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Where There Is No Psychiatrist

This document appears to be the table of contents for a book titled "Where There Is No Psychiatrist" by Vikram Patel and Charlotte Hanlon. The book is divided into 5 parts covering an overview of mental health problems, specific treatments, clinical problems, integrating mental health, and localizing the manual. The table of contents lists 18 chapters that provide information on topics like assessing mental health issues, emergency management, childhood problems, integrating care, and local resources. It was intended to serve as a reference for mental healthcare in areas without access to psychiatrists.

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518 views335 pages

Where There Is No Psychiatrist

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Where There Is No Psychiatrist

Vikram Patel and Charlotte Hanlon

RCPsych Publications

RCPsych Publications is an imprint of the Royal College of Psychiatrists,

21 Prescot Street, London E1 8BB
http://www.rcpsych.ac.uk
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or
other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval
system, without permission in writing from the publishers.
British Library Cataloguing-in-Publication Data.
A catalogue record for this book is available from the British Library.
ISBN 978-1-909726-83-3
The views presented in this book do not necessarily reflect those of the Royal College of Psychiatrists, and the publishers are not
responsible for any error of omission or fact.
The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in Scotland (SC038369).

Printed by Bell & Bain Limited, Glasgow, UK.

Careif is an international mental health charity that works towards protecting and promoting mental
health and resilience, eliminating inequalities and strengthening social justice. Its principles include
working creatively with humility and dignity, and with balanced partnerships in order to ensure all
cultures and societies play their part in their mission to protect and promote mental health and
wellbeing. It does this by respecting the traditions of all world societies, whilst believing traditions can
evolve, for even greater benefit to individuals and society.

Careif believes that knowledge should not only be available to those with wealth or those who live
in urban and industrialised parts of the world. It considers knowledge-sharing to be a basic human
right, where this knowledge can change lives and help realise true human potential regardless of
their geographical location. Furthermore, there is substantial knowledge to be found in the less
developed, rural and poorer areas of the world and this is valuable to the wellbeing of people in
areas which are wealthier.
www.careif.org

BIPA works to protect and promote good health among people with mental illness or intellectual
disability, particularly – but not exclusively – among those from black and minority ethnic
communities.
bipa.org.uk

List of contributors ix
Preface x
Foreword xiii

Part 1: An overview of mental health problems

1 An introduction to mental health problems 3
2 Core skills for mental health care 21
3 Assessing someone with a mental health problem 29
4 General approach to treatment of mental health problems 37

Part 2: Treatments
5 Specific treatments for mental health problems 51

Part 3: Clinical problems

6 Emergency management 111
7 Behaviours causing concern 123
8 Symptoms that are medically unexplained 167
9 The person with problems due to habits 191
10 Problems arising from loss and violence 214
11 Problems in childhood and adolescence 229

Part 4: Integrating mental health

12 Integrating mental health into health care platforms 271
13 Integrating mental health into community platforms 283

Part 5: Localising this manual for your area

14 Medications for mental health problems 315
15 Resources in your area 340
16 Psychiatric terms for mental health problems 344
17 Glossary 346
18 Resources used in the manual 351

Index 353

Authors
Vikram Patel
Charlotte Hanlon

Other contributors
Neerja Chowdhary
Gauri Divan
Christopher G. Fairburn
Abebaw Fekadu
Pramada Menon
Abhijit Nadkarni
Maryam Shahmanesh
Suvrita
Manjari Tripathi

There is no health without mental health! Even common a low level of awareness about mental
though mental health and physical health go hand health problems and their treatments.
in hand, in reality the focus for most health work-
ers is mainly on physical health. In recent years,
there has been growing awareness about the bur- Where will this manual be most
den of mental health problems, from relatively
useful?
mild and short-lived states of distress, to more
severe clinical disorders and disabilities which Given that all societies face similar mental health
can last for long periods. Mental health problems problems, the manual should be of use anywhere
are common, occurring in all societies and in all in the world. But the manual has been designed
social classes, and across the life course. They are specifically to meet the needs of health workers
particularly common in certain groups of people, in low- and middle-income countries and in low-
for example, those attending primary health care resourced settings of high-income countries. Even
facilities, people with chronic physical health though this scope includes nations and societies
problems (e.g. HIV, diabetes), pregnant and post- which are very diverse, there are many features
natal women, and people who have been exposed that they share which make this manual appli-
to conflict or violence. All can benefit from inter- cable to them all. These settings are character-
ventions which can be delivered by general health ised by relatively few mental health workers and
workers equipped with the necessary knowledge higher levels of social disadvantage. The few men-
and skills and, where possible, supported by mental health specialists who are available are mostly
tal health specialists. based in cities and spend most of their time caring
Mental health is a basic aspect of care for for those with severe mental disorders in psychi-
all health workers. It is essential that, just as atric institutions or private practices.
with physical illnesses, the health worker is well The vast majority of common mental health
informed about how to detect mental health and substance use problems are not seen in spe-
problems and how to help people recover. It is cialist settings. Further, most care is restricted to
with this goal in mind that this manual has been the clinics, with no continuing care in the com-
written. munity, and psychosocial interventions are rarely
available. It is obvious that mental health special-
ists cannot even remotely achieve the goal of pro-
Who is the manual for? viding mental health care for all (and this is true
for all settings globally). On the other hand, many
This manual has been written to meet the needs countries have large numbers of general health
of the general health worker. This broad term workers and medical practitioners who are at the
includes anyone who works in a health care or actual frontline of mental health care.
community setting, and is not specially trained We have also sought to make this manual
to work with persons with mental health prob- applicable in different social and cultural con-
lems. Thus, the manual can be used by the com- texts. The theories that underlie psychiatry and
munity health worker, the primary care nurse, the other mental health disciplines are deeply rooted
midwife, the social worker and the family doctor. in European and North American cultures and in
This diverse group will have different levels of the experiences of mental health specialists work-
training and skills. However, they all often have in ing in hospitals. This has had a profound effect

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Preface
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on what mental health problems are called and by general health workers since then. This second
how they are recognised and managed in the rou- edition has been significantly revised in a number
tine care settings in diverse cultural and social of key ways.
contexts. Rather than take a top-down, medical ●● Treatment recommendations have been
diagnosis-based approach, in this manual we aligned with the World Health Organization
have taken a person-centred, symptom-based mental health Gap Action Programme
approach to mental health care. (mhGAP) evidence-based guidelines.
●● A new section covers core skills for mental
health care which are relevant to all health
The approach taken in this care encounters.
manual ●● Expanded chapters provide step-by-step
advice on brief counselling and social inter-
In order to make training on mental health prob-
ventions that general health workers can pro-
lems practical and useful, there is a need to
vide for a range of mental health problems.
adopt a more clinically relevant, problem-based
approach. The current ICD-10 classification ●● A strengthened focus on the person-centred
devised by the World Health Organization (which approach: how to support recovery of the
will soon be replaced by ICD-11) is an example of whole person and promote social inclusion.
how complicated we have made the diagnosis of ●● Elven flow charts for emergency management
mental health problems. Even the primary care of mental health crises.
version has 24 categories of psychiatric disorder, ●● Updated and expanded coverage of clinical
which are often very difficult to diagnose and problems, with new sections on eating disor-
distinguish in routine health care. The problem- ders, internet addiction, bipolar disorder and
oriented approach that we have taken in this autism spectrum disorders.
manual is to begin with clinical presentations
●● The topic of integrating mental health is
which have a mental health component and then
aligned with the concept of ‘platforms of care’,
to describe how to deal with these problems. The
i.e. the different settings (e.g. health care,
problem-solving-based approach emphasises the
schools) for the delivery of mental health
experiences of the person with a mental health
interventions.
problem rather than a medical diagnosis. Another
approach taken in the manual is to describe the ●● An expanded team of experts to ensure that
relevant mental health problems as they arise the manual is providing the most relevant and
in specific health care contexts. Health workers effective advice across more conditions and
may often find themselves working in a special- settings.
ist setting, such as a reproductive health clinic.
What are the mental health problems relevant to
this setting? These problem- and setting-oriented How to use this manual
approaches are two key deviations from the tra-
The manual is divided into five parts. It is impor-
ditional approach to writing manuals on mental
tant that readers familiarise themselves with
health for general health workers.
Part 1 before reading the other parts. This is
because much of the rest of the manual requires
an understanding of the basic concepts presented
How does this edition build on the in Part 1. Part 5 contains a guide on medica-
first edition? tions, a glossary of terms for mental health prob-
lems and symptoms, and information on local
The first edition of this manual was written more resources. Throughout the manual, use is made
than 15 years ago. There have been tremen- of crossreferencing with other sections. External
dous advances in our knowledge of how mental resources used in writing the manual are listed in
health problems can be detected and cared for Part 5.
Prefaceat| xii
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A final word We only hope that most find it easy to use in their
day-to-day work. We welcome comments on how
We have tried to communicate complex issues in to improve the manual and ensure that future
everyday language, with the goal of being able editions can reach out to more users around the
to demonstrate the diversity of mental health world.
problems and their prevention and management
in routine care settings in an accessible style.
Inevitably, some readers may find the manual Vikram Patel and Charlotte Hanlon
too simple, while others may find it too complex. New Delhi and Addis Ababa, 2017

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| Preface
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Foreword

If the numbers of us who will one day experience In an inviting, rather than a hectoring, tone,
one of the conditions classed under the broad this volume serves to remind the reader that
rubric of mental illness are substantial, and a social context shapes symptoms, illness experi-
majority of families are likely to be affected, then ence, and outcomes. Although these are well-
the truly staggering number is how few in need recognised facts in American and European
will receive much in the way of help from pro- psychiatry, clinic- or hospital-based practitioners
fessionals trained to provide it. Where There Is often forget that one person’s serious mental ill-
No Psychiatrist summarises this grim maths, as ness causes social suffering within families and
do hundreds of studies of communities, coun- social networks. Here, too, this manual is a model
ties, countries, and continents. That’s one reason of pragmatism and inviting erudition, since the
the book deserves ubiquity more than any oth- authors’ own experience has shown that acknowl-
ers that have come along in recent years. (Even edging this daunting fact, and working with com-
Antarctica’s tiny and snowed-in population could munity health workers and households, is one
use a shelf-full of copies.) way to improve outcomes even if formally trained
But Where There Is No Psychiatrist is anything clinicians remain office-bound. It is not too much
but grim, and for three reasons. to ask that this be required reading for their fel-
First, it is, like its earlier edition, an admira- low psychiatrists, who are likely to learn a good
bly concise overview of what might be done to deal about psychopharmacology and proper case
respond to common mental disorders, and also management, too.
to the even more common disorders of everyday
life: disturbing behaviour, prolonged sadness and ***
grief, addiction, abuse. This doesn’t sound like a
cheerful list, and it’s not, but the reason the book A second and related reason this manual on a gru-
isn’t grim is that it underlines just how much can elling topic isn’t grim is that it dispenses with the
be done to ease suffering, fear, and stigma. Not all, social fiction that psychiatrists alone are fighting
perhaps not even most, of the afflictions classed a lonely and hopeless battle for individuals with
as mental illness require pharmaceutical inter- mental illness. Where There Is No Psychiatrist vali-
ventions, and this new edition has been updated dates the efforts of the many others who wage a
to reflect the best evidence gathered over the past lonely battle – sometimes lonely because they
few decades about both pharmacotherapy and enjoy little in the way of material or moral sup-
non-pharmaceutical interventions. Where There port from credentialled health professionals.
Is No Psychiatrist not only avoids jargon, it also Barefoot doctors, medicine men and women,
eschews the partisan debates that have riven aca- traditional healers of every stripe, diviners, cler-
demic psychiatry for a century, in part by draw- ics, concerned citizen activists, community health
ing on evidence and experience from around the workers, home health aides, allied health profes-
world. The fact that both authors are psychiatrists sionals, and above all family members – all have
and social scientists is clear in these pages, as in faced the dilemmas addressed squarely in this
their other work, but this book is not promoting useful and inspiring book. What people in dis-
cultural competence so much as cultural humil- tress and their families are after is effective care
ity. (A watered-down Diagnostic and Statistical and expert mercy. Since they so rarely find these,
Manual of Mental Disorders this is not.) they are usually obliged to manage on their own,

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with the help of a diverse group of caregivers and have had the good fortune to work since 1983. If
diagnosticians classed under the term ‘traditional they had been there once, they were gone by then,
healers’. It is in part this professional abandon- when there were more Haitian psychiatrists in the
ment, rather than some inherent cruelty native city of Montreal, for example, than in all of Haiti.
to poor families living in the clinical desert, that We need more of them, but how long do we think
leads them to lock-up or chain family members it will take to see enough psychiatrists able and
who suffer psychosis or other disturbances fright- willing to address the mental health problems of
ening to them and to their neighbours. the poor and underserved? Even at a more rapid
And that is why this book should be in the clip than now registered, even optimists respond
hands, or on the screens, of millions of people in terms of centuries. To extend this metaphor, the
asking the questions that serious mental illness entire world is a clinical desert when we take the
invariably sparks among those affected most trouble, as Patel and Hanlon and their colleagues
directly: What is happening to my child, parent do, to survey it from the point of view of the poor
or friend? What is likely to happen next? What can who suffer major mental illness and families who
be done? Is this incurable? Where does it come suffer along with them.
from? Who can help my son, daughter, parent or
friend? What is the best treatment? How will we ***
pay for it? Admittedly, other questions rise to the
fore, including the famous, ‘Is this person a dan- The fact that Where There Is No Psychiatrist can
ger to self or others?’ That important query leads, help us water the clinical desert is the third
often, to efforts to restrain or extrude the erratic or reason it is an uplifting volume and pragmatic
violent, a minority of those afflicted with mental guide to action. Although colonial-era distinc-
disorder. But those who live in places where there tions regarding aetiology continue to hold sway
are no psychiatrists know that many more people, today – the bright line between communicable
especially family members, are likely to ask the and non-communicable illnesses remains prob-
most common question: What can I do to help? lematic and unquestioned – aetiology of afflic-
Patel and Hanlon did not call their book Where tion is not always as important as its chronicity,
We Need No Psychiatrist. But the guild mentality associated stigma, access to community-based
of credentialled health professionals does not care and insurance, and social suffering. In the
help. The problem the manual addresses – how rural reaches of Haiti and Rwanda, where (along
to help people facing the world’s most prevalent with Harvard teaching hospitals) I have spent
condition, major mental illness – has not, how- much of my professional career, diabetes, hyper-
ever, been addressed squarely by the medical tension, HIV disease, tuberculosis, and severe
profession, including those who specialise in pro- asthma join major mental illness as a series of
viding mental health services. In what are these afflictions of varied aetiology but similar and grim
days termed resource-poor settings, they cannot, outcomes without the sort of interventions Patel
because there are so few of them. Nurse practi- and Hanlon advocate in this manual. These were,
tioners and others with the power to prescribe until recently, clinical deserts, but are much less
cannot help in rural areas, since they are not pre- so now than 20 years ago. This is in part because
sent there either. (The desire to proliferate a series of the recognition that community-based care in
of books with titles like Where There Is No Nurse such settings is not only feasible but is the highest
Practitioner is unlikely to improve matters much standard of care, even where there are infectious
for the rural poor, or for the urban poor locked out disease doctors, endocrinologists, pulmonolo-
of nearby services by user fees, co-pays, and the gists, and the like on hand. As far as AIDS goes,
usurious cost of branded pharmaceuticals.) some of the outcomes in Haiti and Rwanda are far
Nor are social workers, psychologists or other better than in American cities.
credentialled professionals around to address a The problems addressed in Where There Is No
long list of eminently addressable afflictions that Psychiatrist are not seen only in rural backwaters,
one encounters in places like rural Haiti, where I nor with chronic disease alone. If parts of Chicago,

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| Foreword
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the third largest city in the USA, can reasonably be and for greater investments in understanding and
called a ‘trauma desert’ due to the lack of a trauma improving health care delivery. Although some of
centre, imagine what it is like for someone with the best examples involve introducing and then
acute psychosis in the vast and uneven metropo- improving care for chronic infectious disease,
lis that is Calcutta in India. This implementation it is clear from this manual that this approach
gap is profound when we leave the affluent world has implications across the globe and for other
for places of poverty. chronic afflictions (often classed as non-commu-
One illustration of the ‘know–do’ gap – and nicable) and sequelae increasingly recognised as
the cost of ignoring the obstacles posed by a lack the leading causes of premature death and dis-
of insurance and a lack of community-based care ability in settings rich and poor.
– comes from a Kenyan colleague, a neurologist
reporting not from a rural village far from a medi- ***
cal centre (and far from paved roads, electricity,
a reliable pharmacy, to say nothing of physicians) The earthquake that levelled much of Haiti’s capi-
but from a neurology clinic in Kenya’s capital. tal city in 2010 remains one of the most person-
Nairobi, a bustling city replete with traffic jams ally traumatic events of my life. But everyone who
and tall buildings, does boast the amenities of has worked in the clinical desert has stories of
a modern city for those who can afford them. In trauma. I refer not just to that experienced in war
a series of patients already diagnosed with epi- or in allegedly natural disasters like earthquakes
lepsy and for whom anti-seizure medications had or tsunamis. I refer to the experience of not hav-
been prescribed and, by report, dispensed, our ing a book like this one when faced with patients,
colleague found that none of these patients had friends and colleagues who fall ill with psychosis,
therapeutic levels of anti-seizure medication, depression, or who are stricken with delirium or
and in no instance was a supratherapeutic level confusion. What too often follows is our own con-
registered. They were underdosed, if dosed at all. fusion about what to do.
Most patients in this referral clinic had no trace of If I may be permitted to illustrate from painful
such agents in their peripheral blood: this among personal experience in rural Haiti, I will close with
patients already diagnosed and living in, or able a story that might have been a lot less grim if we
to present to, a big-city subspecialty clinic in East had had the advice laid out in Where There Is No
Africa’s most sophisticated city. For some decades Psychiatrist available to us. In our first few years
now, similar studies were published in analyses of of a health survey conducted in Haiti’s Central
adherence to antihypertensive and antitubercu- Plateau the late 1980s, we lost three of our close
lous regimens in countries rich and poor. friends and co-workers. That was almost half the
Even though we know how to diagnose and team working on the survey. All of them were just
treat epilepsy and chronic mental illness (and as enthusiastic as I was about introducing health
most other chronic afflictions), if we refuse to services to this region; not one lived to see 30.
apply the lessons of Where There Is No Psychiatrist Acephie died of cerebral malaria, misdiag-
to the delivery of therapy in settings of poverty, a nosed as a psychotic break. She perished sitting
know–do gap can occur. Working with local part- in a psychiatrist’s waiting room. That meant she
ners to develop health care systems able to man- had travelled hours to the capital city, since that
age both acute and chronic disease suggests that is the only place where there was one. Michelet
we can improve delivery systems in ways that was felled by typhoid fever, complicated by severe
help bring about sharp declines in mortality and neurological symptoms, which were attributed by
morbidity. It is also true that some experience in his family to sorcery after a short course of antima-
such settings might plausibly inform the transfor- larials failed to drop his fever. His illness was then
mation of American health care, which is increas- complicated by an ileal perforation: microbes
ingly deemed urgent. Whether this is termed ate through his small intestine. He was taken too
‘reverse’ or ‘frugal’ innovation, Where There Is No late to the operating room, and died in a busy
Psychiatrist advances the case both for optimism referral hospital – again in far-off Port-au-Prince

available at| xvi

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| Foreword
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Foreword
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Part 1
An overview of mental health
problems

Part 1 provides the essential foundation on which the rest of the manual is built. It has four chapters
covering four broad areas of knowledge needed to give confidence to the health worker to provide
mental health care.
Chapter 1 introduces a simple approach to understanding and classifying the types of mental
health problems in community and general health care settings: distress, disorders and disabilities.
In Chapter 2 we cover the core skills needed to interview a person with a mental health problem.
These skills are just as important in assessing the problem as in providing care and support. Chapter 3
describes how to assess a person with a mental health problem. In particular, it addresses how to dis-
tinguish distress from disorders and disabilities. Chapter 4 then outlines the general principles of how
to treat mental health problems.
It is essential that the reader goes through Part 1 at least once before reading any other part of the
manual. This is because many of the later chapters assume that the reader is already familiar with the
basic information on the types of mental health problems and the general approaches to interviewing,
assessment and treatment.

