts of harming oneself: D
9. change in appetite or weight: D
10. lack of ability to begin or sustain planned activities: S
11. constipation: D
12. lack of affect (appearing emotionless): S
13. unexplained aches and pains: D
14. lack of interest in sex: D
15. changes to menstrual cycle: D
16. disturbed sleep: D
17. hallucinations (eg hearing voices or seeing things that do not exist): S
18. feeling tearful: D
19. feeling irritable and intolerant of others: D
20. lack of energy: D
21. feeling hopeless and helpless: D
22. socially withdrawn: S

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GHM 202 – Session 2: Priority disorders

23. poor hygiene: S

24. talking to oneself: S
25. having low self-esteem: D
26. bizarre behaviour: S
27. disorganised speech: S
28. moving or speaking more slowly than usual: D
29. agitated movements: S
30. lack of pleasure: S
31. lack of concentration: D

Part B: Short answer questions

What does this exercise tell us about the challenges of diagnosing a mental disorder?
Differences in the symptoms of depressive disorder and schizophrenia are not always
readily distinguishable. For example, being socially withdrawn and displaying lack of
affect (schizophrenia) can, without careful investigation, be mistaken for having no
motivation or interest in things (depressive disorder). Similarly, lack of pleasure
(schizophrenia) may be mistaken for lack of interest in sex or not getting enjoyment out
of life (depressive disorder). Given a lack of clear biomarkers, diagnosis is dependent on
the clinician’s judgement.

10.4. Activity 5
1. Did she report any symptoms of psychosis? If so, which ones?
a. Hallucinations
b. Delusions
c. Poor insight into the nature or presence of disorder
d. Significant changes in behaviour (poor hygiene or ‘neglecting usual
responsibilities’)
e. None (she didn’t report any of these symptoms)

2. Did she report any additional symptoms of bipolar disorder? If so, which ones?
a. Increased activity and energy
b. Talkativeness or rapid speech
c. Decreased need for sleep
d. Elevated mood
e. Reckless behaviour
f. Feelings of grandiosity
g. Socially inappropriate behaviour
h. None (she did not report any of these symptoms)

3. How might her treatment differ if she is ultimately diagnosed with bipolar disorder as
opposed to schizophrenia or another psychotic disorder? Write a short (one-sentence)
answer.

While she might receive the same psychosocial interventions and would probably be

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GHM 202 – Session 2: Priority disorders

prescribed an anti-psychotic in either case, she might also be prescribed a mood

stabiliser if diagnosed with bipolar disorder.

4. Does the ICD-10 (http://www.icd10data.com/ICD10CM/Codes/F01-F99 ) classify bipolar

disorder with psychotic disorders like schizophrenia?

No, bipolar disorder is categorised as a mood disorder; schizophrenia is categorized

as a ‘non-mood’ psychotic disorders.

5. Why might a non-specialist provider be better served by the mhGAP-IG, as opposed to ICD-
10, if this woman were to present to his or her clinic?

It seems very possible that this woman could be suffering from bipolar disorder.
mhGAP-IG doesn’t necessarily require that the non-specialist make a diagnosis of
bipolar disorder; he or she could, for example, start by prescribing psychosocial
interventions and an anti-psychotic, then add a mood stabiliser later, if needed. This
process is streamlined in mhGAP-IG for the purposes of clinical utility. Conversely,
the ICD-10 places bipolar disorder in an entirely different category from other
psychotic disorders, which could complicate diagnosis and subsequent treatment.

10.5. Activity 6
Explain, in a short paragraph, how Wafulu’s experiences with epilepsy might overlap with others’
experiences of mental disorders in Kenya.
Sitawa Wafulu describes her experience of epilepsy as an ‘affair’—something shameful.
She explains how she was excluded from school, had to drop out of university, was fired
from her job, and was basically treated as ‘an outcast’. Epilepsy is a chronic condition, as
are many mental disorders. Wafulu has battled epilepsy for 15 years, spending large
stretches of time either at hospitalised or housebound, often struggling to function at all.
At times, she felt an extreme sense of loss and even lost her ‘will to live’. She describes
the stigma faced by people with epilepsy, who are sometimes treated as though there is
something spiritually wrong with them; this stigmatisation is often experienced by
individuals living with other mental disorders, as well.

10.5. Activity 7
Part C: Multiple choice
How can non-specialist intervention guidelines like mhGAP reduce the risk of unnecessarily
exposing people to potentially dangerous side effects of psychotropic drugs?
a. By specifying the clinical and laboratory monitoring requirements which must be in place

25
GHM 202 – Session 2: Priority disorders

before certain high-risk drugs can be prescribed

b. By recommending psychosocial interventions as a first-line of defence, as much as possible
c. By supporting non-specialists to effectively distinguish between various MNS disorders,
particularly between those that do require medication in most cases, and those that do not
d. All of the above

10.6. Integrating activity

Fill in the Blank/Short Answer
It is unlikely that any country will ever achieve 100% service coverage for MNS disorders;
inevitably, some cases will go untreated. However, it is useful to set targets for coverage, in
order to aid in planning for mental health services. Below is an incomplete table from a WHO
report that set targets for coverage of mhGAP conditions based on a review of the literature and
expert consultation (Sheffler et al, 2011). Using the targets provided for other conditions as
benchmarks, make a guess of the targets for depression, psychosis, and epilepsy, respectively.
Then in a few sentences, explain what informed your guesswork. Upload your answers to
Moodle and then check the model answer at the end of session notes.
Condition Target Coverage %
Depression 33%
Psychosis 80%
Epilepsy 80%
Child and Adolescent Conditions 20%
Dementia 80%
Substance Use 25% for alcohol, 50% for other drugs
Suicide 80%

These targets primarily reflect three factors: the severity of the condition, the ability to
detect cases in the population, and the likelihood that people will seek care for the
condition. For example, epilepsy and psychosis are often severely disabling and have
obvious symptoms which can increase help-seeking and identification. It is therefore
unsurprising that the targets for coverage of psychosis and epilepsy are on par with the
target for dementia, which is similar in these aspects. The target for depression, on the
other hand, is quite low, mainly due to low detection, access to services and treatment-
seeking. The challenges are similar—and perhaps even more pronounced— for
hazardous alcohol use and child and adolescent conditions.

26