1.1 Mental health, distress,

disorders and disabilities
In the same way that the physical body can
fall ill, so too can the mind. This is when a mental
health problem is present, defined as:
There is more to good health than just a physi-
a problem experienced by a person which
cally healthy body. Most of us would agree that a
affects their emotions, thoughts or behaviour,
healthy person should also have a healthy mind.
which is out of keeping with their cultural be-
This can mean a number of different things. The
person should be able to think clearly. They liefs and personality, and [which] is producing a
should be able to solve the various problems they negative effect on their lives or the lives of their
may face in life. They should feel satisfied with families.
the quality of their life and enjoy good relations
This definition hides a very important fact
with friends, colleagues at work and family. They
about mental health problems, which is that they
should feel spiritually at ease. It is these aspects of
differ greatly in terms of their severity. This, in
health which can be considered as mental health.
turn, influences what kind of help the person may
Even though we talk about the mind and body
need and the long-term outcome of the problem.
as if they were separate, in reality they are like two
In this manual, we broadly categorise mental
sides of the same coin. They share a great deal
health problems into three types.
with each other, but present a different face to the
world around us. If one of the two is affected in ●● Distress is the most common type of men-
any way, then the other will almost certainly also tal health problem. Distress is characterised
be affected. Just because we think about the by a mixture of different complaints (such as
mind and body separately, it does not mean that feeling sad, worried, tense or angry), often of
they are independent of each other. short duration, and in response to difficulties
in one’s life (such as the loss of a loved one).
●● Disorder is a more severe, but less common,
type of mental health problem. Disorders are
characterised by more clearly defined groups
of complaints which can be classified using a
medical diagnosis, typically of a longer dura-
tion than distress, and not necessarily associ-
ated with, or explained by, difficulties in one’s
life.
●● Disability is the most severe, and least
common, type of mental health problem.
Disabilities are characterised by enduring
impairments in a person’s daily functioning
(e.g. the ability to communicate with others)
Mental health problems are common: at least two of and may be present from birth or very early
those people are likely to suffer from a mental health childhood, or appear later in life as a conse-
problem at some point in their life. quence of a mental disorder.
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In many cases, mental health problems can 1.2 Why are mental health
be suspected when the person’s symptoms can-
not be attributed to a clear physical disease. As problems of concern to health
our knowledge advances, we are discovering that workers?
some mental health problems, especially disor-
ders and disabilities, have physical causes in the There are many reasons why health workers need
brain. In this manual, we also cover the conditions to be concerned about mental health problems.
of epilepsy (where a person has seizures), devel- ●● Because mental health problems affect us
opmental disabilities (when a person has difficul- all. If we put together all types of mental dis-
ties in learning from birth or early childhood) and order and disability, at least 1 in 5 of all adults
dementia (where a person, typically over the age will experience one of these problems in their
of 60 years, gradually loses their memory); all are lifetime. At least 1 in 10 people at any moment
neurological conditions with clear signs of brain in time are experiencing a mental disorder or
dysfunction, but they are often associated with disability. Thus, in a community of 1000 peo-
mental health problems. ple, at least 100 will have a mental disorder or
There are four important points which form disability. Even more will have mental distress.
the basis of the material in this manual. Put simply, any person in the community can
1. Mental health problems cover a broad range of suffer from a mental health problem.
severity. For most, they take the form of a dis- ●● Because mental health problems can be
tress state, but for some the problem becomes very disabling. Even though the popular
a disorder. For a small number of people, they belief is that problems with mental
lead to disability, which can last a lifetime. health are less ‘serious’ than
2. For most people, mental health problems are physical illness, we
thought of as a disorder associated with dis- know that they can
ruptive behaviour, such as violence, agitation lead to severe
or being sexually inappropriate. However, the disability. Indeed,
vast majority of people with mental health more than a
problems look no different from any other quarter of the
person. The common mental health problems total amount of
often present as physical complaints – aches disability due to Mental health problems can
and pains or tiredness without any obvious health problems affect a person's ability to do
in the world is things at home and at work.
physical cause, sexual problems and excessive
alcohol drinking. caused by
mental disorders and disability.
3. Mental health problems can affect a person at
any time in their life, from early childhood to ●● Because mental health problems can kill.
old age. Most mental health problems begin People who suffer from a mental disorder or
before the age of 25. The earlier a person disability die younger than those who don’t
receives help, the better the chances that they have a mental health problem. For example, in
will recover. some places, people with severe mental disor-
ders live 20 to 30 years less than those with-
4. There have been tremendous advances in our
out these disorders. Mental health problems
understanding of the causes and treatment
cause death in a number of ways: through
of mental health problems. Most of these
suicide, through accidents (e.g. in people with
treatments can be provided effectively by the
drinking problems), through unhealthy life-
general or community health worker, but ide-
styles (e.g. smoking to cope with symptoms)
ally all should be provided by a team which
and because people with mental health prob-
involves the person and their family, a doc-
lems tend to get poorer quality medical care
tor or nurse, and a mental health professional
when they have a medical problem.
where available.

4 | Chapter
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●● Because mental health affects other health ●● Because mental health problems can be
problems. Many people suffer from a mental treated with simple, relatively inexpensive
health problem and a physical illness at the methods. It is true that many mental disor-
same time. In such people, the mental health ders and disabilities cannot be ‘cured’.
problem can make the outcome of the physi- However, many physical illnesses (HIV, can-
cal illness worse, for example, by increasing cers, diabetes, high blood pres-
the risk of death in a person after a heart sure, asthma, rheumatoid
attack or in a person with HIV. Mental health arthritis) are also not cur-
problems can affect those who live with the able. Yet, much can be
ill person (e.g. the babies of mothers who are done to reduce symp-
depressed have poorer health, growth and toms and to improve
development). the quality of life of
●● Because mental health services are inad people who have
equate. There is a severe shortage of psychia- these conditions.
trists, psychologists and other mental health The same applies
professionals in most countries. These special- to people affected
ists spend most of their time caring for people by mental health Most mental health
who suffer from severe mental disorders (or problems and problems can be treated.
‘psychosis’) and do so in big hospitals in cit- those who live
ies. On the other hand, most people with more with them.
common types of mental health problems
would not consult a mental health specialist.
General health workers are ideally placed to 1.3 The features of mental health
treat these mental health problems. problems
●● Because our societies are rapidly changing.
Many societies around the world are facing The health worker has to depend almost entirely
dramatic economic and social changes. The on what the affected person and their family tell
social fabric of the community is changing as a them in order to detect and diagnose a mental
result of rapid development and growth of cit- health problem. The main tool in diagnosis is
ies, the massive migration of peoples for eco- a detailed interview with the affected person.
nomic reasons, widening income inequality, Mental health problems produce symptoms
and the brutal conflicts affecting our world. which the person or others close to them notice.
These are all the very factors which are linked There are five major types of symptoms.
to poor mental health. ●● ‘Physical’ or somatic symptoms:these are
●● Because mental health problems lead to symptoms affecting the body or physical func-
stigma. Mental health problems are the most tions, such as aches, tiredness and sleep dis-
feared of all health conditions. Most people turbance. It is important to remember that
with a mental health problem would never physical symptoms may be the most impor-
admit to it. This is one of the major reasons tant or even the only feature of the mental
why so few seek help from health workers health problem.
and, when they do, they rarely mention their ●● ‘Feeling’ or emotional symptoms:these are
mental health as the reason for seeking help. symptoms related to one’s feelings. Typical
People with mental health problems are often examples are feeling sad, worried, irritable or
discriminated against by the community and scared. Most often, the person may not talk
their families and they are not treated sym- openly about their feelings and the health
pathetically by health workers, which is one worker needs to ask specifically about them.
reason they get poorer quality of care and die It is also helpful to observe the person’s facial
early. expressions and body language.

a. b. c.
d. A person can hear people talking about him:
a complaint of imagination…
e. which makes him think that his life is in danger:
a thinking complaint…
f. which makes him attack others to protect himself:
a 'doing' complaint.

d. e. f.

●● ‘Thinking’ or cognitive symptoms:typical (thinking). This makes him feel frightened of peo-
examples are thinking that life is not worth ple (feeling) and leads to aggression (doing). We
living, thinking that someone is going to harm will now use these types of symptoms to describe
the person, or difficulty in thinking clearly the various types of mental health problems.
and forgetfulness. As with feelings, the health
worker may need to ask about these symp-
toms, but they can also be detected using 1.4 The types of mental
good observational skills.
health problems
●● ‘Doing’ or behavioural symptoms:these are
symptoms related to what a person is doing. The World Health Organization uses a classifica-
Examples include behaving in an aggressive tion of mental health problems which has more
manner, becoming less communicative with than 100 types of disorder (ICD-10). However, in
others or being very restless and fidgety. These this manual, we use far fewer categories by com-
symptoms can be almost always picked up on bining mental health problems into those which
careful observation. look similar and which have similar treatments.
●● ‘Imagining’ or perceptual symptoms:these Some of these problems can range from relatively
are symptoms arising from one of the sensory short-lived states of distress to long-term states of
organs, such as hearing voices or seeing things disability, while some are always long-term states
which others cannot hear or see (hallucina- of disability.
tions). Their presence is most often identified The categories we are going to use are:
by asking questions about such experiences or 1. ‘common’ mental disorders such as depres-
from the observations of family members. sion and anxiety
In reality, these different types of symptoms 2. habits that cause problems, such as depend-
are closely linked to one another. For example, a ence on alcohol or drugs
woman may be worried about the future (think- 3. ‘severe’ mental disorders or the psychoses
ing), which makes her feel anxious (feeling), as a 4. states of confusion
result of which she experiences headaches (physi- 5. mental health problems in children and
cal). Taking another example, a man can hear adolescents
people talking about him (imagining) and expe-
6. other conditions such as epilepsy and suicidal
rience thoughts that they are going to harm him
behaviours.
6 | Chapter
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Chapter 16 for a table of psychiatric diagno- case 1.2 I feel pain
ses and where discussion about these diagnoses Rita is a 58-year-old woman all over my body and I
can be found in the manual. whose husband suddenly cannot sleep at night.
died the previous year. Her
1.4.1 ‘Common’ mental disorders children have all grown up
and left their home in a vil-
Common mental disorders are, as their name
suggests, the most common of all mental health lage for better employment
problems. They account for more than half the opportunities in a big city.
total number of mental health problems in a Rita started experiencing
community. poor sleep and loss of appe-
tite soon after her husband
case 1.1 died. The symptoms wors-
Lucy was 23 when she had her first baby. During ened once her children left
the first few days after the baby was born, Lucy the village after the funeral.
had been feeling tearful and mixed up. The She started experiencing headaches, backaches,
Even though I should midwife reassured her that stomach aches and other physical discomforts,
be so happy with my baby, she was only passing through which led her to consult the local clinic. There
I just feel tired all the time. a brief phase of emotional she was told she was all right but was prescribed
distress common in many sleeping pills and vitamins. She immediately felt
mothers. She suggested that better, particularly because her sleep improved.
Lucy and her husband should However, within 2 weeks, her sleep got worse
spend a lot of time together again and she went back to the clinic. There, she
and care for the baby, and was given more sleeping pills and vitamin injec-
that her mood would improve. tions. This went on for months, until she could no
As expected, Lucy felt better longer sleep without the sleeping pills.
within a couple of days and
WHAT’S THE PROBLEM? Rita has a ‘physi-
was discharged to go home.
cal’ presentation of depression (a ‘disorder’)
Everything seemed fine for the resulting from the death of her husband
next month or so. Then, quite gradually, Lucy and loneliness because her children are no
began to feel tired and weak. Her sleep became longer living with her. The clinic doctor has
disturbed. She would wake very early in the not asked about her emotions but prescribed
mornings even though she felt tired. Her mind Rita sleeping pills. This has led to Rita becom-
was filled with negative thoughts about herself, ing dependent on sleeping pills (drug depen
and, to her fright, about her baby. She began to dence, another type of ‘disorder’).
lose interest in her home responsibilities. Lucy’s Sometimes my
husband was becoming irritated with what he
case 1.3 heart beats so fast, I feel
Ravi was 25 when he had a like I am going to die.
saw as being lazy and uncaring. It was only
serious road accident. He
when the community nurse visited for a routine
was riding his motorcycle
baby check that Lucy’s depression was correctly
with a close friend on the
diagnosed.
pillion seat. The motorcycle
WHAT’S THE PROBLEM? At first, Lucy has ‘dis-
was hit from behind by a bus,
tress’, which gets better with explanation and
and Ravi and his friend were
support from the midwife, but she then devel-
thrown off it. Ravi’s friend fell
ops a kind of depression (a ‘disorder’) which
under the wheels of the bus
sometimes occurs in mothers after childbirth.
This is called postnatal depression. and died instantly. After a few
days of deep sadness and
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shock, Ravi began to experience spells of fear. BOX 1.1 THE KEY FEATURES OF DEPRESSION
The spells started when he had been shopping
in the market. Ravi suddenly experienced a chok- Feeling:
○○ sad and miserable
ing sensation and felt his heart beating hard.
○○ a loss of interest in life, relationships, work or
His father had a heart complaint and so Ravi be-
other activities
came worried that he too had a heart problem.
○○ guilty
This made him fearful. The doctor sent him for
○○ irritable and short-tempered.
tests, which showed that he had a healthy heart.
Physical:
Ravi also started getting nightmares, in which he
○○ tiredness and a feeling of fatigue and weak-
would see the whole accident played out. Some-
ness
times, even when he was awake, he would get
○○ aches and pains all over the body.
images of the accident in his mind and would
feel scared and tense. His sleep began to suffer Thinking:
and soon he began to have thoughts about end- ○○ ‘thinking too much’
○○ difficulty in concentrating
ing his own life.
○○ hopelessness about the future
WHAT’S THE PROBLEM? Ravi is suffering from ○○ difficulty making decisions
an anxiety disorder, which may occUr after a ○○ thinking that one is not as good as other
person has been involved in a traumatic event. people
This is sometimes called post-traumatic
○○ thinking that it would be better if one was not
stress disorder (PTSD).
alive
○○ having suicidal ideas and plans.
1.4.1.1 Depression
Behaving:
Depression literally means feeling low, sad, fed ○○ disturbed sleep (usually worse, but occasion-
up or miserable. It is an emotion which almost ally too much sleep)
everyone experiences at some time in their life ○○ poor appetite (sometimes increased appetite)
in response to loss, disappointment or hurt. For ○○ reduced sex drive
most people, these feelings are short-lived and ○○ preferring to be alone and not socialise with
can be considered a ‘distress’ state in reaction others
to life difficulties. But there are times when the ○○ problems with work or stopping work alto-
depression lasts for a long period of time, typi- gether.
cally more than 2 weeks, and starts to interfere
with life. For example, it may lead to tiredness and
difficulty concentrating, a loss of interest in one’s are anxious when they have had a frightening
work or social life and, sometimes, feelings that experience such as being in an accident. Just like
life is not worth living anymore. In these situa- depression, anxiety becomes a disorder if it per-
tions, the depression has become a disorder (Box sists (generally for more than 2 weeks), is interfer-
1.1). ing with the person’s daily life or is causing severe
symptoms (Box 1.2).
Most people with common mental disorders
1.4.1.2 Anxiety
have a mixture of symptoms of depression and
Anxiety is the experience of feeling fearful and anxiety. The main challenge is that these are
nervous. Like depression, this is a normal expe- typically invisible to the health worker because
rience, or at most a short-lived distress state for they are very frequently associated with physical
most people. For example, an actor before going symptoms which become the focus of attention
on stage or a student before an examination will for both the person and the health worker. Thus,
both feel that their heart is pounding. Some peo- most people who come to the health facility never
ple seem to ‘live on their nerves’ – meaning they complain of the ‘feeling’ or ‘thinking’ symptoms
are always anxious, but still seem to cope. Others as their main problem, but instead talk about the

8 | Chapter
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BOX 1.2 THE KEY FEATURES OF ANXIETY breathes much faster than usual. This leads to
changes in the blood chemistry, which causes
Feeling: physical symptoms.
○○ feeling as if something terrible is going to
●● Phobias are when a person feels scared (and
happen
often has panic attacks) only in specific situa-
○○ feeling scared.
tions. Common situations are crowded places
Physical: such as markets and buses (as in the case of
○○ heart beating fast (palpitations) Ravi), closed spaces like small rooms or lifts,
○○ can’t breathe properly and social situations such as meeting people.
○○ dizziness The person with a phobia often begins to avoid
○○ trembling, shaking all over the situation which causes the anxiety so that,
○○ headaches in severe cases, they may even stop going out
○○ ‘pins and needles’ (like the sensation of ants of the house altogether.
crawling) on limbs or face. ●● PTSD is a disorder which may develop after a
Thinking: terrifying experience, for example, when a per-
○○ worrying too much about one’s problems or son’s community is attacked in a conflict, or
one’s health when a person is a victim of a crime or has had
○○ thoughts that one is going to die, lose control a terrible accident. It is characterised by symp-
or ‘go mad’; these thoughts are often associ- toms of anxiety, phobia and panic. People
ated with severe physical symptoms and may relive the terrifying experience again and
extreme fear. again in their mind.
Behaving: ●● Physical symptoms with no medical cause.
○○ avoiding situations which one is scared of, Although all common mental disorders are
such as market places or public transport strongly associated with physical symptoms,
○○ asking for reassurance again and again, but some may present only with such symp-
still being worried toms, making these conditions very difficult
○○ experiencing poor sleep. to distinguish from other medical disorders.
Important examples are long-standing fatigue
or headaches.
physical and behavioural symptoms they expe- The ways depression and anxiety present in
rience (as in the case of Rita). This could be for health care settings and how to manage these
many reasons, for example, they may feel that problems are discussed in Chapters 7 and 8.
‘feeling’ or ‘thinking’ symptoms may lead them
to being labelled as being ‘mad’. However, with a
bit of time for sensitive questioning, it is usually
1.4.2 Habits that cause problems
easy to identify these symptoms of depression 1.4.2.1 Alcohol abuse
and anxiety.
Apart from depression and anxiety, there are
case 1.4
four varieties of common mental disorders which Michael is a 44-year-old man who has been
may present with specific or unusual complaints. attending the clinic for several months with
various physical complaints. His
●● Panic attacks are when anxiety occurs in
severe attacks, usually lasting only a few min- main complaints are that
utes. Panic attacks typically start suddenly. his sleep is not good, that
They are associated with severe physical he often feels sick (like he
symptoms of anxiety and make the person is about to vomit) in
feel terrified that something terrible is going the mornings and that
to happen or that they are going to die. Panic he is generally not
attacks occur because the person who is fearful feeling well. One day,

BOX 1.3 THE KEY FEATURES OF ALCOHOL DEPENDENCE

Physical: ○○ getting into fights and becoming violent when

○○ stomach problems such as ulcers drunk
○○ liver disease and jaundice ○○ driving dangerously
○○ vomiting blood ○○ drinking in the mornings to relieve physical
○○ vomiting or sickness, especially in the mornings discomfort
○○ tremors, especially in the mornings ○○ skipping work or school.
○○ accidents and injuries Thinking:
○○ withdrawal reactions: seizures, sweating, ○○ strong desire for alcohol
confusion. ○○ continuously thinking about the next drink
Behaving: ○○ thoughts of suicide.
○○ alcohol taking priority over everything else Feeling:
○○ drinking stronger types of alcohol ○○ feeling helpless and out of control
○○ needing to drink more alcohol to get the same ○○ feeling guilty about drinking behaviour
effect ○○ feeling angry when people ask them about
○○ sleep difficulties their drinking.

10 | Chapter
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was missing from her BOX 1.4 THE KEY FEATURES OF DRUG
purse. She was worried DEPENDENCE
that Farai may have stolen
it. She had also noticed Physical:
○○ breathing problems such as asthma
that Farai was spend-
○○ skin infections and HIV/AIDS in persons inject-
ing less time with his old
ing drugs
friends and family and
○○ withdrawal reactions if the drug is not taken
seemed to be moving
(nausea, anxiety, tremors, diarrhoea, stomach
around with a new group
cramps, sweating).
of friends whom he did not introduce to his
Behaving:
parents. His mother had suggested to him that
○○ sleep difficulties
he should see a counsellor, but he refused. She
○○ irritability (i.e. becoming short-tempered)
spoke to a health worker about Farai, and the
○○ stealing money to buy drugs
health worker decided to visit Farai at home.
○○ getting in trouble with the police
Farai was very reluctant to discuss anything at
○○ not fulfilling usual duties and responsibilities.
first. However, as he became more trusting of
Thinking:
the health worker, he admitted that he had been
○○ strong desire to take the drug
smoking heroin regularly for several months,
○○ continuously thinking about the next drug use
and now he was ‘hooked’. He had tried to stop
○○ thoughts of suicide.
on many occasions, but each time he felt so sick
that he just went back to the drug. He said he Feeling:
○○ feeling helpless and out of control
wanted help but did not know where to turn.
○○ feeling guilty about drug-taking
WHAT’S THE PROBLEM? Farai has become ○○ feeling sad and depressed.
dependent on heroin (a ‘disorder’). Because
of his dependence, his school performance
had suffered and he had been moving with The most common habit that causes problems
new friends who also used drugs. He had been is tobacco use. This is a major cause of physical
stealing things to pay for the drug. health problems in all communities. Any tobacco
use, even just one cigarette a day or chewing
Problems with drug use can take many differ- tobacco, is potentially harmful to health.
ent forms, depending on which drug is being used The final type of problem habit is gambling;
(Box 1.4). The most common drugs to cause prob- even though this is not a ‘substance’ like tobacco
lems are: cannabis, opium and related drugs such or drugs, the symptoms of gambling ‘depend-
as heroin, cocaine and amphetamine (‘speed’) ence’ are very similar.
pills, and sleeping medicines. Cannabis is mostly For advice on how to identify and help people
harmful because of its effects on physical health with habit problems Chapter 9.
(due to smoking). However, young people who
smoke very strong varieties of cannabis also 1.4.3 ‘Severe’ mental disorders
have an increased risk of psychoses. Opium and
related drugs are dangerous because they lead to Severe mental disorders are the most serious type
dependence very quickly and, as they are often of mental health problem, although they are rare
injected, they are associated with serious physi- and affect about 1 in 100 people. They typically
cal health problems such as HIV/AIDS. Sleeping begin in youth, between the ages of 18 and 25,
medicines are important because they are widely and are characterised by marked behavioural and
used in health care, often for the wrong reasons thinking symptoms. People with these disorders
(e.g. to treat common mental health problems) or are often identified by others as being ‘bizarre’ or
for too long, leading to dependence (as happened ‘strange’, and these disorders are the ones most
for Rita, case 1.2). typically associated with the idea of a ‘mental

In psychosis the person may become aggres-

sive or withdrawn (Box 1.5). The person may talk in
an irrelevant manner and talk to themselves. They
may feel suspicious of others and believe unusual
things, such as that their thoughts are being inter-
fered with. They may experience hallucinations
such as hearing voices which others do not hear.
Unfortunately, some people do not recognise that
they are suffering from a disorder and refuse to
seek treatment voluntarily. Psychosis may last person being shunned or discriminated against.
several months or years and may require long- Some people may even be chained or tied up to
term treatment. Because the disorder is associ- control their difficult behaviours. Chronic psycho-
ated with bizarre behaviour, it causes concern to sis is associated with severe disability and nega-
family and community members, and leads to the tive effects on family members.

12 | Chapter
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1.4.3.2 Bipolar disorder BOX 1.6 THE KEY FEATURES OF MANIA
case 1.7 Feeling:
Maria is a 31-year-old woman brought to ○○ feeling on top of the world
the clinic by her husband, because she has ○○ feeling happy without any reason
been behaving in an unusual manner for the ○○ irritability.
past 2 weeks. She is sleeping much less than Behaving:
usual and is constantly on the move. Maria has ○○ talking loudly and fast
stopped looking after the house and the children ○○ reckless behaviour (e.g. being sexually over-
as efficiently as before. She is talking much more active, overspending)
than normal and often says things which are ○○ unable to relax or sit still
○○ reduced sleep
Do you know who I am? I
○○ trying to do many things but not managing to
am very rich. How dare you bring me to this
clinic? There is nothing wrong with me! complete anything.
Thinking:
○○ thinking that one has special powers or is a
special person
○○ thinking that others are trying to harm one
○○ denying that there is any problem at all.
Imagining:
○○ hearing voices that others cannot. Often,
these voices tell the person that they are great
and can do great things.

unreal and grand. For example, she has been 1.6). The depressed phase is similar to depression
saying that she can heal other people and that (1.4.1) except that it is usually severe. A typical
she comes from a very wealthy family (even feature of this disorder is that it is episodic. This
though her husband is a factory worker). She has means that there are periods during which the
also been spending more money on clothes and person is completely well, even if they are not tak-
cosmetics, which is not normal for her. When her ing treatment. This is in contrast to chronic psy-
husband tried to bring Maria to the clinic, she chosis where, in the absence of medication, many
became very angry and tried to hit him. Finally, people will become ill or remain disabled.
he had to take the help of his neighbours to force
her to come. 1.4.3.3 Obsessive–compulsive disorder
WHAT’S THE PROBLEM? Maria is suffering Another mental disorder that can be severe is
from a severe mental disorder called mania, obsessive-compulsive disorder (OCD). A per-
which is a problem associated with bipolar son gets repeated thoughts (obsessions) or does
disorder. This makes her believe grand things things repeatedly (compulsions) even though
about herself and makes her irritable when they know these are unnecessary or stupid and
her husband tries to bring her to the clinic. they try to stop them. The obsessions and com-
pulsions can become so frequent that they can
Bipolar disorder is a mental disorder which is consume a great deal of the person’s time, affect
associated with two poles (or extremes) of mood, their concentration and make them depressed.
i.e. ‘high’ mood or mania, and ‘low’ mood or For advice on how to deal with problems due
depression. The disorder often begins in young to severe mental disorders Chapter 7.
adulthood and mostly comes to the notice of the
health worker because of an episode of mania (Box

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I can't BOX 1.9 TYPICAL FEATURES OF
seem to remember INTELLECTUAL DISABILITY
things. I even forget what
day it is or what I had ○○ Delays in achieving milestones in the child’s
for breakfast.
development, such as sitting up, walking and
speaking
○○ Difficulties in school, especially coping with
studies and repeated failures
○○ Difficulties in relating to others, especially
other children of the same age
temper, while on others he would sit for hours ○○ In adolescents, inappropriate sexual behav-
without saying a thing. Raman’s physical health iour
began to deteriorate and one day he had a sei- ○○ In adults, problems in everyday activities such
zure. His son brought him to the hospital where as cooking, managing money, finding and
a computed tomography (CT) scan of the brain keeping a job
was done. It was discovered that Raman’s brain
had shrunk in size. in communication, for example, how the child
WHAT’S THE PROBLEM? Raman is suffering talks or relates to others in the family. Many chil-
from a kind of brain disease typically found in dren with autism also have intellectual disability.
older people, called dementia. This disorder Specific learning disabilities are usually spotted
begins with making him forgetful. It gets pro- only when the child is in school, and problems
gressively worse as time passes and leads to associated with learning or performing in particu-
behaviour problems. lar academic subjects, such as reading or math-
ematics, become obvious.
Problems associated with dementia are dis-
The degree to which the intellectual disability
cussed in 7.1 and integrating mental health in
affects the daily life of the child can vary greatly
health care in Part 4.
according to its severity. For example, children
with mild intellectual disability might only expe-
1.4.5 Mental health rience some difficulties with educational perfor-
problems in children mance; at the other extreme, a child with severe
intellectual disability may need help even with
There are two broad categories of mental health simple activities such as feeding. Whereas those
problems in children. The first category is the in the mild category may be able to live alone and
developmental disabilities, a group of conditions work in certain types of jobs, those in the severe
which can sometimes be lifelong. While category will almost always need close supervi-
there are a wide range of developmen- sion and care. Children with developmental dis-
tal disabilities, only a few are particu- abilities are typically brought to the attention of
larly relevant for this manual. health workers or teachers by concerned family
Intellectual disability, which members for reasons such as poor self-care, dif-
was called mental retardation in ficulties at school and behavioural problems such
the past, is a condition in which as aggression. (Advice on how to help children
the brain development (and with intellectual disability 11.1; information on
thus the mental abilities) of the how to prevent some causes of intellectual dis-
child are slower or delayed com- ability Part 4.)
pared with other children (Box The second group of mental health problems
1.9). It is usually present from very in childhood are distress and disorders, which
early life, even from birth. Autism is are frequently short lived, either because there
a condition which is usually evident from are effective treatments or because the child ulti-
age 3, and is associated with problems mately ‘grows out’ of them. However, without
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treatment, disorders can last for much longer and 1.5 The causes of mental health
cause great harm to the child’s life. These disor-
ders include: problems
●● hyperactivity, which makes children overac- In many cultures, both medical and traditional
tive (11.4) explanations are used to understand the causes of
●● conduct disorders, when children behave in a ill health. Traditional models are often related to
disruptive way (11.6) spiritual or supernatural causes such as bad spir-
●● bed-wetting, when children bed-wet at an its and witchcraft. As health workers, you should
age when they should not (11.7) be aware of the beliefs in your culture. However,
you should also be aware of the medical theories
●● depression, when adolescents become sad and use these to explain mental health problems
and unhappy (11.8). to people who come to you for help. It is useful to
The final important area affecting children’s keep in mind the following main factors which can
mental health is when a child is abused. Such lead to mental health problems.
children are not only more likely to suffer mental ●● Stressful events. Life is full of experiences
health problems, even in adult life, but may also and events. Some of these events make a per-
be at grave danger for their physical well-being son feel worried and stressed, even when they
(11.5). are positive events, such as marriage. Most
Finally, it is important to remember that many people will learn how to deal with the event
children with a developmental disability can also and carry on with life. However, sometimes
have a mental disorder and can benefit from the these events can lead to mental distress and,
same treatments as children without a disability. in some people, mental disorder. Events which
(For more information Chapter 11.) cause great stress include sudden or long-
term unemployment, death or separation
1.4.6 Other mental health from a loved person, financial difficulties such
as being in debt, loneliness, infer-
problems tility, marital conflict, and expo-
In this manual, we will also address two other con- sure to violence.
ditions: epilepsy and self-harming behaviours. ●● Difficult childhood.
Epilepsy is a brain disorder which is characterised People who have had
by ‘seizures’ of different types. Many people with an unhappy childhood
epilepsy also have a mental disorder, experience because of violence or
discrimination and are brought to mental health emotional neglect are
care facilities (7.10). Self-harming behaviours, more likely to suffer mental
in which a person harms themself, are not ‘dis- health problems in childhood
orders’ but the result of a range of mental health and later in life.
problems (in particular distress due to severe
●● Brain diseases. Diseases such as brain infec-
life difficulties and disorders such as depression,
tions, AIDS, head injuries and strokes can
harmful use of alcohol and psychosis). Suicide
lead to epilepsy, dementia and mental health
is a major cause of death in people with mental
problems. No definite brain pathology has yet
health problems (7.6).
been identified for most mental health prob-
Finally, we wish to stress that the mental health
lems, but there is evidence to show that many
problems included in this manual cover over 90%
mental health problems are associated with
of people who have a mental health problem in
changes in the way the brain functions.
a community, but not all. There are some types
of mental health problems which are beyond the ●● Heredity or genes. This is an important factor
scope of this manual, either because they are rare for some mental disorders and disabilities.
in many parts of the world or because their treat- However, even if one parent has a mental dis-
ments need mental health professionals. order or disability, there is a very small risk

16 | Chapter
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that the children will have the same condition. severe mental disorders, such as psychosis
This is because, similarly to illnesses such as and mania, although they may be considered
diabetes and heart disease, these disorders to be due to spiritual problems rather than a
are also strongly influenced by environmental mental health problem. However, the common
factors. mental disorders and problems associated
●● Medical problems or medicines. Both with alcohol and drug dependence are rarely
medical illnesses (such viewed as being mental health problems by
as kidney and liver people attending the health facility or health
failure) and certain workers. Although the health worker should
medicines (such be aware of these mental health problems,
as some which are he need not add to the person’s problems by
used to treat high using labels with shame or stigma attached to
blood pressure) can them. Instead, one can use locally appropri-
sometimes cause men- ate words to describe these conditions as a
tal health problems. way of communicating the diagnosis in a way
which is culturally appropriate. (For more on
All the causes described explain why individu- the main mental health problems in a primary
als experience mental health problems. However, care clinic Part 4).
they do not explain why certain groups of indi-
●● Words used to describe emotional distress.
viduals are more likely to suffer mental health
The description of human emotions and ill-
problems. For example, women, refugees from
ness varies in different languages. Consider
conflict or disasters, people who are marginal-
the word ‘depression’. This word means sad-
ised because of their race, ethnicity, religion or
ness and is used to describe both a feeling (‘I
sexual orientation, and people who live on the
feel sad’) and a mental health problem (‘The
fringes of society are all more likely to suffer men-
person has depression’). In many languages,
tal health problems. These larger social issues are
however, while there are words to describe the
discussed later in Part 4. However, it is important
feeling of sadness, there are no words which
for the health worker to keep in mind that the rea-
describe depression as a health problem. Thus,
son that certain mental health problems are more
it is important to try to understand the words
common in people who belong to these groups
in the local language which best describe
is because of social factors. For example, women
depression as a feeling and as a health prob-
are much more likely to experience domestic vio-
lem. For example, in some cultures, the term
lence, which helps us understand why they are
‘thinking too much’ is understood to explain
more likely to develop a common mental health
the experiences which medical classifications
problem.
refer to as depression or anxiety. Sometimes, a
phrase or series of words will need to be used
to convey the meaning of depression as a dis-
1.6 Culture and mental health order. The glossary at the end of this manual
problems (Chapter 17) provides the words in English
to describe various mental health problems
There is a close relationship between cultural fac-
and symptoms. Space is provided next to each
tors and health problems. There are many ways
word and its meaning. The reader should write
in which culture can influence mental health
down the term which means the same thing in
problems.
their local language.
●● What is a mental health problem? The con-
●● Beliefs about witchcraft and evil spirits.
cepts about what a mental health problem
People in many societies feel that their men-
(distress, disorder or disability) is differ from
tal health problem has been caused by witch-
one culture to another. The group of disorders
craft, evil spirits or some other supernatural
most often recognised as abnormal are the
cause. There is little to gain from challenging
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the person’s views (which are often shared by and is just as effective. The main adapta-
the person’s community). Such an approach tion is the need to include coping strategies
will only make the person feel uncomfort- and resources which have evolved in one’s
able. Instead, it would be better to understand own culture. This manual describes several
these beliefs and explain the medical theory in specific counselling strategies, which can be
simple language. applied for a range of mental health problems
●● Priests, prophets and psychiatrists: what (Chapter 5).
do people do when they are in distress? Sick
people seek help from a variety of alternative, 1.7 Experiences of people with
religious and traditional health care providers.
Examples include: homeopathy, Ayurveda,
mental health problems
traditional Chinese medicine, spiritual heal-
ers, shamans, priests, pastors, prophets and case 1.10
others. This is for several reasons. First, medi- A 24-year-old woman with
cal care does not have the complete answers panic attacks and phobia
for all health problems, and this is especially ‘It was so frightening when it
true for mental health problems. Second, as first happened. I was sitting
many symptoms are associated with spiritual on a bus, when all of a sud-
or social factors, people tend to first seek help den my heart started beating
in these sectors. Traditional treatment may so fast that I felt I was having
help some people get better more quickly than a heart attack. I had difficulty
medical treatment. At the same time, though, breathing, and then, I started feeling as if ants
some traditional treatments can make people
were crawling on my hands and feet. My heart
worse, delay appropriate health care, and be
started pounding even faster, my body felt hot
associated with human rights abuses.
and I was trembling all over. I just had to get off
●● Counselling people with mental health the bus, but it was moving fast and I began to
problems. In many Western societies, coun-
choke. My biggest fear was that I might collapse
selling to help people with mental health
or go mad. Then, the bus came to a stop and I
problems is based on psychological theories
rushed to get off even though I was still far from
which have evolved from within their cultures.
While these theories may appear foreign to home. Since then, I have never been able to
the cultural beliefs in many non-Western com- get on a bus … just the thought of using a bus
munities, this does not mean that the counsel- makes me feel sick. For the past 2 years, I have
ling approaches which have been developed stopped going out of the house because of this
will not be useful. Indeed, there is now a large fear, and now I have few friends and almost no
body of evidence showing that, even after sen- social life … I didn’t know what to do and I was
sitive cultural adaptation, the basic nature of too scared to see a psychiatrist … after all, I am
counselling remains the same across settings not mad.’

People with mental disorder

seek help from different sources.

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case 1.11 schemes and plans, but never really managed to
A 23-year-old man with chronic psychosis finish any of them properly. I would lose my
‘I was only 17 when I first temper if anyone tried to stop
started hearing the voices. me. Once, I got into a big fight
At first, I wasn’t sure whether with my business partners
they were in my mind or real. over one of my crazy
But later, I used to hear stran- schemes. But when I was
gers talking about me, saying high, I never realised how
nasty things. Once I heard wrong I was. I even felt
a voice telling me to jump sometimes that I had special
into a well and for days I would stand near the powers to heal others. The worst thing about my
well feeling that I should obey the voice. I used illness was how I would spend so much money
to feel that my thoughts were being controlled that I almost bankrupted the family.’
by the radio and sometimes, I was sure that my
case 1.14
food was being poisoned and that gangsters
A 68-year-old man with dementia
were out to kill me. I used to get angry, and it
‘I don’t know what’s hap-
was when I lost my temper so badly that I hit my
pening … I seem to forget
neighbour that I was taken to the hospital.’
things so easily. The other
case 1.12 day, my wife came to give
A 43-year-old woman with depression me my morning tea and,
‘It started quite gradually, but for a moment, I did not
before I knew it, I had lost all know who she was. And
interest in life. Even my children then, I was walking home
and family didn’t make me feel from the market and,
happy. I was tired all the time. I even though I was in my village, I suddenly found
could not sleep. I used to wake I had no idea where I was. I always thought I was
up at 2 or 3 in the morning and getting absent minded as I grew older, but this is
then just toss and turn. I lost too much … and then I remember my father who
the taste for food which I used to love and I lost died after years of losing his memory and now I
weight. I even lost interest in reading because I am scared that I may have the same problem…’
just could not concentrate. My head ached. I felt
case 1.15
so lousy about myself, that I was a burden on
A 44-year-old man with a drinking problem
the family and so on. The worst thing was that I
‘My problems started at work when I started
felt embarrassed about the way I felt and could
taking too much sick leave. I
not tell anyone … my mother-in-law complained
kept getting stomach upsets
that I had become lazy. Once I felt like ending my
and, recently, I had jaundice.
life and it was then that I got so scared that I told
It was then that I started
my husband … that was 2 months after I started
worrying about my drinking.
feeling ill.’
What frightens me is that I
case 1.13 wake up feeling terrible. It’s
A 38-year-old man with mania like I must have a drink to get
‘I used to feel as if I had so much energy that I myself going in the day. These days I am starting
did not need to sleep at all. In fact, I hardly slept to drink even before lunch. I don’t know exactly
in those days. I would rush about with all my how much I am drinking but it never seems to be
enough…’
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chapter 1 summary box
things to remember about mental health problems
○○ Mental health problems can be broadly catego- ○○ Psychosis and bipolar disorder are conditions
rised as distress states, disorders or disabilities, which are most often recognised by the com-
based on their duration, severity and impact. munity and health workers as ‘mental disor-
○○ Mental health problems are very common, are ders’ because of the unusual behaviour of the
associated with social disadvantage, cause affected person.
considerable disability and early death, and ○○ Stressful events, changes in brain function and
adversely affect the physical health and the genetic factors are the main causes of mental
well-being of others in the family. health problems.
○○ The most common types of mental health prob- ○○ Some people may believe that spirits or super-
lems in the community or general health care natural forces cause mental health problems.
settings are common mental disorders and dis- The health worker should not challenge these
orders related to alcohol use. However, many beliefs but should try to put forward the medi-
people and health workers do not consider cal explanations for these problems.
these conditions to be mental disorders.

notes

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2 Core skills for mental
health care

There are some core skills that you need in order

to make a proper assessment of a person with a
mental health problem, and to be able to deliver
communication skills that are relevant for every
clinical encounter.

treatment in the most effective way. These skills Communicating respect and preserving
are not new for most health workers and they will dignity
help you when dealing with people who have all
kinds of health problems. However, these core It is crucial that you convey respect to each and
skills are at the heart of mental health care. Not every person. Even people who have very severe
every health worker has these skills naturally, but behavioural disturbance and seem to have lim-
they can all be learned with a bit of practice and ited awareness of their surroundings will detect
supervision. whether you are being respectful towards them.
Always make an effort to address the person
directly. Introduce yourself and explain what you
2.1 Core skills for working are doing and what is going to happen. If you need
to ask questions from family members or other
with people with mental accompanying people, first explain to the person
health problems that you are going to do this.
Because there is often stigma against peo-
2.1.1 Communication skills ple with mental health problems, they are often
not taken seriously and may not be treated with
We cannot detect mental health problems using respect and dignity in the community. It is impor-
a stethoscope or with laboratory investigations. tant that you clearly show the person that you do
Instead, we rely on our skills at communication not share this view and that you value them the
and observation. Different people may need a same as any other person.
different approach, and so there is a need for
flexibility and tailoring of the way that you inter- Being warm, encouraging and empathic
act with people. That said, there are some core
It can be difficult for a person to feel comfortable
Hello, my name is to speak about their mental health problems and
Jerome. I am a nurse and I will be asking the difficulties that they are facing. An encourag-
you some questions about your health. ing smile and a friendly attitude can give a person
the confidence to open up about their problems.
‘Empathy’ is when you put yourself in the person’s
position and imagine how they must be feeling.

Not judging the person

Sometimes a person might tell you about some-
thing that you do not approve of or something
that is against your values. For example, they may
tell you about use of illegal substances or marital

TABLE 2.1 EXAMPLE OPEN-ENDED AND CLOSED QUESTIONS THAT HEALTH WORKERS MAY ASK
PATIENTS
Open-ended questions Yes/no questions
‘How have you been feeling recently?’ ‘Have you been feeling sad?
‘What problems do you face when you are with ‘Do you think people are talking about you?’
people?’
‘How do you feel people treat you?’ ‘Do you think you are more important than other
people?’

22 | Chapter
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for example, as possession by an evil spirit or pun-
You seem
upset. Would you like to sit here
ishment for sinful behaviour. Sometimes, symp-
and then we can talk about why? toms of mental health problems are religious in
nature, for example, if a person with mania claims
to be appointed by God to save the world. The
important thing to remember is that any care
delivered by a health worker should be the kind
of care that the worker has been trained to deliver
as part of their job. The care you give should be
consistent with the kind of care a person with a
physical health problem receives. This means
that, while you should be respectful of the per-
son’s religious beliefs, you should not allow them
(or your own beliefs) to influence the care you will
offer. If people are looking for spiritual care then
Being observant they can be guided to the appropriate religious or
spiritual professional, but delivering spiritual care
While we rely a lot upon what the person says is not the role or expertise of the health worker.
in our assessment, we can also learn important
things from careful observation. The types of Respecting confidentiality
things that are important to observe are covered
in Chapter 3. Learning how to observe is a skill As with all health care, any information given
in itself. A systematic approach is needed. As with by the person to the health worker should be
all health conditions, we need to observe the kept confidential. The sensitive nature of mental
physical appearance of the person. In addition, health problems and the risk of discrimination
we can also observe whether there is a mismatch against the person make this especially important
between what the person is saying and their emo- for mental health care. Never discuss a person’s
tional state and behaviour (e.g. they describe feel- story with anyone who is not a colleague and,
ing happy but look miserable), and how the per- even in this case, only do so if it is relevant to the
son makes us feel (e.g. frightened). care of the person. Explain that what the person
This information will help us to fully assess tells you will be kept confidential and will only be
the mental health problem and how to help the shared with your colleagues if you wanted to con-
person. sult them for advice. An example of when break-
ing confidentiality could be necessary would be
Being respectful of religion the rare situation when the person tells you that
they are planning to kill themselves and refuses
As described in Chapter 1, people may concep- all care, or if the person expresses a clear threat to
tualise mental health problems in religious terms, harm a specific person.

Do not gossip about patients. Always store patient clinical notes in a secure location.
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Engaging the person not cross while being a health worker for the per-
son. These include:
Most people would like a quick fix for their prob-
lems. They may expect that one consultation with ●● accepting gifts
a health worker will be enough to make them feel ●● asking the person to carry out work for you
better. Unfortunately, many mental health prob- without proper remuneration
lems require more than a one-off consultation. ●● developing an intimate or romantic
Even with appropriate treatment, the symptoms relationship
may not disappear straight away and there may ●● any form of sexual contact.
be a need for ongoing care for months or even
years. Added to this challenge, some people with
Communicating with families
a mental health problem do not believe that any-
thing is wrong with them. Effective mental health People often come to the clinic with members of
care requires the health worker to make an effort their family or, less commonly, a friend or unre-
to engage and motivate the person to continue lated carer. It is vital to try to speak to the person’s
with the treatment to derive the maximum ben- carers as well as to the person to help you to carry
efits. Some ways to engage the person in care are: out your assessment. By speaking to the fam-
●● good communication skills, so the person feels ily you can find out whether there is a difference
understood (as described in this chapter); between how the person sees the problem and
how the problem is seen by others. Sometimes
●● focusing on the person’s priorities (e.g. if they
this can give you important clues about the
come to the clinic because of sleep problems,
nature and impact of the mental health prob-
start with a discussion about this problem,
lem. Building a connection with the family is also
and make sure you explain how the treatment
important when it comes to treatment (Chapter
will help with that problem);
4). Family members can play an important part in
●● making sure the person understands about monitoring the health of the person and encour-
the mental health problem and treatment; aging the person to take prescribed treatment.
●● saying encouraging things like: ‘It is good that When speaking with families, there are a few
you came to the health centre and spoke to things to bear in mind.
me about these problems. I am sure that if you ●● The health worker must balance the need to
continue with the treatment we discussed you communicate with the family with the need to
will feel much better soon’; ensure the person’s privacy.
●● giving the person a reason to come to the ●● Wherever possible, ask the person about their
follow-up appointment: ‘It is important that difficulties (without the family present) before
you come to see me after one week so that I asking the family. Your primary responsibil-
can hear about how you are getting on and ity is to the person with the mental health
review your treatment’. problem.

Keeping a professional distance

The relationship between a person and their
health care worker depends on trust and respect.
People with mental disorder can easily be
exploited within this relationship as their prob-
lems are often associated with difficulties in their
personal lives. Keeping a professional relation-
ship at all times can be especially difficult if you
live together in the same community and if you
know the person in an informal way. However,
there are some clear boundaries which you must

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●● Ask permission from the person before you ●● Assessment: current status of the person (e.g.
speak to the family alone. Check with the ‘Partially improved with antidepressants (after
person whether there are things that they do 3 weeks) but still feels sad (mood improved by
not want you to discuss with their family, for 50% since the last appointment) and hopeless
example, about substance use. on a daily basis. Ongoing difficulties in marital
●● The person may not want you to talk to their relationship’).
family. In some cases this is because the men- ●● Plan: advice given, the focus of any counsel-
tal health problem is affecting their judgement ling, goals set, medication dosage, prescrip-
(e.g. if they believe their wife is poisoning their tion given, date of next planned review (e.g.
food), but whatever the reason, you should try ‘Discussed crisis plan if hopelessness wors-
to respect their wishes. First try to reassure ened, continue on fluoxetine 20 mg once daily
them that your primary motivation to speak to (given 2-week supply), to bring partner to next
the family is with their best interests in mind. appointment, next review in 2 weeks’ time’).
If the person continues to object to your pro-
posal, then explain to the family that you are
not able to discuss details but that you can 2.2 Core skills for yourself
give them guidance on what they can try to
do to help the person, as well as listen to any 2.2.1 Staying safe
concerns that they have. The only exception is
Mental health problems are rarely a cause of vio-
if the person tells you that they have a plan to
lence. However, when a person is acutely mentally
harm themselves or someone else. In such a
unwell, there is a need for caution to minimise the
situation, explain to the person that you are
possibility of a health worker being harmed. This
going to inform the family because you are
can be done in a number of ways.
concerned about their immediate safety.
●● Make your space safe. Remove any objects
●● Although families usually play an important
that might be used as a weapon and make
part in caring for people with a mental health
sure that the room is arranged so that you can
problem, there are times when they can be the
easily access the door.
cause of the problem or even abusive towards
the person. Keep this in mind and be alert to ●● Be alert to warning signs for violence. For
the way that the person interacts with the example, if the person is highly agitated, pac-
family. If the person appears fearful then make ing, shouting or hostile, intoxicated, very
sure you have an opportunity to speak to them suspicious and believes that they are under
alone and consider their safety. threat, invading your personal space, for
example trying to touch you, or making you
Clear and relevant documentation feel frightened.
●● Take proper safety steps if there are warn
Clear and focused clinical notes will allow you
ing signs. Do not see the person on your own,
to easily monitor progress over time, reduce the
inform colleagues and make sure you have
risks of prescribing mistakes and communicate
sedative medication (oral and injectable)
your assessment to your colleagues. Always write
available in case the need arises (flow chart
the date, put the name of the person on each clini-
6.1). If you feel under threat, abandon the con-
cal sheet and sign each entry (with your name in
sultation immediately.
capital letters underneath). A simple approach to
documentation is SOAP.
●● Subjective: the main problems reported by
2.2.2 Keeping on learning
the person (e.g. headache, sleep problems). We get more satisfaction from our job if we feel
●● Objective: the main problem identified by the that we are doing good work of a high quality.
health worker (e.g. depression). When health workers first start delivering mental
health care, they may not feel confident that they

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are doing it correctly. Even when you get more ●● refer to treatment guidelines (e.g. this manual)
experience, there is always something new to to identify whether treatment was adequate
learn. There are two ways to make sure that we ●● where there is need for improvement, focus on
are delivering good-quality mental health care. problem-solving and setting realistic goals.
First, it is good to get into the habit of review-
ing and reflecting on your own work. Try to keep Perhaps the most important thing to keep in
a note of things that you are not sure about. mind is to know your limits and consult with a
Then make sure you read about those areas, for mental health specialist or someone with more
instance, by consulting with this manual. mental health experience than you when you are
Second, always try to keep up with new devel- stuck with a person whose problem is compli-
opments in mental health care, for example, cated or not improving despite your best efforts.
by checking reliable websites on the internet Discussing cases will help you to improve your
(Chapter 18). technical skills and the quality of care that you
Third, you need to take active part in regular deliver, but it can also be an important source of
supervision sessions, at least once a month, with support.
your colleagues or with a mental health special-
ist. During that time you can review case notes 2.2.3 Looking after your
and find support for the difficulties or uncertain-
own mental health
ties that you faced when delivering mental health
care. Just as health workers can suffer colds and infec-
To get the most out of this approach: tions, they may also suffer mental health prob-
●● schedule a regular time for discussion lems. There are many reasons for this. One, of
course, is that health workers are human beings
●● be punctual; take these sessions seriously and
themselves, with worries and concerns like any
participate in them actively
other person. In addition, while spending most of
●● keep the discussion confidential their time caring for other people, health workers
●● take turns to talk about people that you have may ignore their own problems or feelings.
seen The kind of work which a health worker does
●● start with feedback on the positive aspects of or the setting in which he or she works may pose
care special stresses. These are some examples of such
situations:
●● always be constructive in your criticism of oth-
ers by focusing on the quality of the treatment ●● when the health worker is also a victim, for
delivered rather than the person whose work example, in a disaster or war situation –
is being reviewed despite being a victim, the health worker may
be required to ignore her own needs in order to
●● do not take criticism of your work personally.
counsel other people who have been affected;
it is your work which is being assessed, not you
●● when the health worker is faced with very sick
people, for example, persons in terminal care,
or where many people are sick (for example,
because of HIV/AIDS) – each time a person
dies, the health worker may feel sadness;
●● when the health worker faces a history of
trauma – health workers who deal with vic-
tims, or perpetrators, of violence (e.g. in pris-
ons, or working with rape victims) can develop
strong emotional reactions to their clients.
If your mental health is not good, this will
Keep up with new developments in mental health care affect not only your own well-being but also your
by reading and browsing the internet.
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ability to work properly. Therefore, it is important friends, reading a book,
for you to be aware of your own mental health gardening, sewing or taking a
and seek help from someone else if you are con- walk are examples of simple
cerned. Sometimes, you may feel that admitting activities you might enjoy.
to feeling under stress at work is a sign of weak- Creative activities may
ness or lack of commitment to work. This is not include writing a poem or
true. If a health worker approaches you for help, story, or drawing.
it is extremely important to observe the rules of ●● Improving your surroundings. If your work
confidentiality, just as you should with anyone surroundings are dirty, this is bound to have
else. an effect on your mental health. Tidying up,
fixing broken windows or chairs, putting col-
2.2.4 Managing stress ourful drawings or posters on the walls, trying
to cut down on noise and allowing as much
Stress isn’t always bad, but it can cause problems.
natural light into the rooms as possible can
Some clues that stress might be affecting you are
help improve your work environment and
listed in Box 2.1.
your mental health. This is best achieved by
It is useful to plan how you might look after
working together with all the other people
yourself when working in a situation which is
who share your work setting.
known to be stressful. This can be seen as a kind
of immunisation to prevent mental health prob- ●● Sharing and socialising. There is no sub-
lems later on. The kinds of activities you may do stitute for sharing and talking to others to
to look after your mental health can be practised improve your mental health. Take time to talk
by any health worker. to your spouse or friend about your day at
work. Listen to your colleagues’ experiences,
●● Relaxation and meditation. Relaxation exer-
so you might support them in their difficult
cises (5.12) can be very helpful in dealing
moments and learn from them.
with stress when practised daily. These exer-
cises are very similar to meditation techniques ●● Forming a support group. This is a very
such as yoga and prayer. useful way of helping yourself and your col-
leagues. A support group consists of people
●● Creative and fun activities. Set aside some
who share something in common, in this case,
time each day for activities which you find
the fact that they are all health workers. The
interesting or fun, but which are not related
group should meet regularly to discuss shared
to work. Spending ‘fun’ time with family or
concerns and problems (Chapter 5).

BOX 2.1 SIGNS OF STRESS IN

A HEALTH WORKER
2.3 Seeking professional help
○○ Worrying all the time There are some situations in which it is essential
○○ Sleeping badly for you to seek professional help.
○○ Being irritable ●● Suicidal feelings. We can all experience feel-
○○ Drinking too much alcohol or using other ings of hopelessness or wishing to end our
drugs (including prescription medications) lives at some time. It is very helpful to talk
○○ Not wanting to be with people about these feelings, however embarrassing it
○○ Feeling mentally or physically fatigued may feel, to someone you trust. If you find that
○○ Physical health problems (high blood pres- you are making plans on how to end your life
sure, peptic ulcer disease) or that the suicidal feelings are present all the
○○ Getting into conflicts over small things (e.g. time, then you should seek professional help
with your work colleagues, family or spouse) from another health worker.
○○ Developing depression or an anxiety disorder

chapter 2 summary box

things to remember about core skills for mental health care
○○ Knowledge is not enough: good communica- ○○ All people deserve to be treated with dignity:
tion is essential for mental health care always be respectful and empathic
○○ Communication skills can be learned, even if ○○ Providing care for others can be stressful: look
they don’t come naturally after your own mental health
○○ People with mental health problems may not
be able to express their problems easily: take
time, speak to carers and observe carefully

notes

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3 Assessing someone with a
mental health problem

This chapter is about how a health worker can

carry out an interview to diagnose the type of
mental health problem. It will cover the common
attitudes will also make the person less comfort-
able and less likely to share their feelings with
the health worker. Treat a person with a mental
symptoms of mental health problems and spe- health problem with the same respect and com-
cific tips on difficult interview situations, such passion as any other person. Then will you find
as crowded primary care clinics or people who that working with a person who has mental health
refuse to talk. It will also describe the questions problems is a challenge which will be both fulfill-
which may be asked of the person or their fam- ing and rewarding. The single most important
ily to confirm the existence of a mental health aspect of assessing mental health problems is
problem. to give the person enough time.

3.1 Am I capable of examining 3.2 Do I have the time to talk to

a person with a mental health the person?
problem? The most important thing to remember is that
You do not need to be a specialist to assess men- time spent finding out why a person has come
tal health. The assessment of mental health pri- to see you may actually save you time later on.
marily requires ‘core skills’ (these were covered in We know that many mental health problems,
Chapter 2), as well as the knowledge described in especially common mental disorders and alco-
this manual. hol problems, are rarely recognised by the health
Some health workers have mixed feelings worker. The health worker in the busy clinic sim-
about assessing a person with mental health ply accepts the person’s complaints and gives
problems, for example: medications for them. Thus, painkillers are pre-
scribed for aches and pains, vitamins for fatigue
●● frustration that the interview may take longer and sleeping pills for sleep problems. However,
than a regular examination the person’s real problem, the mental health
●● amusement at the odd behaviour shown by
the person
●● anger that the person is wasting the health
worker’s time with ‘no real illness’
●● fear that the person may attack them
●● disgust that the person is unclean
●● worry that they may not be sufficiently skilled
to carry out a competent assessment.
Such feelings usually make it harder for Don’t be in a hurry – time
the health worker to provide help for a per- spent now can save you more
son affected by a mental health problem. Such time later.

1. Do you have any problems sleeping at night?

BOX 3.1 PRESENTATIONS THAT SUGGEST A 2. Have you been feeling as if you have lost
MENTAL HEALTH PROBLEM IN ADULTS interest in your usual activities?
3. Have you been feeling sad, unhappy or irrita-
○○ When the person or a family member com- ble recently?
plains directly of a mental health problem, 4. Have you been tired a lot?
such as depression or an alcohol problem 5. Have you been worrying too much about
○○ When the person or family members suspect things, feeling stressed or tense?
supernatural causes for the health problem 6. Have you been feeling scared or frightened of
○○ When a specific cause of a mental health anything?
problem, such as problems with alcohol or 7. Have you been worried about drinking too
family violence, is obvious much alcohol recently/using _____ drug (de-
○○ When you know that the person has relation- pending on local context)?
ship problems such as marital and sexual
If any of the answers are ‘yes’, ask more detailed
problems
questions to confirm the diagnosis.
○○ When you know that the person has life
problems such as unemployment or death of
a close friend
○○ When there are many physical complaints
which do not fit into a pattern of any known
physical illness
○○ When there is a personal or family history of
mental health problems
○○ When the person is unusually quiet or behav-
ing strangely

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mental health problems in general health care, you can then use a standard form of interview
common mental disorders and alcohol problems. (Box 3.3). There are three types of information you
If any of the answers to the questions are positive, need to understand the problem (this information
you could then ask more questions about these should also suggest ways in which the person can
conditions. be helped):
●● basic information on age, address, family
details and employment;
3.4 What to ask when you suspect ●● information about the problem itself, which
a mental health problem should begin with finding out about the symp-
toms, for example, how long they have been
If, as a result of the screening process, you suspect present and how they affect the person’s life;
that a mental health problem could be present,
●● the person’s social situation and what they
think is the cause of the problem. This should
BOX 3.3 INFORMATION TO COLLECT FROM include who they are living with and who their
A PERSON WHEN YOU SUSPECT A MENTAL main sources of social support are. Questions
HEALTH PROBLEM about recent stressful events, such as a death
in the family, may help explain why the person
General information is suffering from a mental health problem.
○○ Gender
○○ Age
○○ Occupation 3.5 How do I conduct the
○○ Marital status
interview?
History of current problem
○○ When and how did it start? Here are some hints on how to go about an inter-
○○ Is it getting worse? view with someone who may have a mental
○○ Are medications (or other treatments) being health problem.
taken? ●● Introduce yourself to the person. Some peo-
○○ The person’s beliefs about the problem – ple may be confused or suspicious. Clearly
what the person feels the problem is and state that you are a health worker and that you
why it has happened. You may ask questions wish to talk about the person’s recent health.
about beliefs regarding stress and supernatu- ●● Establish rapport. To this end, you can begin
ral factors causing the problem. the interview with a general subject such as a
Other information recent news event.
○○ Is there any history of mental health prob- ●● Use good communication skills(Chapter 2).
lems? (If so, ask for old prescriptions or old ●● Try to ensure privacy; this may be impossi-
clinical notes.) ble in crowded clinics, but even here you can
○○ Relevant medical history, such as recent head speak softly so that the discussions of personal
injury. problems are not heard by others in the room.
○○ Relevant history of substance use, including Alternatively, ask the person to wait until the
alcohol and tobacco. clinic is less crowded and then talk in private.
○○ Recent major stressful events, such as separa- ●● Keep safety in mind(2.2) but remember
tion, death in the family, unemployment. that most people with mental health problems
○○ Social support – specifically, who does the are not dangerous.
person live with; who cares for the person; ●● Ask everyone the ‘golden questions’(Box
and is there any form of support from outside 3.2). If any of the answers are positive, do
the home such as religious or spiritual sup- a more thorough assessment using the
port and friends? checklists.

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3.6 What to look for
●● Facial expressions of sadness or fear (with
psychosis and depression).
●● Restlessness, i.e. unable to sit relaxed (with
psychosis, depression, drug and alcohol
dependence, and as a side-effect of some psy-
chiatric medications).
●● Strange movements (associated with psy-
chosis and as a side-effect of some psychiatric
●● Keep in mind the main types of mental dis medications).
orders and their symptoms(1.4). This is ●● Irrelevant answers to your questions (associ-
especially important because many people ated with psychosis and delirium).
may not openly come out with emotional com- ●● Very fast rate of talking (associated
plaints unless you specifically ask about them. with mania).
●● Try not to appear pressured for time, for ●● Very slow rate of talking (asso-
example, by constantly checking a wristwatch! ciated with depression, drug
Remember that just 10 min is often all that is dependence and psychosis).
needed to understand the person’s problem
●● General hygiene and self-
and guide treatment choices. Of course, it is
care (poor in depression, drug
better if you can spare more time.
and alcohol dependence,
●● Give the person a chance to talk to you with delirium and psychosis).
out family members present. Never consider
people ‘unreliable’ simply because they suffer
from a mental health problem. 3.7 How do I reach a diagnosis?
●● Try to speak to the family membersas well,
but always make an attempt to ask permission Diagnoses are important for two reasons:
from the person before you do so. Some peo- 1. to help explain to the person the cause of their
ple with mental health problems may deny complaints
they have a problem. Some may not be fully 2. to help guide you in selecting the right
aware of the nature of their behaviour. Family treatment.
members and friends can often give you infor-
mation which is valuable in making a clinical There are only a few diagnoses of special
decision. interest in a general health care setting. In Part 3
we will describe how you can diagnose different
●● Use the right amount of eye contactfor your types of mental health problems. The key is to be
culture to help make the person feel confident familiar with the types of mental disorders (1.4)
that you are interested in what they are saying.
●● Record key information for future refer
ence, especially the main symptoms, current
diagnosis, and important information such as
the presence of any marital problems.

Take note of the person’s facial expression.

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and the questions to assess mental health as dis- They may be angry for having been brought to
cussed in this chapter. Practise the questions with the clinic. They may be scared that talking to you
your colleagues. might mean they will be labelled a ‘mental case’.
They may be suspicious of your motives.
The general advice in such situations is to
3.8 Special situations in allow more time. Interview the person in a private
room if possible. If this is not possible, at least
assessment
ask any family members to stand far away so that
There are some special situations in assessing your conversation cannot be heard by them. This
mental health problems. These include: may help the person feel more confident to share
●● assessing someone who refuses to talk personal problems. Do not threaten the person,
for example, by saying that you do not have time
●● assessing physical complaints in a person with
to waste. Instead, reassure the person that you
a mental health problem
are interested in their problems. If the person
●● assessing someone on the telephone refuses to talk and you have other work to attend
●● assessing someone with the family present to, say you need to go to complete the work and
(p. 24) that you will return later when you have more
●● assessing someone who is violent (flow time. This will allow the person some more time
chart 6.1 and 7.2) to think. It will also demonstrate your concern. Of
course, you must always remember to return to
●● assessing someone who is confused (7.1)
the patient as promised, and within a reasonable
●● assessing someone who is suicidal (7.6) period of time.
●● assessing children with mental health prob-
lems (Chapter 11). 3.8.2 Assessing physical complaints
in a person with a mental health
3.8.1 Assessing someone who
problem
refuses to talk
Imagine that someone who is known to have a
Sometimes you may be faced with someone who
mental health problem comes to the clinic with
refuses to talk. This could be for many reasons.
a new complaint of a headache. Often, health

Look, it seems as if you may be

Look, I don’t have time unhappy or angry for some reason. It will help if you
to waste. Are you a mental case or what? share this with me, so that I can help you.
Why can’t you tell me your problem?

a. b.

If a person refuses to talk, do not (a) threaten them by saying that you do not have time to waste.
Instead, (b)reassure them that you are interested in their problems.
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workers will assume that the complaint is just Avoid giving vague advice or reassurance on
another symptom of the mental health prob- the phone. You should approach the caller in this
lem. However, this attitude may lead to a seri- way.
ous physical illness being missed. It is important ●● Find out the person’s name, age, address and
that the physical health of a person with mental which telephone number they are calling from.
health problems is given due attention. Do not
●● Ask them to tell you exactly what the problem
dismiss new physical complaints without prop-
is, how it started, what has happened recently.
erly assessing them and, if required, carrying out
Get an idea of the situation they are facing.
tests. Remember that people with mental health
problems may neglect their physical health. ●● Find out about any close friends or family
Some kinds of mental health problems are members to whom they can talk. Encourage
closely associated with physical health problems. the person to share their distress with them
The most important examples are: now.
●● alcohol and drug dependence which can seri- ●● If a person is abusive, explain that you would
ously damage physical health (9.1 and 9.2) like to help but cannot if they do not change
their attitude. If the caller remains difficult,
●● women who have been hurt by violence or
then hang up the telephone.
raped (10.3)
●● If a person is confused, explain that it is diffi-
●● confusion and agitation, which can often be
cult for you to understand the problem prop-
caused by physical health problems (7.1)
erly and ask them to come to the clinic straight
●● people receiving antipsychotic medication, away.
typically for severe mental disorders (7.3)
●● disturbed behaviour in elderly people (7.1 Why are you so distressed?
and 7.8). Can you come to the clinic to talk to me?

3.8.3 Assessing a person

on the telephone
Mobile phones are available in most places, and
you may encourage people to call you to report on
their progress or for advice if you feel comfortable
about this. In fact, this can save time for both you
and the caller by avoiding unnecessary visits to
the clinic. However, always use a separate phone
number for such professional work.
Sometimes, a person may call you with a
problem that is related to a mental health crisis. ●● Ask any person to come to the clinic if you feel
Examples of such calls could be: they are in need of a face-to-face assessment.
●● a person who wishes to die ●● With children in distress, immediately inform a
●● a child who is in need of help local child welfare team or the police. Ask the
child to stay where they are and say that some-
●● a person who is drunk and confused
one will come to help them.
●● a person who is angry and abusive.

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3.9 Symptom checklists to diagnose mental disorders†
Common mental disorders Severe mental disorders (psychoses) 7.3
Depression 7.4 At least two of these symptoms:
At least one symptom affecting the person’s daily Believing things that are untrue (delusions, £
life activities for at least 2 weeks: e.g. that their thoughts are being controlled
Feeling sad or irritable £ by outside forces, that people are trying to
poison them)
Loss of interest in daily activities £
Hearing or seeing things that no one else £
Tired all the time or lacking energy £
can (hallucinations); often these are fright-
Other symptoms which are frequently present ening
and should be asked for:
Agitation and restlessness, or withdrawal £
Disturbed sleep £ and lack of interest
Tiredness £ If the symptoms have been present for less than
Loss of appetite £ a month and the person is confused (doesn’t
Poor concentration £ know where they are, who people are or the day
Feeling worthless or guilty or time) the diagnosis may be delirium (flow
£
chart 6.2 and 7.1). If the person appears con-
Hopelessness or suicidal thoughts £
fused and is older than 60, then the diagnosis
Aches and pains all over the body £ may be dementia (7.8).
Anxiety 8.2 If there is a history of episodes in between which
Feeling tense/nervous/worrying a lot for at £ the person seems to recover completely, the
least 2 weeks (affecting daily life activities) diagnosis may be bipolar disorder (7.5). The
Other symptoms which are frequently present ‘high’ or manic episode can be diagnosed on the
and should be asked about: basis of:
Disturbed sleep £ Increased speed of talking £
Tiredness £ Not needing to sleep £
Loss of appetite £ Restlessness £
Poor concentration £ Irritable mood (getting angry easily) £
Palpitations (heart beating fast)/trembling/ £ Grand ideas about oneself £
dizziness Alcohol (or drug) dependence 9.1, 9.2
Persistent nausea, vomiting or diarrhoea £ At least two of these symptoms:
Aches and pains all over the body £ Drinking (or drug use) has led to personal £
For anxiety symptoms that come on very sud- problems (loss of job) or health problems
denly and severely and last up to 30 min 8.2.1 (accidents, jaundice)
(panic attack). For situation-specific anxiety Difficulty in controlling the use of alcohol £
symptoms 8.2.2 (phobia). (or drug) even though it causes problems
Using alcohol (or drug) throughout the day £
Feeling sick or unwell unless the person £
drinks alcohol (or takes the drug)
Using gradually increasing amounts of £
alcohol (or drug)

†
These checklists refer to major mental disorders in adults. For children Chapter 11.
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chapter 3 summary box
things to remember when assessing someone with mental health problems
○○ Privacy, the ability to listen without becoming ○○ A systematic assessment interview is the first
fidgety and adequate time are the key elements (and a very important) step in the treatment of
in assessing a person with a mental health the person.
problem. ○○ Most common mental health problems can be
○○ Most people with mental health problems can easily diagnosed by asking questions about
give a clear and complete history of their prob- specific complaints.
lem. Family members can also provide useful ○○ People with mental health problems may also
additional information. suffer from a physical illness; never dismiss a
physical complaint just because a person also
has a mental health problem.

notes

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4 General approach to treatment
of mental health problems

There was a time when many people with mental

health problems were locked up in asylums and
treated in a degrading manner. People blamed
the right period of time. Counselling can be as
effective a treatment as medication, depending
on how the counselling is carried out and for what
the person for the way they behaved and would reason. Tackling a person’s social difficulties can
abuse them. Even today, people with mental also help to alleviate mental distress.
health problems may suffer human rights abuses There are two important points for health
in traditional healing centres and mental hos- workers to remember while reading this chapter.
pitals. Many never get effective treatment at ●● General health workers can treat mental
all and are restrained at home for the lack of an health problems. The vast majority of men-
alternative. tal health problems can be treated with confi-
There are many myths about the treatment dence by any general health worker equipped
of mental health problems. For example, some with the basic knowledge described in this
people think that mental health problems cannot manual. Thus, the diagnosis of a mental health
be treated. Some people cannot understand how problem does not mean that the person needs
‘talking’ to someone (or ‘counselling’) can be con- specialist care. It means that you now know
sidered a ‘medical’ treatment. The truth is very what type of treatment is needed.
different.
●● There are many effective ways of treating
Most mental health problems can be effec-
mental health problems. The usual approach
tively treated. The real problem is that many
of using different treatments for different
people with mental health problems rarely see
physical symptoms of mental health problems
health workers. Even when they do, they tend to
(e.g. sleeping pills for sleep problems, ton-
receive treatments which are not effective or may
ics and vitamins for tiredness, and painkillers
even be harmful. Like medications for physical ill-
for aches and pains) is often the least helpful
nesses, medications for mental health problems
in the long run. Understanding the type of
only work when taken in the right dose and for
mental health problem and providing spe-
cific treatments is just as important for mental
health problems as it is for physical illnesses.
The general principles of planning treatment
for a person with mental health problems will
now be covered. (Chapter 5 for details about
how to deliver specific treatment.)

Even today, people with mental disorders are treated

inhumanely in many places.
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4.1 Treat the whole person health problems. This happens for a variety of rea-
sons: difficulty being taken seriously (by family or
When you plan treatment for mental health prob- health workers), being less likely to receive health
lems, you need to consider the person in their promotion or illness prevention interventions, dif-
entirety, including their physical, mental and ficulty communicating to people what is wrong,
social needs. Treatments for mental health prob- the effects of the illness interfering with looking
lems can usefully be divided into medications, after themselves properly, side-effects of medica-
counselling and social interventions. For most tions and lifestyle (e.g. smoking, poor diet). The
people with mental health problems, a combina- reproductive health needs of women with mental
tion of these treatment approaches is needed. health problems are easily overlooked, for exam-
Deciding on which treatments to give depends ple, with regard to family planning. People with
on the particular type of mental health problem, mental health problems have a greater need for
but also on the person’s unique circumstances physical health care than the general population
that may have contributed to the development (Box 4.2), but tend to receive less care and care of
of the problem in the first place or that may be lower quality. The general health worker is ideally
helping or hindering recovery. An example of this placed to help manage both a person’s physical
approach is given in Box 4.1. and mental health problems. Therefore, be care-
‘Treat the whole person’ also means consid- ful not to forget about the body while you are
ering the physical health of people with mental treating the mind.
health problems. Often their physical health is
worse than that of people who don’t have mental

BOX 4.1 PLANNING CARE TO TREAT THE BOX 4.2 PHYSICAL HEALTH PROBLEMS IN
WHOLE PERSON PEOPLE WITH SEVERE MENTAL HEALTH
PROBLEMS
Selam is a 35-year-old woman with moder-
ate depression. Her mother died 2 years ago ○○ Increased risk of some infectious diseases,
and, since then, domestic violence from her such as HIV and sexually transmitted diseases
husband has increased. She no longer meets (STDs), tuberculosis (TB)
up to talk with family or friends because she ○○ Heart disease
feels that nobody would be interested in ○○ Diabetes
hearing about her problems. She is struggling ○○ Poor dental health
to care for her children (aged 2 and 5 years) ○○ Late presentation of cancer
because of low motivation and a feeling that ○○ Unplanned pregnancies and gynaecological
she is not good enough. She is tearful most of diseases
the time and feels like giving up on life. ○○ Obesity or undernutrition

An approach to helping Selam might combine the

following interventions:
○○ counselling – giving hope (5.9.2), problem-
solving (5.11), getting active (5.13), think-
ing healthy (5.14)
○○ medication – antidepressant medication
(Box 5.1 and Table 14.1)
○○ social intervention – improving contact with
her social networks (5.18), community-level
interventions for domestic violence (13.10).

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4.2 Put the person at to understand where the two approaches may
complement one another to maximise the
the centre of care benefit for the person. If the traditional healer
The treatment of mental health problems needs is giving advice that directly contradicts the
to be tailored to the particular needs of a particu- message that you are giving the person, then
lar individual. Put the person at the centre of your try to meet with the healer or find a way to rec-
treatment plan in the following ways. oncile the treatment perspectives.
●● Always involve the person in decisions
about their treatment. The majority of peo-
ple with mental health problems are able to
take an active role in their own treatment and
should be involved in decisions about their
care. In rare circumstances, the person may be
too unwell to make decisions, but the health
worker may feel that they need treatment in
their best interests; in such a situation, you
should follow the laws in your country which
regulate whether, when and how treatments
can be given for mental health problems with-
out the person’s consent. If treatment in such Understand and respect the person’s perspective on
circumstances is permitted, then this should traditional healing.
only happen if the following conditions are
met: it is an emergency; you are convinced 4.3 Think beyond the individual
that without treatment there is a significant
risk of harm to the person’s well-being; your Mental health problems can be the result of dif-
best efforts to support the person to make ficulties within a family (e.g. domestic violence)
their own decision have not been successful; or within a community (e.g. poverty, inequal-
and you have sought the opinion of a third ity, child abuse, political unrest). Although it is
party, such as the person’s family members or important to focus on the treatment needs of
other health care or social workers, and they the individual with a mental health problem, it
agree with you. is vital not to forget the wider social factors that
●● Try to make sure that the treatment contribute to mental health problems (13.11).
addresses the problem that concerns the For individual cases, there may be clear family-
person the most. For example, a person with level interventions that are needed, for example,
psychosis may be more concerned about sleep addressing domestic violence, so that the person
problems or not having friends than hearing can recover. When such family or community-level
voices. In this case, choose a medication that interventions are beyond the scope of a health
also helps sleep or focus on social interven- care worker, at the very least you could refer the
tions so that the person’s main concern is person to other sources of help for the particular
addressed. problem.
●● Work with traditional and religious healers.
Even while attending a health facility, many
people will continue to consult with religious 4.4 Take a long-term perspective
or traditional healers. It is important for you Mental health problems can start suddenly and
to understand how the treatment you are resolve in a short period of time (e.g. in a person
proposing for the person will fit in with their who has been exposed to a very stressful event).
other sources of help and healing. Do not be However, it is also common for mental health
dismissive of other approaches to healing. Try problems to start gradually and for the symptoms
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to persist over a period of months, and in some functioning or that make them so drowsy that
cases years. Even if a person recovers from an epi- they are unable to work). Always try to base treat-
sode of mental disorder, there can be a relapse ment goals first and foremost on the person’s pri-
in the future. If we approach the treatment of orities and values.
mental health problems in the same way that Family members also have an important role in
we approach the treatment of acute infections goal-setting. If the person is affected by a mental
like malaria or diarrhoea, our treatment may not disability (e.g. dementia or developmental disor-
be as effective as we might expect. For example, der) which affects their ability to understand and
the person may stop taking medication as soon decide on treatment goals, speak to the family
as they feel better, even though it is needed to so that you can understand the goals that would
keep them well and prevent relapse. Therefore, most improve the person’s quality of life. Family
for all long-term (also called ‘chronic’) health members sometimes have competing priorities
conditions, which include many mental health for treatment, for example, preferring symptom
problems, we need to pay greater attention to the control even when side-effects may be burden-
following approach to care: some for the person. Again, always prioritise the
●● engage the person person’s well-being and preferences but, at the
same time, be sympathetic to the family member
●● set goals and track progress
and try to find ways to help reduce the burden on
●● support the person in self-care the family that comes from challenging behav-
●● involve people who are close to the person iour, for example, aggression or incontinence.
●● coordinate care with other health care work- Although it is not always possible to achieve a
ers, including specialists selected goal fully, it is important to have a shared
●● actively follow up. understanding of what you are aiming for. When
discussing treatment goals with the person, try to
We have already discussed how to approach agree on a treatment goal that is SMART, by which
engaging the person and their family members we mean:
(Chapter 2). The other aspects of longer-term ●● Specific: the goal should be clearly defined.
care will now be considered and are also dis- For example, in a person disabled by psycho-
cussed in Part 4 (12.4). sis, ‘improved self-care’ could be specified as
being able to wash themselves once a day.
●● Measureable: there should be a way of know-
4.5 Set goals and track progress
ing whether the goal has been achieved, for
If you don’t know what you are aiming for then it instance, number of days in the week when
is difficult to achieve it! Each time you meet with the person was able to bathe themselves.
the person you should review progress towards
the goal you had both agreed on. Usually, health
workers think in terms of ‘cure’ or symptom con-
trol as the goal of treatment. These are certainly
important goals but they are not the only, or the
most important, goals of treatment. Particularly
when a person is affected by a long-term severe
mental disorder, their treatment goals may have
a different focus. For example, the focus might
be on getting a job, entering into a relationship
or achieving spiritual peace. They may even
decide that they prefer to live with some symp-
toms of mental disorder and take a lower dose of
medication than be affected by medication side-
effects (e.g. side-effects that affect their sexual Agree on when the goal can be achieved.
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●● Achievable: by breaking down goals into questions. Make time to clarify any issues
smaller steps, the goal can be made achiev- which they might find difficult.
able. For example, although ‘able to look after ●● Actions for mental health. Ask the person
their personal hygiene’ may be an ultimate what helps them to relieve their mental health
goal, washing with support is a more realistic problems. Many people find their own ways of
goal as a first step. managing their symptoms. Encourage the per-
●● Relevant: the goal should be valued and prison to stick with actions that are ‘mentally
oritised by the person affected by mental healthy’ (help to improve their mental health)
disorder. and to try to stop any ‘mentally unhealthy’
●● Time-bound: always decide on a time frame behaviours (that make mental health prob-
for achieving the goal, for example, ‘by the end lems worse).
of the week’. ○○ Mentally healthy
behaviours might
More detail about how to work on achiev-
include: talking
ing recovery goals is given in Chapter 5 (5.20).
with a trusted
When you next see the person, don’t forget to ask
person, praying or
them about progress towards the treatment goal.
other forms of reli-
Use problem-solving strategies (5.11) to under-
gious observance,
stand why things have not gone to plan. Develop
getting enough
a revised goal if necessary. Keep reviewing and
rest, taking a walk,
setting goals to help the person work towards
listening to music, getting some exercise,
achieving their full potential.
and eating and sleeping regularly.
○○ Mentally unhealthy behaviours might
4.6 Support the person include: alcohol or substance use, sleeping
all day, working all the time, avoiding peo-
for self-care ple or situations which make them anxious,
In addition to the treatment that is given by health neglecting personal hygiene, and getting
workers, there are many things that the person angry with other people. These activities
can do for themselves to stay mentally healthy. are likely to make mental health problems
The health worker can help the person to help worse and to prevent treatments working
themselves in a number of ways. properly.
●● Clear and accurate information is key to ●● Strategies to deal with stress. Stress is part
helping the person play an active part in and parcel of life. It is not always bad. For
managing their illness. People with mental example, a reasonable amount of work stress
health problems, and their family members, can help to motivate us and get things done.
need to be informed about the nature of the But too much stress can trigger mental health
illness, the various treatments available and problems or make recovery harder to achieve.
how they work best, and how they can help Each person will have their own way of dealing
themselves to improve their health. It is impor- with stress, and you can advise the person on
tant that this information is given in a language which approaches are most helpful for achiev-
that the person is comfortable with and using ing and maintaining good mental health.
words which are easy to understand. Where a ○○ Advise the person to avoid too much stress
local word is available to describe a particu- in the first place, for example, not taking on
lar mental health problem, and is not hurtful too much work and trying not to get drawn
or associated with shame, use it. Always ask into conflicts.
the person whether they have understood ○○ Explain that the person needs to recognise
your explanation and whether they have any when stress is affecting them before it gets

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●● Support the person to get the best out of
treatment. Regardless of the type of treat-
ment, people usually only get the maxi-
mum benefit from treatment if they take it
as intended. In the case of medications, it
means taking the medication as prescribed
(right dose, right frequency, right duration). In
the case of counselling treatments, it means
being an active partner in the treatment: not
just expecting advice and for someone else
to solve their problems, but also working to
change their way of doing things or seeing
Taking a walk can help to reduce stress. the world. Counselling treatments also need
the right frequency and duration. The key
too much. Some people don’t notice when
approach is to build up a trusting relationship
they are stressed. Tell-tale signs are feeling
with the person, ensure that they are properly
tense, getting upset easily, shouting at peo-
informed about the treatment, listen to their
ple, getting headaches and sleep problems.
concerns about the treatment and adapt or
○○ Advise the person to work out what is caus- change where necessary, and support the per-
ing the stress and do something about it. son to continue the treatment.
Ignoring stress or keeping the stress inside
just makes things worse. Talk to someone More specific information is given in the indi-
or use problem-solving (5.11) or relaxa- vidual sections on medications (5.1–5.8) and
tion techniques (5.12). counselling (5.9–5.17).
●● Increase physical activity. If a person does
not do much physical activity, then their men-
tal health will benefit from doing some physi- 4.7 Work with families
cal exercise. Of course, their physical health Most often it is the family who provides the lion’s
will also improve, which is an added bonus, share of care when a person develops mental
especially to prevent weight gain that can be a health problems. Here we use the term ‘family’
result of an unhealthy lifestyle or a side-effect for convenience, but everything we discuss would
of medications. Motivation for physical activ- also apply to carers other than the family (such as
ity can be a serious challenge. Approach this a friend or a paid carer). Even though we are treat-
by: ing the individual person for their problems, we
○○ giving people a clear explanation for how also need to take the family into account. This is
exercise will benefit them (improve their a good idea for several reasons. First, it is impor-
mental and physical health and reduce the tant that everybody involved in the person’s care
risk of illness relapse), and has a clear understanding of the problem and the
○○ trying to make the exercise plan as simple proposed treatment. Second, the person is likely
as possible and integrated into the person’s to need support and encouragement on a daily
current lifestyle. basis for an extended period of time, and we need
Walking for 20 min every day instead of tak- to work with the people who are providing such
ing a bus to work is one way of making exer- support. Third, sometimes families get frustrated
cise become part of a person’s routine and not or overwhelmed and act in a way that worsens
seem like extra work. Counselling strategies the person’s mental health problems. In such
for improving motivation are described later cases we need to support families to learn how
(5.17). to behave more constructively. Fourth, family

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members commonly experience a number of dif- BOX 4.3 FOLLOW-UP CHECKLIST
ficulties and stresses because of the person’s ill-
ness and may need their own care and support. 1. Screen for symptoms of the mental health
The approach needed for all people caring for a problem and note whether these are improv-
person with long-term illness, whether physical, ing or getting worse.
mental or both, is described in Part 4 (12.4). 2. Review functioning and progress towards
Some particular issues which families of a person goals.
with a mental health problem may face include: 3. Check for risk: to self or to others. Consider
stigma and discrimination from the community, whether the person is at risk of abuse from
fear of violence and the emotional burden of car- others.
ing for someone with a mental health problem 4. Review whether treatment is being taken.
(5.23, 5.24). 5. Screen for medication side-effects and physi-
cal health concerns (e.g. check weight if they
are taking medications for psychosis).
4.8 Work as a team 6. Take the opportunity to make sure the person
is included in health promotion and illness
Because people with mental health problems may prevention activities (e.g. cervical screening in
have many different treatment needs, for exam- women who are sexually active).
ple, for physical health problems, medications,
7. Assess the coping and mental health of family
counselling, spiritual recovery and livelihood sup-
members.
port, they may end up consulting with lots of dif-
ferent people, including specialists, healers and
community workers. The result can be confusion making contact with them. If you have colleagues
and chaos! Try to identify all of the people who who work in the community, you may be able to
are involved in the person’s care and what they ask them to carry out a home visit to check that all
are doing. Then ensure that there is clear commu- is well and encourage the person to attend. Peo-
nication between each of the care providers. For ple who receive treatment as planned will gener-
example, after reviewing the person’s medication ally have better symptom control and quality of
you could send a brief note to the general physi- life than those who stop and start treatment.
cian to explain the current treatment plan. Mental
health care, by its very nature, is a team effort.
(Part 4 for further details on developing a ser- 4.10 Refer when needed
vice that is collaborative and coordinated across
health sectors.) Even though most mental health care can be
delivered by general health workers, there are still
times when referral to a specialist is needed. The
4.9 Follow up actively types of specialist that can support you with men-
tal health care are described in Table 4.1.
Follow-up is an essential part of treatment for
people with mental health problems. One of the
most important reasons to follow up actively
is to review progress and to check whether the
person is responding to treatment. You can then
change the treatment if needed. Box 4.3 contains
a checklist for reviewing people at follow-up
appointments.
For people with long-term mental disorders,
try to establish a mechanism for detecting wheth-
er they have missed their appointment and then Getting lots of different advice can be confusing.

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TABLE 4.1 SPECIALISTS WHO HAVE A ROLE IN MENTAL HEALTH CARE
Psychiatrist Psychiatrists are medical doctors who, after completing general medical
training, have specialised in the treatment of people with mental disorders.
In many countries, the majority of psychiatrists are almost completely based
in hospitals. These may be general hospitals with a psychiatric ward or a
hospital specialising only in mental health problems. Their roles include:
(1) assessment and treatment of people with severe mental disorders (e.g.
psychosis, bipolar disorder), complex presentations (e.g. due to comorbid
drug abuse and mental disorders) or risky or challenging behaviours; (2)
giving advice on treatment for people who have not responded to first-line
treatments; and (3) providing in-patient care or specialist interventions.
Psychiatrists mainly use medications, but some are also trained to provide
counselling. Psychiatrists may also have subspecialist expertise, for exam-
ple, in child and adolescent psychiatry.
Psychiatric nurse or Psychiatric nurses are nurses who have specialised in psychiatry. They may
psychiatric clinical work either in hospitals or in the community. While all psychiatric nurses are
officer trained to provide care for people who are admitted to hospital, if there are
no psychiatrists available, they may take on some of the roles of psychia-
trists. Many psychiatric nurses have developed expertise in counselling and
supporting people with long-term disability. Increasingly, psychiatric nurses
play an important part in providing supervision and consultation services to
primary care and general health workers.
Clinical psychologist or Clinical psychologists and counsellors are trained in treating mental health
counsellor problems using counselling strategies.
Social worker Psychiatric social workers tend to work either in hospitals or in the com-
munity and deal with social problems and life difficulties faced by people
with mental health problems. They also have a role in protecting people
with mental health problems from abuse and helping them to exercise their
rights. Social workers may also be trained as counsellors.
Neurologist A neurologist is a medical doctor who has specialised in the treatment of
people with neurological disorders (e.g. those affecting the brain or nerves).
Neurologists have expertise in the treatment of some conditions which are
also treated by psychiatrists, for instance, epilepsy, dementia, headache, or
loss of function in a limb.
Paediatrician A paediatrician is a medical doctor who has specialised in the treatment of
children with illness. They have expertise in assessing children with devel-
opmental disorders and epilepsy.
Speech and language Speech and language therapists can support children and adults with
therapist developmental disabilities to learn more comprehensible speech and other
communication strategies.
Other therapists There are a number of other types of therapists, for example, occupational
and play therapists, who can provide psychosocial interventions, in particu-
lar, for severe mental disorders and child mental health problems.

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4.10.1 Urgent referral ●● Any person who is continuing to be seriously
disabled with respect to personal life or work,
As a general rule, it is best to refer urgently to spe- despite your efforts to provide treatment.
cialists in the following circumstances.
●● Any person who needs a treatment that
Urgent referral to a general hospital requires specialist oversight, such as:
●● A person has made a serious suicide attempt ○○ children with hyperactivity who need
and needs urgent medical care (e.g. for organ- medication
ophosphate poisoning, overdose of tricyclic ○○ people with psychosis who are not respond-
antidepressants). ing to regular antipsychotic drugs and need
●● A person who is confused or who has abnor- clozapine
mal behaviour and evidence of a physical ill- ○○ people with opioid dependence who need
ness such as head injury or high fever. substitution therapy
●● A person with uncontrolled seizures. ○○ people with alcohol dependence who
●● A person who is taking large amounts of alco- might benefit from medications to reduce
hol or drugs so that stopping it suddenly may the risk of relapse
lead to a severe withdrawal reaction. ○○ people with epilepsy who may need two
Urgent referral to in-patient mental health anti-epileptic medications in combination
services ○○ people with early dementia who might ben-
●● A person who is so disturbed that they can no efit from an anticholinesterase.
longer be managed at home. When you refer someone, it can be very help-
●● A person who is at imminent risk of suicide. ful if you write a short note explaining a little
about the background to the problem and what
4.10.2 Referral for out-patient treatments you have already tried. You can also
ask the specialist to write to you advising on how
mental health assessment the person should be cared for in the community.
Referral or consultation with a mental health spe- We have created a chart showing the impor-
cialist is preferred in the following circumstances, tant information that should be provided by the
if available, but should not be a barrier to the pro- referring health care worker; one chart has been
vision of care in primary or general health care filled in as an example (p. 46), and a clean chart
settings. is provided for you to use (p. 47).
●● Before starting a person with psychosis, bipo-
lar disorder or epilepsy on regular medication.
Sometimes this is not possible, in which case
try to obtain specialist review as soon as pos-
sible in the future.
●● To conduct a review of medical causes for a
child with developmental disability or a per-
son presenting with dementia.
●● When you are starting medications in a per-
son with mental disorder who is pregnant or
breastfeeding, who has a medical condition or
who is very young or old.

Risk issues:
Gets lost for extended periods
of time
Treatment given:
Vitamins and diazepam
Response to treatment:
None

Specific reason for referral:

Please help with diagnosis and
management plan

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REFERRAL CHART
Date:
__ /__ /____
Referrer details:

Name of health facility:

Patient’s name:

Patient’s age:

Patient’s gender:

Main problems:

Possible diagnosis:

Risk issues:

Treatment given:

Response to treatment:

Specific reason for referral:

notes

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Part 2
Treatments

Now that we have covered the general principles of treatment for people with mental health prob-
lems, we will look at the three main types of treatment in detail: medications, counselling and social
interventions. The interventions included are evidence based, feasible and best value for money in any
setting.

●● the person is not adequately informed about

the nature of their problem or why they should
take the medication
●● the person, and even the health worker, is
afraid that medications for mental health
problems are too dangerous
●● the person prefers a counselling treatment
●● the person experiences unpleasant side-
effects of medications
●● the person is too ill to make a decision.
Nowadays, there are different types of medi-
5.1 When should I use cations available for different mental health prob-
medications? lems. Whenever you prescribe medications, there
are some general rules which you should follow
Medications are essential for some mental health (Box 5.1). If these general rules are followed prop-
problems, but they are no use for others. erly, then medications for mental health prob-
First, the health worker must decide whether lems are as safe as any other medications. Do
or not to use a medication. As a principle, only use not make the error of avoiding medications when
a medication when indicated for a specific type there is clear evidence that the person suffers
of mental disorder. Do not use a medication only from a mental health problem which will benefit
because the person expects it. If a person expects from medications.
medication, it is often because they are used to As a rule of thumb, the following mental health
getting medications every time they consult the problems will benefit from medications:
health worker. They may believe that the only
●● severe mental disorders such as psychosis, bi-
way to help a sickness is with pills and injections.
polar disorder and epilepsy
They may not be aware of the important roles of
counselling, lifestyle changes and emotional sup- ●● common mental disorders that have lasted
port. If you do not take this chance to educate more than 2 weeks and are seriously affecting
them and, instead, use unnecessary medications, the person’s day-to-day life or are associated
the person’s problem may take much longer to with suicidal ideation or behaviour (1.4.1)
improve. In the long run, the person may come to ●● severe alcohol or drug use disorders, in particu-
see you more often and for much longer and take lar when a person has a physical dependence
up more of your time. ●● some forms of child mental disorder, specifi-
On the other hand, there are some situations cally attention-deficit hyperactivity disorder
where people with mental health problems are (ADHD) (11.4).
very reluctant to take medications at all! This can
happen when:

†
With Abebaw Fekadu.
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5.2 Which medication should I use? anticholinergic medications for managing
side-effects of antipsychotics.
The next step is deciding which medication to
Boxes 5.2 to 5.8 contain the general guidelines
use. The major groups of medications for mental
on which medications to use for specific types of
health problems that can be prescribed by gen-
mental disorders. The availability of specific med-
eral health workers are:
ications varies across countries, as does their cost.
●● antipsychotic medications(to treat psycho- For that reason we have included a wide range of
sis, manage severe behavioural disturbance medications used for mental disorders (and given
and control bipolar disorder) their generic names), but distinguished between
●● antidepressant medications(to treat moder- those that are:
ate to severe depression or anxiety disorders) 1. recommended by the World Health
●● mood stabilisers(to control bipolar disorder) Organization in the Mental Health Gap Action
●● antiepileptic medications(to control Programme (mhGAP) Intervention Guide
epilepsy) (bold);
●● benzodiazepines (as emergency sedation for 2. other medications which may be more costly
someone who is agitated, for short-term man- but can be prescribed by general health work-
agement of anxiety disorders or sleep prob- ers (no emphasis);
lems, to manage alcohol withdrawal, and in 3. medications requiring specialist oversight
the emergency management of seizures) (italics);
●● other medications used in mental health care 4. recommended in mhGAP and requiring spe-
in general health settings, including sedat cialist oversight (bold italics).
ing antihistamines for sleep problems and
Chapter 14 for dosages and side-effects.

BOX 5.1 GOOD PRACTICES IN USING MEDICATIONS FOR MENTAL HEALTH PROBLEMS

○○ Knowing the diagnosis can help make the ○○ Most people only need one medication at a
choice of treatment much more accurate. time; try to avoid prescribing multiple medica-
○○ Depending on the type of symptoms or diagno- tions, especially of the same type.
sis, and the severity of the mental health prob- ○○ Avoid using some medications for too short a
lem, decide whether medication is required. period (e.g. antidepressants and antipsychot-
○○ Medications for the same mental disorder differ ics) and be careful not to use other medications
in their side-effects; choose a medication which for too long a period (e.g. benzodiazepines).
the patient is most likely to tolerate. ○○ Most medications ‘interact’ with others and
○○ Be aware that the safety of a medication may also with alcohol or drugs, so their side-effects
be different if a person is pregnant or breast- may be worse. Reduce the dose accordingly.
feeding, is a child or adolescent or above the ○○ Combine medications with counselling and
age of 60, or has a medical condition. social interventions.
○○ Explain to the person why they need the medi- ○○ Resist the temptation to continue medications
cation, how to take it and for how long. ‘as before’ in follow-up clinics. If someone
○○ Begin with the recommended starting dose of has been taking a medication for a long time,
the medication and increase it in steps until the review whether they still need the medication.
recommended therapeutic dose is reached. ○○ Advise the person/family members to store the
○○ Always keep a close watch for side-effects. Most medication safely and away from children.
medications for mental health problems are ○○ Be aware of the common trade names and
quite safe. costs of medications in your area. Space is pro-
○○ Never exceed the maximum dose. vided for this information in Chapter 14.

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BOX 5.2 ANTIDEPRESSANTS

Antidepressant medications can be used for de- ○○ Avoid prescribing antidepressants to a person
pression and anxiety disorders which are persis- who has bipolar disorder (Box 5.6 for advice
tent, associated with severe symptoms such as on how to treat depression in bipolar disorder).
suicidal thoughts, and causing problems in the per- ○○ Take care before prescribing to a person who
son’s day-to-day life. They can also be used when has just been bereaved (10.4). Unless the
depression occurs along with other mental health person has severe depression, it is better to
problems such as alcohol problems or psychosis. provide support, counselling and ‘watch and
wait’ rather than prescribing an antidepressant.
Types of antidepressants
○○ Antidepressants are not addictive.
There are two main types of antidepressants which ○○ All antidepressants are equally good overall at
general health workers can use: treating depression in adults, but they differ in
○○ tricyclic antidepressants: these include their side-effect profiles, and individuals may
amitriptyline, clomipramine, dothiepin, respond differently to different types of antide-
doxepin, imipramine, lofepramine, nortriptyline pressant.
and trimipramine ○○ Side-effects are often short-lived and resolve by
○○ SSRI antidepressants: these include fluoxetine, themselves. However, if they persist, consider
citalopram, escitalopram, fluvoxamine, parox- swapping to another antidepressant with
etine and sertraline better-tolerated side-effects.
Other antidepressants: these include agomelatine, ○○ Most antidepressants take up to 2 to 4 weeks to
bupropion, duloxetine, mianserin, mirtazapine, start working. Thus, you should allow enough
reboxetine, trazodone, venlafaxine and vortioxetine. time to see an effect (4 to 6 weeks in working-
There is another type of antidepressant which age adults, 6 to 12 weeks in elderly people and
should only be prescribed by a mental health adolescents).
specialist: ○○ You must continue treatment at the recom-
○○ monoamine oxidase inhibitors (MAOIs): mended dose for at least 9 to 12 months after
isocarboxazid, phenelzine, tranylcypromine and the person has recovered to avoid relapse.
moclobemide. ○○ If the person has had more than one episode of
depression or relapses, then antidepressants
Points to remember when prescribing
could be continued for at least 2 years.
antidepressants
○○ Prescribing two antidepressants at the same
○○ It is important that you still give counselling
time can be dangerous and usually has no
and provide social interventions, even if you
therapeutic benefit.
are prescribing an antidepressant.
○○ When stopping antidepressants, do so gradual-
○○ Antidepressants may be associated with
ly – inform the person that they may experience
increased suicidal thoughts in adolescents.
symptoms while stopping. If this happens, slow
Monitor carefully.
down the pace of reducing the dosage.
○○ Do not prescribe antidepressants for children
under 12.
○○ For adolescents (aged 12 and above), do not
prescribe tricyclic antidepressants (they do
not work well in this age group). If counselling
has not helped the young person, consider
fluoxetine (not the other SSRI antidepressants).

Antipsychotic medications are used to treat Antipsychotics for psychosis

psychosis and mania and in the prevention of ○○ It can take several weeks to see the full effect of
episodes of bipolar disorder. When all other non- antipsychotic medications.
medication approaches fail, they may be used to ○○ For any episode of psychosis, treat for at least
help calm people who are aggressive in the context 1 year after recovery to prevent relapse; many
of delirium or dementia. people will need treatment for longer.
○○ Antipsychotic medications can also be given in
Types of antipsychotic medications
a LAI form (depot), which relieves the person
There are many types of antipsychotic medica-
from having to remember to take tablets daily
tions. A simple way of grouping them is into three
(5.7).
types:
○○ Antipsychotic medications can also be used to
○○ ‘typical’ antipsychotics, which include
treat mania or bipolar disorder (Box 5.6).
chlorpromazine, haloperidol, thioridazine,
flupentixol, pericyazine, perphenazine, Side-effects
pimozide, sulpiride, trifluoperazine and Make the initial choice of antipsychotic based on
zuclopenthixol the preferred side-effect profile for the person. If
○○ ‘atypical’ antipsychotics, which include side-effects are problematic, swap to a medication
olanzapine, risperidone, amisulpride, with a different side-effect profile.
aripiprazole, asenapine, iloperidone, lurasidone, Side-effects of typical antipsychotics
paliperidone, quetiapine, sertindole, ziprasidone ○○ The most common side-effects are tremor,
and clozapine rigidity and slow movement (‘pseudopar-
○○ long-acting injectable (LAI) antipsychotics kinsonism’). Anticholinergic medications
(depot), which include fluphenazine, (procyclidine, biperiden or benzhexol) may re-
aripiprazole, flupentixol, haloperidol, duce these side-effects. It is not recommended
paliperidone, olanzapine, pipotiazine, that you routinely prescribe these medications
risperidone and zuclopenthixol. alongside antipsychotics, but you may do so
The typical antipsychotic medications are just for first-episode psychosis in people who have
as effective as the atypical antipsychotics with difficulty in accessing the clinic if they have
one important exception: clozapine can lead to side-effects. This may help improve adherence.
improvements in people who have not got better ○○ Severe side-effects which require urgent action
with the other antipsychotics, but it is only used are described in Box 5.5. Another severe side-
when other treatments have failed, because of rare effect can develop slowly (usually after years of
but potentially life-threatening side-effects. Usually treatment): the person develops movements
clozapine should be prescribed by mental health that they cannot control (e.g. of the tongue or
specialists. mouth) – ‘tardive dyskinesia’. Anybody with this
problem should be seen by a specialist.
Points to remember when prescribing
○○ Antipsychotic medications can be started by a Side-effects of atypical antipsychotics
general health worker. This will help to make ○○ Monitor blood glucose and lipids, blood pres-
sure that people get timely treatment, rather sure and weight regularly, as atypical antipsy-
than delaying until they can see a mental chotics are associated with increased risk of de-
health specialist. veloping diabetes and cardiovascular disease.
○○ If possible, the person should be reviewed by Give the person advice about healthy diet (low
a specialist after starting treatment and then fat, low sugar) and lifestyle (e.g. exercise).
periodically (e.g. at least once a year), while the
general health worker continues to prescribe
and provide ongoing care and monitoring.

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BOX 5.4 SIDE-EFFECTS OF ANTIPSYCHOTICS
The side effects of antipsychotics:

a. Tremors (trembling movements,

especially in the hands).
b. Stiffness (the person may feel stiff
all over, which can affect movements,
e.g. walking).
c. Dystonia (sudden movement of
parts of the body, such as the head).
a. b. c. d.
d. Akathisia (feeling very restless and
being unable to sit still).

The steps to take to stop or reduce

these side-effects:

e. Reduce the amount of medicine.

f. Try a different medicine to reduce
the side-effect.
g. Change to another medicine for the
mental disorder.

e. f. g.

BOX 5.5 SEVERE SIDE-EFFECTS OF ANTIPSYCHOTICS REQUIRING URGENT ACTION

1. Sudden muscle spasm of the neck, tongue or ○○ Reduce dose or swap to an atypical antipsy-
eyes (‘dystonia’). This is more common with chotic medication (olanzapine).
typical antipsychotic medications, especially ○○ Consider propranolol up to 30 mg to 80 mg
haloperidol and trifluoperazine, where it can per day (starting at 10 mg tds).
affect one in ten people. It can be painful and 3. Fever, stiffness, fluctuating blood pressure and
frightening for the person. confusion (‘neuroleptic malignant syndrome’).
○○ Treat with benzhexol 4 mg or biperiden This rare reaction to antipsychotic medications
2 mg. Depending on severity, use p.o., i.m. or is more likely when starting medications for the
i.v. first time or when using typical antipsychotic
○○ If possible, swap to a lower potency typical medications such as haloperidol. This is a
antipsychotic (e.g. chlorpromazine) or an medical emergency.
atypical antipsychotic medication. ○○ Give intravenous fluids and resuscitation.
2. Severe inner restlessness causing distress ○○ Stop the antipsychotic medication.
(‘akathisia’). Make sure the restlessness is not
○○ Refer for urgent hospital treatment.
agitation due to psychotic or depressive symp-
toms. Screen for suicidal ideas or plans.
i.m., intramuscular; i.v., intravenous; p.o., oral; tds, three times per day.

Mood stabiliser medications can be used to treat Points to remember when prescribing mood
manic episodes and also to reduce the risk of stabiliser medications
relapse (with depression or mania) in a person who ○○ Mood stabilisers can be started by a general
has bipolar disorder. health worker. If possible, the person should
also be reviewed by a specialist as soon as
For prevention of relapse in bipolar disorder
possible to confirm that a mood stabiliser is
○○ First-line treatments include mood stabiliser
needed, and then periodically after that (e.g. at
medications (lithium and valproate) and/or
least once per year), while the general health
atypical antipsychotic medications (olanzapine,
worker continues to prescribe and provide
risperidone (depot or tablet), quetiapine,
ongoing care and monitoring.
aripiprazole, paliperidone extended release).
○○ Lithium must not be used unless laboratory
○○ Second-line treatments include: the mood
and clinical monitoring is available.
stabiliser carbamazepine and/or typical
○○ All mood stabilisers should be avoided in
antipsychotic medications.
women who are pregnant or who are planning
For treatment of mania to have a baby. The risk to an unborn baby is
○○ Typical antipsychotics (e.g. haloperidol or highest with valproate and so this medication
chlorpromazine) or atypical antipsychotics should not be prescribed to a woman of child-
(e.g. olanzapine or risperidone) or mood bearing potential unless recommended by a
stabilisers (e.g. lithium or valproate). specialist.
For treatment of bipolar depression ○○ Check for cardiovascular, renal or he-
○○ If the person is already taking a mood stabiliser, patic disease before starting valproate or
start by adjusting the dose. There is better carbamazepine. Refer to a specialist if these
evidence for lithium. conditions are present.
○○ Consider counselling. ○○ Mood stabilisers have a number of important
○○ Quetiapine (an atypical antipsychotic) can be interactions with other medications (Chapter
used as a sole treatment for depression in peo- 14). Make sure that the person is adequately
ple with bipolar disorder. informed.
○○ If none of the above is available or effective, ○○ When switching from one mood stabiliser to
consult with a specialist. another, start the new mood stabiliser while
○○ Consider starting an antidepressant, but the person continues taking the old mood
the person must also be prescribed a mood stabiliser. Treat with both mood stabilisers for
stabiliser or antipsychotic medication. Monitor at least 2 weeks before slowly stopping the old
carefully and stop the antidepressant straight mood stabiliser.
away if the person develops high mood. Mood stabilisers need to be taken for long periods
(a minimum of 2 years). If possible, consult with a
specialist before stopping and be especially cau-
tious if the person has a history of severe episodes
or frequent relapses. Slowly reduce and stop over
a period of at least a month. Sudden stopping of a
mood stabiliser can trigger a relapse.

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BOX 5.7 BENZODIAZEPINES

Benzodiazepines are sometimes called ‘anti- Points to remember when prescribing

anxiety’ medications or ‘sleeping pills’, although benzodiazepines
they are not a good long-term treatment for anxiety ○○ Avoid with alcohol.
or sleep problems, because it is easy to become ○○ Avoid in pregnancy.
dependent on them. ○○ Advise people to take care if driving and operat-
Benzodiazepines have a variety of uses: ing heavy machinery until they get used to the
○○ short-term treatment of acute and severe sleep medication.
problems, anxiety or distress ○○ Take care in the elderly as they may cause falls.
○○ behavioural disturbance in mania or psychosis ○○ Avoid in people with breathing problems.
(but not recommended for behavioural distur- Do not prescribe benzodiazepines for more than
bance in people with delirium or dementia) 2 to 3 weeks because the person can easily become
○○ managing detoxification for people who are dependent on them.
physically dependent on alcohol
○○ emergency management of seizures.
Types of benzodiazepines
The following are common preparations of
benzodiazepines: diazepam, lorazepam,
nitrazepam, clonazepam, alprazolam and
oxazepam. They differ in their duration of action.

5.3 What other medications 5.3.2 Clozapine

do I need to know about? Clozapine is an ‘atypical’ antipsychotic medica-
tion which is prescribed for people who have not
There are some medications used in mental responded to other antipsychotic medications.
health care which should only be started by spe- Clozapine has to be prescribed with guidance
cialists and which need ongoing monitoring by from specialists because of potentially life-threat-
specialists. Nonetheless, the general health work- ening side-effects. You should know about the
er needs to have some knowledge about these following.
medications and their side-effects in case people
●● People who take clozapine need to have regu-
taking them require care in the general health care
lar blood tests to check their white cell count.
setting (Chapter 14 for details of these medica-
If the white cell count is low, speak with a spe-
tions and their side-effects).
cialist immediately. The medication may have
to be stopped straight away to prevent fatal
5.3.1 Methylphenidate bone marrow suppression.
Methylphenidate is a stimulant medication that ●● Clozapine can also cause constipation which
is used to treat children who ADHD (11.4). is so severe that it can even lead to bowel ob-
The medication is only prescribed to children struction and death. If you see a person who is
aged 6 years and above. Monitor children taking taking clozapine, always ask them about their
methylphenidate for growth retardation, low bowel habit and advise them to eat plenty of
weight and sleep problems. Refer for specialist fruit and vegetables. Take any complaint of
review if these problems develop. constipation very seriously.
●● More rarely, clozapine can cause inflamma-
tion of the heart (‘myocarditis’ – signs include
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BOX 5.8 ANTIEPILEPTIC MEDICATIONS

Antiepileptic medications are used to prevent ○○ Be cautious about interactions between

seizures in people who have epilepsy. Some anti antiepileptic medications and any other medi-
epileptic medications are also effective as mood cations that the person is taking.
stabiliser medications. ○○ If an antiepileptic is not effective at the
maximum dose, carefully swap over to another
Types of antiepileptic medications
antiepileptic: start the new medication at a low
○○ First-line antiepileptic medications for
dose while the person is still taking the previ-
convulsive seizures include phenobarbitone,
ous medication, slowly increase the dose until
phenytoin, carbamazepine and valproate.
it is effective (or the maximum dose). Only then
○○ For people with HIV, the following newer-
reduce the first medication slowly and stop.
generation antiepileptic medications may
○○ If the person continues to have seizures,
be preferred, if available and affordable:
refer for specialist advice. The specialist may
levetiracetam, lacosamide, topiramate,
combine antiepileptic medications and/or try
gabapentin and pregabalin.
newer-generation medications: lamotrigine,
Points to remember when prescribing levetiracetam and topiramate.
antiepileptic medications ○○ Inform the person about the delay before the
○○ If the woman is pregnant: avoid valproate. medication works and the risk of having a
○○ In a woman of child-bearing age, do not use seizure if they stop the medication suddenly or
valproate unless there is a good reason and miss doses.
in consultation with a specialist. If valproate
Consider stopping antiepileptic medications if the
is prescribed, prescribe folate 5 mg once daily
person has been seizure-free for 2 years. However,
(even if the woman has no plan to become
long-term treatment might be needed if the sei-
pregnant) and ensure that the woman is
zures were difficult to control, if previous attempts
using an effective contraception (the oral
to wean the person off led to renewed seizures,
contraceptive pill may not work so well with
or if seizures occurred because of a head injury
some antiepileptic medications).
or infection of the brain. If the medication is to be
○○ If the person has an intellectual disability, try to
reduced, do this slowly, over a period of at least 2
avoid phenobarbitone and phenytoin.
months.

fever and racing pulse) or clots in the lungs basis to reduce the harmful use of opioid (e.g. in-
(breathing problems). Refer for urgent medi- jecting and illegal activities). Methadone comes
cal treatment. in a syrup form. Misuse of methadone can be a
●● Other more common but less dangerous side- problem, so it is necessary to observe the person
effects of clozapine include drooling of saliva drinking the methadone (on a daily basis) in the
at night (advise the person to put a towel over clinic or their homes. If people use street opiates
their pillow), sedation and weight gain. at the same time as methadone then they can eas-
ily overdose. When treating overdose, don’t forget
that the effects of methadone take time to wear off
5.3.3 Medications to manage (flow chart 6.5).
opioid dependence
Methadone Buprenorphine
Buprenorphine is an opioid substitute used for
Methadone is a long-acting opioid substitute that
both withdrawal and as a long-term substitu-
can be used to treat acute symptoms of opioid (e.g.
tion therapy. It is a tablet which is placed under
heroin) withdrawal or can be taken on a long-term
the tongue. It is less dangerous than methadone.
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5.4 What if the person
doesn’t take the medication
as prescribed?
The most important thing a health worker can
do to support a person to take medications is to
build a trusting relationship with the person and
to educate them about their illness and the medi-
cation. Some important points are listed below.
●● Explain that the symptoms are caused by an
illness and that, just as with physical disor-
ders, medications can be of help.
●● Explain that the medications need to be taken
However, it is still possible for people to overdose for a while after the person feels better so that
accidentally if they use street opioids at the same the problem won’t return.
time as buprenorphine.
●● Explain that many medications for mental
health problems take some time to act, so pa-
Clonidine, lofexidine tience is needed. The most common example
Clonidine or lofexidine can be used to reduce the is antidepressants, which usually require at
symptoms of opiate withdrawal. They can cause least 3 weeks before they start to work.
light-headedness and sedation. Blood pressure ●● Take steps to minimise the risk of side-effects
monitoring is required. by starting with a small dose and gradually in-
creasing the dose to the required level.
5.3.4 Medications to prevent ●● See the person at least once every 2 weeks (or
relapse of alcohol dependence more often if possible) until they show signs of
recovery. Keep encouraging the person to per-
●● Acamprosate helps to reduce craving for al- severe with treatment.
cohol. It is taken for 12 months after a person ●● If side-effects occur, follow the steps outlined
stops drinking alcohol. Rarely, people who in Box 5.4.
take acamprosate can get a skin reaction
●● Involve the family (with the person’s permis-
which needs urgent medical review.
sion) in encouraging the person to take the
●● Naltrexone is another medication that helps medications.
to reduce cravings for alcohol. It is taken for
●● Try strategies for improving motivation
12 months after the person has stopped drink-
(5.17).
ing. If a person taking naltrexone needs pain
relief for some reason, do not give them an
opioid type of pain relief (e.g. tramadol, pethi-
dine, morphine) because it will not work –
naltrexone blocks these kinds of painkillers.
●● Disulfiram helps to deter a person from drink-
ing alcohol by causing a very unpleasant re-
action if it is taken with alcohol. The reaction
can be dangerous. The person experiences
flushing of the face, nausea, vomiting and
fainting. Even if the person does not drink,
disulfiram can cause serious side-effects, in-
cluding psychosis. Some people refuse medicines.
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●● Stick to simple dosage schedules; many psychi- 4. Wrong diagnosis. Reconsider your diagnosis
atric medications can be given once a day (e.g. if the person has been taking the full recom-
most antipsychotics and antidepressants). mended dose for enough time of at least two
●● Monitor whether the person is taking medi- different types of medication for a mental
cations as prescribed; for example, you can health problem and shows no sign at all of
check to see whether the expected number of recovery.
pills has been taken by counting the number 5. Coexisting substance use. If a person contin-
of pills left over in the medication bottle/strip. ues to use substances (e.g. alcohol) this may
reduce the benefits of the medication.
Families may try to give the person medica-
tion secretly, for example, crushed up in food. It 6. Ongoing social stressors. Difficult social cir-
is important to be sympathetic to the family and cumstances may get in the way of a person re-
their dilemma, but also to explain that there are covering from a mental disorder.
potentially bad consequences of deceiving the If, despite your efforts to identify and address
person this way: the above factors, the person still fails to improve,
●● it does not respect the person’s right to know you may need to consider a referral to a specialist.
what is going on with their treatment If that is not possible, try swapping to a different
●● the person may experience dangerous side- class of medication (e.g. from typical to atypical
effects but not realise what is going on antipsychotic medication, or from tricyclic to SSRI
antidepressants). In general, do not use two med-
●● if the person finds out then they will lose their
ications of the same type (e.g. two antidepres-
trust in family members
sants or two antipsychotic medications) at the
●● if the person doesn’t find out and gets better same time apart from when swapping from one
then they will not understand that medication to another.
helped them to recover.
Instead, try all of the suggestions to support
the person to take the medication. If these fail and 5.6 What if there are side-effects?
the person remains unwell or is at risk of harming
First, make sure that the problem reported by the
themselves or others, consider injectable medica-
person is really a side-effect. To be a side-effect,
tion (5.7) or admission to hospital.
the symptom should have started only after the
medication was started. Often, the symptoms
5.5 What if the person were present even before the medications were
started and are due to the mental health prob-
does not improve? lem. The person may misinterpret symptoms as
Consider the following reasons. side-effects. In such cases, reassure the person by
pointing this out. Remember the common side-
1. Poor adherence. Poor adherence with medi-
effects of medications for mental health prob-
cations may occur because the person feels
lems; if a complaint does not fit with these side-
better and decides that there is no more need
effects, consider other reasons for them.
for medications. Another reason is because the
Once you are sure that the person does have
person is worried about becoming addicted to
side-effects, you have the following options.
the medications. Side-effects can also make a
person stop (5.6). ●● Are the side-effects tolerable? Most medi-
cations produce some side-effects, but most
2. Not enough medication. If a medication is not
are minor and temporary. Ask the person how
prescribed at the right dose, it may not work.
much distress the side-effect causes them.
3. Medications not taken for long enough. Often people will say that they can tolerate the
Most medications take at least a few weeks at symptoms, provided the benefit of the medi-
the recommended dose before a positive re- cations will also be evident in a short time.
sponse is obtained.
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BOX 5.9 LONG-ACTING INJECTABLE ANTIPSYCHOTIC MEDICATIONS (‘DEPOT’)

Long-acting injectable antipsychotic medication Points to remember when prescribing long-

is injected into muscle (usually the buttock) and acting injectable antipsychotic medication:
is then released slowly into the bloodstream. The ○○ Never give a long-acting injection to a person
injection has to be given every few weeks (usually who has not previously been prescribed oral
once per month). antipsychotic medication.
○○ Ideally, consult with a mental health specialist
Types of long-acting injectable antipsychotic
before initiating long-acting injections.
medication
○○ Always start with a test dose in case the
○○ The common examples of long-acting inject-
person has a bad reaction to the medication
able antipsychotic medications are usually
or to the oil preparation (e.g. 12.5 mg i.m. for
‘typical’ antipsychotics. The most commonly
fluphenazine) – wait for 5 to 7 days.
encountered medications are: fluphenazine
○○ Give the injections as far apart as possible (up
decanoate, flupentixol decanoate, haloperidol
to the maximum licensed interval).
decanoate, pipothiazine palmitate,
○○ Remember that a depot takes time to work.
zuclopenthixol decanoate.
Wait 2 to 3 months before increasing the dose
○○ New long-acting injectable antipsychotics
and to evaluate the effect of any dose increase.
are increasingly becoming available. There
○○ Avoid prescribing depot to pregnant women.
is no evidence that they work better, but the
side-effects may be more acceptable to the
person. These include: injectable aripiprazole,
olanzapine pamoate, paliperidone palmitate
and risperidone microspheres.

a. b.

a. Give the injection in the upper arm or buttocks,

into the muscle. If this is the first time the patient is
receiving the medicine, always give a test dose of a
quarter of the full dose you want to give.
b. Clean the injection site.
c. If there is no allergic reaction after 1 h, give the
rest of the dose.

i.m., intramuscular.

5.7 When are injections needed?

Injections have a very limited role in the treatment
of mental health problems. Rarely, injections may
be necessary as an emergency intervention if
somebody is violent or agitated (flow chart 6.1). Some health workers feel that ‘proper’ health care
Long-acting injectable ‘depot’ medications (Box should involve something more than counselling,
5.9) can be helpful in reducing the need for hos- or ‘just talking’. Many doubt that counselling can
pitalis admission. They are most commonly used even be considered a treatment at all. This is why
for people with chronic psychosis who refuse to many health workers give medications every time
take oral antipsychotic medications but keep ex- a person comes to the clinic. The person, too, of-
periencing relapse when they are not taking med- ten expects medications. Some people may even
ication. They are also sometimes used to prevent tell the health worker that they need an injection!
relapse in bipolar disorder when mood stabilisers It is important to clear up a few doubts and myths
are not available. Some people prefer long-act- about counselling.
ing injections because they are more convenient The term ‘counselling’ is used in different ways
than daily medications. Besides these situations, and can mean different things to different people.
it is advisable not to use injections to treat men- Thus, a caring person with no formal training
tal health problems. Avoid using unnecessary could ‘counsel’ friends who are distressed. In this

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kind of counselling, the person is often follow- It is important for the health worker to avoid the
ing their own instincts and compassion. While mistake of saying ‘there is nothing wrong with
this approach has its own strengths, counselling you’. Most people will be upset with this sort of
has some important differences from talking to a remark. After all, there is something wrong with
friend (Table 5.1). them. The person does not feel well: that is the
In this manual, we use the term counselling reason that they have come to you for help. Many
to refer to all forms of psychological treatment. people are worried that they are suffering from
Counselling involves a set of skills and approach- a serious physical illness. This makes them even
es which can be learned by any health worker who more tense and unhappy. Thus, the health worker
has an interest and an open mind. should reassure the person that they do under-
stand that the person is suffering from a number
of distressing symptoms, but that these symp-
5.9 General principles of toms will not result in a life-threatening or dan-
gerous illness. The health worker should reassure
counselling
the person that such symptoms are common and
that the cause and treatment of the problem will
5.9.1 Who is counselling for? be explained to the person.
In the next section we will discuss some basic
skills for counselling someone, such as giving Provide an explanation
hope. These are non-specific counselling skills
Explaining the nature of the problem helps to
that can be useful for every person you work with
make the person aware of the reasons for their
and will greatly improve the quality of the care
symptoms and to clear any doubts in their minds.
you give and increase the person’s satisfaction.
First, explain the symptoms in general terms.
Some other types of counselling strategies,
Taking the example of Lucy in case 1.1 (p. 7),
such as ‘problem-solving’, ‘thinking healthy’, ‘get-
you could explain her symptoms in the following
ting active’, ‘improving motivation’ and ‘address-
manner:
ing relationship issues’, have been shown to help
people with particular types of mental health ‘After childbirth, many women feel pain and
problems. These are called ‘specific’ counselling discomfort now
methods.
and then. In fact,
Counselling is not in competition with medi-
it is quite
cations. For some people, counselling may be
sufficient in itself, but others may also need common to feel
medications. tired and have
sleep problems.
Some women
5.9.2 Basic counselling for all may also become sad and lose interest in their
people with mental health babies.’
problems You can then move on to focusing on the spe-
We will now describe some simple basic counsel- cific symptoms the person has told you about.
ling skills which should be used for any person You can also put some further meaning on the na-
with a mental health problem. ture of the symptoms if you know how they start-
ed. For example, you could say to Rita, the lady in
Give reassurance case 1.2 (p. 7):
Often, people suffering from mental health prob- ‘When someone is feeling stressed, upset or
lems are dismissed by health workers as being unhappy about things, they often experience
‘mental’ or ‘neurotic’. These remarks suggest that sleep problems, aches and pains, and worries.
the person does not have a ‘real’ health problem.

You have been feeling tired and unhappy in the Or, consider Michael in case 1.4 (pp. 9–10):
past month. This is because you have been
under stress ‘Your complaints of sleep problems, sickness in
ever since your the mornings and burning pain in the stomach
husband died are all related to
and your your drinking too
children have much. Alcohol is
left the village. highly addictive so
You have that now you are
become depressed. This is not because you are feeling like drinking
lazy or are a “mental case”. This is a common all the time. This
problem which affects many people in our is why you wake
community. All the problems you described are up feeling sick: it
because of this emotional illness.’ is part of the withdrawal from alcohol which
makes you sick. This is why you feel better
Or, taking the example of Ravi in case 1.3 when you have a drink in the morning. You
(pp. 7–8): have become depressed and unhappy because
you feel you have lost control of your drinking
‘Your symptoms of difficulty breathing, dizzi-
and because you are feeling sick and unwell. If
ness, heart beating fast and fear are because
you stop drinking, these problems will go away
of attacks of anxiety. These are quite common
and you will feel much better.’
problems and are not signs of a dangerous
illness. In fact, they occur because you were It is more challenging to explain to the person
tense or worried about something. When you what may be happening to them when they do
are tense, this makes you breathe faster than not think they have a mental disorder, for exam-
normal. When you breathe faster, this pro- ple, in some people with psychosis, but it is still
duces changes in your body which make your important to help the person understand your
heart beat fast and make you feel scared that perspective without being confrontational. One
something terrible may happen. Actually, if you approach could be:
had controlled your breathing, you could have ‘You told me that someone is poisoning your
stopped the attack quickly. You are probably food and that people are planning to harm
suffering these attacks of anxiety because of you. I understand that this is causing you a lot
the shock of the accident in which your friend of distress and I would like to help you. In my
died. This can happen to anyone.’ experience, this can happen because of a ‘trick

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of the brain’ which can make things seem real identify somebody known to the person who can
when they are not actually happening. I can’t help them to solve the problem, or you may know
prove this to you but perhaps you could try the of organisations who can help (e.g. for women af-
treatment I am suggesting? I think it will help fected by domestic violence). Even when that is
you.’ not possible, just allowing people to talk about
the difficulties they are facing and listening sym-
It is important that you also ask the person pathetically can be beneficial. Try to ask the per-
what they think has caused the illness and what son about the problems each time they come to
treatment they think might help. Understanding visit. This will show the person that you are listen-
the person’s views can help the health worker plan ing and that you are concerned.
treatment much better. For example, consider a Giving a person direct advice about how to
person who feels that their illness was caused by solve their problems may help in the short term,
bad spirits. The health worker could suggest that, but it doesn’t help them to learn better ways of
while the person may consult the priest for spir- coping with their difficulties (which would be bet-
itual guidance, their symptoms were also caused ter in the longer term). Therefore, if you have the
by stress and for this the person should take treat- time, try to provide more in-depth support with a
ment as directed by the health worker. Do not ‘problem-solving’ strategy (5.11).
dismiss the person’s views, even if they appear
non-scientific. By listening to and appreciating Review, encourage and support
the person’s understanding of the problem, you
For all counselling approaches, it is important to
will achieve a better outcome. After you give your
review the person’s progress, and provide encour-
explanation, always give the person a chance to
agement and support. Give plenty of encourage-
clarify doubts or concerns.
ment to help the person gain confidence that they
can succeed. The person may have a week when
Give hope
they are not able to make as much progress.
Make sure the person understands that their Explain that this is expected, but not to give up.
problem is likely to get better with treatment. For When assessing progress, be specific. It is not
example, in a person diagnosed as having depres- helpful to ask ‘How did you get on?’ and accept a
sion you might say: shrug of the shoulder or a vague answer like ‘OK’.
You should ask for details of exactly how the per-
‘Even though right now you feel as if nothing son did.
can ever help you, in my experience, people
●● What did you do towards achieving what we
with this kind of problem can, and do, get well agreed in the last session?
again.’
●● Was it easy or difficult?
Don’t underestimate the influence that health ●● How did it affect your feelings and emotions?
workers can have in giving people hope for the ●● If the task was done, congratulate the person
future. Indeed, feeling hopeful can increase a per- and ask whether they want to practise the
son’s motivation to follow through with the advice same task again or move on to another goal.
you give and to enhance the chances of healing
●● If the task was not done, what went wrong?
themself. At the same time, you should be realis-
How will the person address the difficulties
tic and honest. A person with long-standing psy-
which got in the way of carrying out what was
chosis may not recover fully; however, they can
agreed before?
almost certainly be helped. Knowing that possi-
bility can give a person hope.
5.9.3 What are the different ways to
Identify and address current problems deliver counselling?
Social problems commonly contribute to mental Counselling strategies can be delivered in various
health problems. Sometimes you may be able to different ways, including individually or in groups
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(Table 5.2), face-to-face, over the internet or over and then the person follows this advice or strat-
the telephone. People can also teach themselves egy by themselves. The big advantages of the self-
counselling strategies with the help of internet or help approach are: the person can easily access
book resources. There are some pros and cons to the materials at their own convenience and with
these different approaches. low cost, stigma does not get in the way, and the
person will always have this resource available to
Individual v. group counselling them to keep well and deal with any future dif-
ficulties. However, self-help on its own may not
be enough for some people. Combining self-help
with some face-to-face or telephone-based advice
from the health worker can make self-help work
better. Familiarise yourself with web-based and
book-based self-help materials to ensure they are
based on sound evidence and consistent with the
advice given in this manual. Also consider prepar-
ing self-help brochures and making them avail-
able in the place where you work.
There does not appear to be a difference in how
well individual counselling works compared with
group counselling. Therefore, choose the ap- 5.9.4 How much counselling is
proach that best suits the setting within which needed?
you work.
The counselling strategies discussed in this man-
ual are intended to be time-limited. However, the
Self-help or face-to-face
exact number and duration of sessions should be
Self-help is when the person accesses materials tailored to the needs of the person as much as
(e.g. books, leaflets or websites) which provide possible. It is useful to think of counselling as hav-
simple advice or a structured counselling strategy, ing a beginning, a middle and an end.

TABLE 5.2 DIFFERENCES BETWEEN INDIVIDUAL AND GROUP COUNSELLING

Individual Group
More flexible timing Time has to be convenient for the whole group
Need to wait until enough people are recruited
Can be done in small consulting room Needs adequately sized room or private area
May be more feasible for clinic-based counselling May be more feasible for community-based
counselling
Content more tailored to the individual Content depends on the needs of the group
Learning depends on the individual and the Learning can be faster in a group as the patient is
patient–health worker relationship exposed to more real-life examples
Helps the patient to make connections with
people who have similar problems
May be more acceptable because not required to May be more acceptable because the problem is
talk about sensitive issues in front of others not focused on the individual patient
Usually more resource-intensive: one health Can be more efficient – one health worker can
worker to one patient provide treatment for a number of patients
Health worker only needs skills in the counselling Health worker needs skills in handling groups
strategy

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The ‘beginning’ is when you: can commit to attending. Ideally, a minimum of 3
●● assess the person’s main difficulties and de- sessions are recommended, so that there is a be-
cide, together with the person, which of these ginning, middle and end; 6–8 sessions are usually
difficulties to address needed to effectively complete the treatment.
It is also helpful to be clear with the person
●● decide which counselling strategy might help
about the expected duration of each session and
●● develop a trusting relationship with the person their frequency. Aim for a minimum duration of
●● explain the specific counselling approach to 20 min (on average, you will need about 30 min)
the person and how it is expected to help them and not longer than 1 h. The frequency should
●● build motivation in the person to be an active usually be every 1 to 2 weeks. For people with psy-
participant in the counselling. chosis or bipolar disorder, counselling needs to be
less frequent (e.g. monthly) but delivered over a
The ‘middle’ is when you: longer period (e.g. 1 to 2 years).
●● work with the person to put the specific strat-
egy into practice
5.9.5 Challenges
●● review progress and provide encouragement
and support Some potential issues that can arise during coun-
selling are described in Table 5.3, with suggested
●● consider alternative strategies if it is not work-
approaches. Good supervision, preferably from a
ing or new problems arise which require a dif-
colleague with experience and expertise in coun-
ferent strategy.
selling, can help with most of the problems de-
The ‘end’ is when you: scribed. If it is not possible for you to have formal
●● work on how the person can stay well by con- supervision, try to develop informal links with
tinuing to use the strategies that they have specialists working in your area so that you can
learned consult them when you are uncertain about what
to do. Discussing with colleagues, even if they are
●● prepare for the ending of the relationship that
not experts, can also be helpful. Try to make sure
has built up between you and the person.
that case discussions happen regularly (e.g. once
Some people may also require ‘booster’ ses- a month).
sions from time to time even after they have
completed a course of counselling. When you 5.9.6 Counselling strategies for
start using a counselling strategy with a person,
make sure that you explain that more than one specific symptoms and problems
session is required to really get the benefit. Try to Counselling will be more effective if it is sensi-
agree on the number of sessions that the person tive to the main problems and symptoms of the

Why don’t you just

get over him? Don’t you want to
get well?

a. b.

Challenges in counselling:
a. when the person gets distressed or expresses suicidal ideas
b. when the health worker gets irritated with the person.
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TABLE 5.3 ISSUES THAT MAY ARISE DURING COUNSELLING AND HOW TO APPROACH THEM
Issue Approach
Person gets Sometimes people get worse before they get better.
distressed If the person is distressed, be supportive and keep calm. Allow them to express their
and/or distress. If the distress does not subside, suggest that you stop the session, assess for
suicidal suicide risk or risk of harm to others (flow chart 6.3), try to arrange for a friend or
family member to come to the health facility to collect the person, and arrange for a
short follow-up appointment.
Person There may be a good reason for not attending, but sometimes this can be a clue that
misses lots of the person is not sure about the usefulness of counselling or is not benefitting from the
sessions or counselling.
comes at the Go back to the ‘beginning’ phase and check that you are focusing on the main problem.
wrong time Also check that counselling is acceptable to the person. Make sure the person is well
informed about the rationale for using that approach.
Session This could happen because of difficulties you have with time management. It may
overruns also be because the person is reluctant to end the session (e.g. they may keep telling
you new things). At the beginning of each session, be clear about the time available.
Remind the patient 5 min before the end that you will be ending shortly. If they start
talking about a new problem, explain that you will tackle that problem the next time,
unless you are concerned about the person’s suicide risk or risk to others (7.6).
Person does Planning ahead can help. Be clear about the number of sessions from the beginning
not want and keep reminding the person about the number of sessions remaining. Focus the last
to stop the session on how the person can stay well to give them confidence. Offer the possibil-
course of ity of booster sessions if they find that they are not managing well, but stress that it is
counselling important for the person to try out the approach on their own.
Person and The counselling relationship can be close – the person may open up about areas of
counsel- their life which are usually private and may feel great gratitude towards the counsel-
lor start an lor. The counsellor may feel as if they are very important to the person. It is within this
intimate context that an intimate relationship may occur. Such a relationship is never the right
relationship thing. It is vital that you discuss any feelings you may have towards a person you care
for with your colleagues or supervisor before you act on them. Stop the counselling but
make sure that the person can continue to receive treatment and does not feel they are
responsible for what has happened.
Counsellor Sometimes you might find yourself getting irritated by a person and their behaviour.
gets irritated Try to discuss your irritation in supervision or with colleagues and find ways to be more
or angry with understanding of the person (and why they behave in a way that annoys you). Never
the person express your anger or irritation to the person. If you cannot control your irritation, stop
the counselling session but make sure that the person can continue to receive treat-
ment.
People People who you care for may approach you when you are socialising, phone you or
contacting even come to your home. This can be exhausting and irritating. Instead of accepting
you when you the informal consultation, explain politely to the person that you will be happy to see
are off-duty them at the health facility. The only exception to this is if it seems to be an emergency,
in which case do what is necessary to help the person to access emergency health
services.
Getting over- Some people get ‘under our skin’. We can’t stop thinking about their problems and
involved their distress, even when we are away from work. If you find yourself taking your work
home, speak with your supervisor or colleagues about the case and share the worry.
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person. In Table 5.4 we list various counselling In the next section we will describe how to deliver
methods alongside the specific symptoms and these specific counselling strategies in detail.
problems which they can address most effectively.

TABLE 5.4 COUNSELLING STRATEGIES AND PROBLEMS THEY MAY ADDRESS

Specific counselling When the strategy might be helpful
strategy
Psychological first For the person who has been raped (10.3), who is overwhelmed by a per-
aid sonal crisis, who reacts severely to a traumatic event (10.1) or who has been
bereaved (10.4).
Problem-solving When the person is overwhelmed by many problems. This could occur in any
person with a mental health problem, but especially so in people with common
mental disorders (1.4.1).
Relaxation exercises For any mental health problem which leads to a person feeling stressed, tense or
anxious.
Getting active For any mental health problem which has led to the person reducing their activ-
ity level and withdrawing from social life.
Thinking healthy For the person who has negative thoughts about themselves or their life and is
thinking too much.
Improving For any person who has difficulties with relationships, either as a cause or con-
relationships sequence of their mental health problems.
Controlling anger For the person who is irritable or angry and for the partner of the person who is
being beaten or abused.
Improving For anyone who needs to make a lifestyle change (for example, diet, physical
motivation exercise, use of substances) and for those who have difficulty taking medicines.

5.10 Psychological first aid provide first aid for accidents that lead to physical
injury, health workers can also provide ‘psycho-
logical first aid’ to people who have experienced
a crisis. The idea behind psychological first aid is
that sometimes people need brief support after
a serious crisis in order to help them to find their
own ways to cope with what has happened. Over
time most people will recover.

5.10.1 When to use psychological

A crisis is a situation in which a person feels com-
pletely overwhelmed or defeated by the problems first aid
they are facing. What one person may see as a cri- Psychological first aid is useful when there has
sis is not the same as how another person might been a serious crisis event which has resulted in
see it. Thus, the definition of a crisis is based on a person becoming very distressed, for example:
the person’s view of their situation, and on how
●● a bad accident
the situation has affected the person’s ability to
cope with the problems. In the same way that we ●● a violent assault (includes sexual assault)

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‘People with difficulties like yours can be BOX 5.10 THE KINDS OF LIFE PROBLEMS
helped by looking at the way in which they han- WHICH CAN AFFECT MENTAL HEALTH
dle stress and deal with problems. I would like
to discuss some of your problems and think of ○○ Relationship problems with a spouse/partner,
such as lack of communication, arguments,
ways in which you can try and deal with them.’
violence in the family and poor sex life
○○ Relationship problems with others, such as
Step 2. Define the problems in-laws, children, relatives or friends
○○ Employment problems, such as not having a
Ask the person a question about which problems
job or feeling overworked
they have been experiencing in their life. It is a
○○ Financial problems, such as not having
good general principle to go from relatively ‘safe’
enough money, being in debt
information (e.g. about work) before tackling the
○○ Housing problems, such as living in a noisy or
most personal problems (e.g. those about sex).
violent neighbourhood
Remember to ask questions about personal prob-
○○ Social isolation, such as being alone in a new
lems – they are often the most upsetting and im-
place or not having friends
portant. A useful method of asking personal ques-
tions is to say something like: ○○ Physical health problems, especially when
painful and long-standing
‘Sometimes when people feel unhappy they ○○ Sexual problems, such as loss of interest in
have less interest in sex; has this happened to sex
you?’ ○○ Bereavement or losing someone you love
○○ Legal problems
‘It is quite common for people who are worried
to drink more alcohol than usual; how much
are you drinking?’ Step 4. Select a problem
and choose a goal
This method of introducing a personal subject
demonstrates you are not going to be shocked if The next step involves selecting a specific prob-
they say ‘yes’ (Box 5.10). lem worth tackling and choosing the goals the
person would like to set. Here are some hints on
Step 3. Summarise the problems how to select an appropriate problem.
●● Ask the person to make a list of all their prob-
Once you have collected information about the
lems. Identify those which are of most concern
person’s problems, summarise the key problems
to the person.
by saying something like this:
●● Target a problem which has a potential so-
‘You have told me that your baby’s arrival has lution in the short term. For example, if the
changed a lot of things in your life. You are not problem is related to a long-standing difficulty
working now, you’re up half the night and you in the relationship with the spouse, it is not
see less of your friends, and it has affected your a good problem to tackle first. On the other
relationship with your husband.’ hand, a recent problem in coping at work or
feeling socially isolated may be a useful one to
Doing this serves several functions. It con- start with.
firms to the person that you have been listening. ●● Once a problem area is selected, confirm with
It shows that there is some structure to the prob- the person that this is indeed the problem
lems. It is also a useful means of getting more per- they wish to tackle during therapy.
sonal information.
Remember that the aim of the treatment is to
teach the person problem-solving skills, not to
solve all their problems.

c. b.

a. b. c.

a. A common problem
is not having enough
money to meet daily
needs.
b. This could make
someone turn to
alcohol.
c. The person becomes
even poorer, because
they spend their money
on alcohol.
d. Their work suffers and
they lose their job.
e. This makes the
person sad and
desperate, and worsens
the drinking and
financial problems.
e. d.

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Your
physical complains are
I get aches because you are upset… What
and pains all over… problems are making you
upset? Ever since
my husband died and
my children left home I Can you
have felt very lonely and think of ways in which
miserable. you can make this
loneliness less?

I feel so
much better – my sister has
invited me to spend a weekend with
Well, shall
her next month.
we agree that in the next 2
Maybe
weeks you will make at least
I could visit friends.
one visit to your sister and
Or make contact with my
call at least one friend from
sisters who live in the
the village to your home?
next village…

After 2 weeks…

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Step 5. Define solutions ●● You may need to take a more direct role with
some people, for example, by writing letters
This consists of the following steps.
to other agencies on behalf of a person who is
1. Generate solutions: think out various solu- unable to read and write.
tions with the person.
●● You may need to provide ideas for solutions to
2. Narrow solutions: if many options are avail- the person’s problems, especially at the begin-
able, focus on those which are most practical ning of the treatment. However, efforts should
given the person’s social situation. be made to get the person to take a leading
3. Identify consequences: consider what might role in problem-solving at some stage.
happen as a result of implementing the
Briefly review all that has been covered during
solutions.
the meeting with the person. In particular, review
4. Choose the best solution. the target and plan for problem-solving.
5. Plan how to implement the solution.
6. Set specific targets which are achievable with- Step 6. Review, encourage and support
in the time before the next meeting with you. The main aims of the subsequent sessions are:
7. Consider what might happen in the worst- ●● to evaluate how well the person managed in
case scenario, for example, if the solution fails trying to solve the target problem
completely.
●● if progress has been made, to apply new solu-
Encourage the person to come up with the tions to the same problem or look at solutions
solutions to their problems. In this way, you will to a new problem
help improve their self-confidence. For example, ●● if progress has not been made, to iden-
if the person has said that being lonely was a ma- tify what went wrong, discuss ways to ad-
jor problem, do not say: dress that (5.11.3) and set new goals for
problem-solving.
‘I think you should sort this out by visiting some
friends’
5.11.3 Challenges
even if this is a perfectly logical and sensible
There are some problem areas which may seem
solution to the problem. Instead, say:
especially difficult to deal with, and you may need
‘Now we’ve identified an area you want to to provide specific advice in case the steps listed
tackle: how do you want to go about it?’ above do not lead to a successful outcome. You
can find suggested solutions in other parts of the
Often, it is difficult to identify solutions and manual in relation to specific problems such as:
you may need to assist the person either through ●● violence in the family (10.1, 10.2)
more questions, or through more direct advice.
●● loneliness and isolation (7.6.4)
●● Identify key social supports so that the person
●● bereavement (10.4)
can be made aware of the people who care
about them. ●● relationship problems (5.15)
●● Identify individual strengths, such as exam- ●● alcohol and drug problems (3.5, 9.1, 13.8)
ples from the person’s past which illustrate ●● caring for a family member who is ill (12.6).
their coping skills.
●● It is important that you are familiar with all the
helping agencies in the area so that practical 5.12 Relaxation exercises
advice for specific problems may be given (a Relaxation is a useful way of reducing the effects
list of all helping agencies in your area can be of stress on the human mind, in particular, help-
entered in the resources section at the end of ing reduce anxiety and tension. There are two
this manual (Chapter 15).
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main approaches to relaxation: muscle relaxa- may be most helpful. For a person with multiple
tion and breathing exercises. Before you teach physical complaints (especially headache) and
these exercises to anyone else, try them yourself. muscle tension, muscle relaxation may be most
You will feel relaxed and calm. It is one treatment helpful.
which the health worker can take without feeling
they have a sickness! 5.12.2 How to use relaxation
exercises
5.12.1 When to use relaxation
Box 5.11 contains advice on the two most popular
exercises relaxation methods. The diagram on the following
Relaxation exercises are recommended for people page illustrates how to do breathing exercises.
who feel tense, irritable, distressed or worried, or
who are suffering from multiple physical com- 5.12.3 Challenges
plaints. Both approaches are effective, but some
people prefer one over the other. For a person Relaxation exercises need to be practised every
who is panicky and anxious, breathing exercises day if they are to be effective.

▶
▶

a. b. c.

▶
a. Lie down in a room that is quiet and where you will
not be disturbed.
b. Close your eyes. Concentrate your mind on your
breathing rhythm. ▶
c. Now, concentrate on breathing slow, regular, steady
breaths through the nose, taking a deep breath in.
d. Then let go of the breath slowly.

Try to spend at least 10 min a day doing this exercise. d.

○○ These exercises can be done at any time of the ○○ Demonstrate to the person how to breathe
day. steady, deep breaths.
○○ They are best done in a room which is quiet and
Muscle relaxation
where the person will not be disturbed. The
○○ Start by asking the person to clench their toes
person must try to devote at least 10 min a day
as tightly as possible. Ask the person to count
to the relaxation.
to three while keeping the toes clenched and
○○ Explain to the person that if they practise daily,
then slowly relax.
they will begin to feel the benefits of relaxation
○○ Ask the person to pay attention to how the
within 2 weeks. With adequate experience, they
muscles feel as they are unclenched.
may even be able to relax in a variety of situa-
○○ You can ask the person to breathe in deeply
tions, for example, while sitting on a bus.
as they clench their muscles and then exhale
○○ Begin the exercise by sitting in a comfortable
slowly as they relax the muscles. Some people
position. There is no special position; any posi-
may struggle to do both at the same time. If
tion which the person finds comfortable is the
that is the case, focus on the muscle clenching
right one.
and relaxing.
○○ The person should close their eyes.
○○ Next, ask the person to pull their toes towards
Breathing exercises them as tightly as possible so that the calf
○○ After about 10 seconds, the person should start muscle is stretched, hold for a count of three
concentrating their mind on their breathing and then relax.
rhythm. ○○ This process should be repeated for different
○○ Now, the person should concentrate on breath- muscle groups, slowly working up the body
ing slow, regular, steady breaths through the (thighs, buttocks, abdomen, chest, back, shoul-
nose. ders, neck, mouth and jaw, eyes and cheeks,
○○ If a person asks how ‘slow’ the rhythm should forehead, upper arms, hands), with particular
be, you can suggest that they should breathe focus on muscles which become tense when a
in until they can count slowly to three, then person is stressed, including the face muscles
breathe out to the count of three, and then (screw up the face, then raise eyebrows as high
pause for the count of three until they breathe as you can), the neck (bend the head forwards
in again. with chin on chest), the arms (bend at the
○○ You can suggest that each time the person elbow), the back (hunch forwards), the legs and
breathes out, they could say in their mind the then the feet.
thought ‘relax’ or an equivalent thought in the
local language. A person who is religious can
use a word which has some importance to their
faith. For example, a Hindu could say ‘Om’.

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5.13 Getting active
5.13.1 When to use ‘getting active’
Mental health problems commonly lead to a per-
son withdrawing from social contact and stopping
activities that they used to find enjoyable. This is
particularly a problem in people with depres-
sion. The ‘getting active’ strategy can work for
anyone who seems to have got stuck in a cycle of
inactivity. Getting active by meeting friends can improve mental
health.
5.13.2 How to use ‘getting active’ the person with the types of activities that usually
Step 1. Explain about ‘getting active’ give people some pleasure or sense of reward, for
example:
For a person who is feeling demoralised and lack-
ing energy, the effort of continuing activities may ●● going for a walk
be too much and it is easier to just stay at home ●● playing with children/grandchildren
all day. The problem with this is that people get ●● meeting with friends for a coffee
stuck in a vicious circle. They don’t go out and so ●● going to see a film
they miss out on the experience of doing activities
●● going to a religious meeting
that might make them feel better. Imagine how
you would feel if you just stayed at home all day ●● listening to music.
and didn’t speak with other people – even if you Once you have a list of activities, ask the per-
were not depressed, it would make you feel sad. son how many times they did any of the activities
This is exactly what happens. People also tend to in the past week. Identify which activities they
lose self-confidence as they get out of the habit of avoided.
being active. The ‘getting active’ strategy is about
supporting people to restart rewarding or pleas- Step 3. Plan activities
urable activities so that they have some good feel-
ings and slowly start to enjoy life again. The next step is to make a plan with the person for
The goals of ’getting active’ are to help treat them to do some activities in the next week. The
depression and depressive symptoms (for exam- person should start with activities that they find
ple, low mood and low self-esteem) by: easier to do. In a very depressed person, going
out for a 10 min walk every day may be the most
●● increasing the person’s involvement in activi-
that they can manage. You need to ask the per-
ties that make them feel rewarded and satis-
son exactly when they plan to do the activity (e.g.
fied, and
Monday afternoon meet a friend for coffee and a
●● supporting people not to avoid essential chat). Make it clear to the person that they need
activities. to do the activity even if they don’t feel like it. The
idea is that they will start to feel better after they
Step 2. Identify rewarding activities start doing the activity.
Ask the person about activities that they used to It is important to motivate the person to re-
find enjoyable or rewarding but no longer do be- ally try to do the activities. When people feel de-
cause of their mental health problems. If some- pressed they may struggle to cope with the plan-
body is very depressed they may find it difficult to ning required for the activity. You can help the
remember anything positive and say ‘I never en- person by breaking the plan down into smaller
joyed anything’. Understand that this is probably steps. For example, making contact with the
the depression talking. You may need to prompt friend to arrange to meet, deciding where to go,

  
0 1 2 3 4 5 6 7 8 9 10
Measuring feelings.

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Step 7. Review, encourage and support following types of thoughts:
Follow the general advice given in 5.9.2. If the per- ●● negative thoughts, for example, ‘I am a failure’,
son was not able to try ‘getting active’, check for ‘Nobody likes me’, ‘There is no future for me’, ‘I
the reason (5.13.3) and support them to work have messed up my life’
out a more realistic plan. ●● worried thoughts, for example, ‘What would
happen to my family if I die?’, ‘What will hap-
pen if I don’t pass this exam?’, ‘Will I ever find
5.13.3 Challenges a husband/wife?’ (general worries); ‘This tired-
●● Trouble understanding the method. To ad- ness means that I have cancer’, ‘There is some-
dress this, you need to communicate the thing wrong with me that the doctors are miss-
method specifically and clearly. For example, ing’ (health worries).
instead of generally telling the person to ‘enjoy People who ‘think too much’ cannot get the
yourself more’, you should take time to explain negative or worrying thoughts out of their head.
how withdrawing from activities affects the The thoughts just go round and round, making
person’s mental health, identifying specific ac- them feel worse and stopping them from doing
tivities that the person enjoys and the specific things that might otherwise make them feel bet-
steps that make up the activity. ter (e.g. spending time with family or friends). It
●● Lack of skills. A person may have difficulty can be frustrating as a health worker or as a fam-
completing an activity not only owing to avoid- ily member. But just telling people to ‘Stop think-
ance but because they lack a required skill ing too much’ or ‘Stop worrying about nothing’ or
(e.g. the person may not engage socially be- saying ‘Why do you always dwell on the negative
cause they lack communication skills). In such side of things?’ does not help. We need a struc-
situations, consider another appropriate strat- tured approach so that we can help people to be
egy (e.g. improving their social skills 5.22) ‘thinking healthy’.
before giving them the task of socialising. For people who have terrifying worries that
●● The activity is too difficult. A common route happen in a moment of panic (e.g. ‘I’m having a
to failure is missing the rule of thumb of ‘start- heart attack’, ‘I’m going to die’, ‘I’m going crazy’);
ing small’. A realistic assessment of how diffi- for people who have fearful thoughts about spe-
cult the activity is prior to setting it as a goal cific situations or things; and for people who have
will maximise the likelihood of success. the same distressing thoughts again and again
(e.g. that their hands are dirty), often accompa-
nied by the urge to repeat a particular behaviour
5.14 Thinking healthy (hand-washing), use the method in 8.2.

People with mental health problems can some-

times have the problem of ‘thinking too much’, for
5.14.2 How to use ‘thinking
example, worrying constantly about something healthy’
or having repeated negative thoughts. ‘Thinking
Step 1. Identify the effects of thinking
healthy’ is a strategy which helps the person to
spend less time thinking too much and helps too much
them to think in a more positive way. This, in turn, First, it is important to identify and highlight the
helps them to feel better and get back to doing effects of thinking too much.
their usual activities. ●● Thinking too much may be such an automatic
experience that the person may do it without
5.14.1 When to use ‘thinking realising how negatively it is affecting their
healthy’ life. We can help the person see the effects of
thinking too much on how they feel.
This strategy is useful for people who have the We may say:

Step 2. Guide the person to learn

actions to take to stop thinking too
much
Thinking too much.
Second, it is important to guide the person to car-
ry out some alternative actions when they notice
‘Anjana, when you are in bed thinking again that they are thinking too much. There are three
and again about the pains in your back and the main options in dealing with thinking too much.
demands at your job, how do you feel? What
about when you get up to prepare dinner for A man was not selected for a job and had these
the family? Do you feel more or less tired?’ thoughts:
a. ‘I’m useless. I will never get a job.’
Or we may say: b. ‘I will always be unemployed and poor. No one will
marry me if I’m jobless.’
‘Anjana, when you think all of the time about c. ‘I may as well end my life.’
the mistakes you think you have made in your
life, how do you feel? Does it make you feel
more or less happy about yourself?’

In these ways, we can begin to help people

to understand the impact of thinking too much
about how they feel.
a. b. c.
●● The person may also believe that thinking too
much is helpful in overcoming their problems. The resulting emotions are those of unhappiness and
We can help the person to see the effects of depression.
thinking too much on the problems in their Now, look at alternative ways of seeing this situation:
lives. We may say:

‘Anjana, we have talked about how you stay

on your own and think again and again about
your husband. It does not appear that this is
helping you to solve the problems you and he
face. Would you agree with that? I know it is
a. b. c.
hard to change the habit of thinking too much,
but one of the first steps is noticing that it does a. ‘There is a recession on and many people are finding
not often solve your problems – even though it it hard to get a job.’
seems like it will.’ b. ‘I can see that my application was not well written
and I should get some help before applying again.’
●● It may be important to help the person to learn c. ‘Well, I didn’t get the job, but there will be many more
to ‘catch’ themselves when thinking too much opportunities. I have held jobs in the past and done
and notice its effects at that moment in time. well.’
We may say: The resulting emotions may be more hopeful.
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Problem-solving mind focused away from your thoughts and on
It is often valuable to help define the problem that what is happening outside by directing your at-
the person is thinking too much about and then tention to what you feel, see, smell, hear, etc…’.
outline steps towards active problem-solving
(5.11). For example, we may teach Anjana to 2. Second, ask the person to focus on one of
define the problems that she thinks about over their senses as you guide them in practising
and over and work on solving these problems the strategy in the session. For example, we
in our sessions, focusing on how to talk with her may ask the person to take note of the room in
husband in more useful ways, how to get support which we are sitting, and to describe all of the
from her neighbour, and how to reduce demands colours that they see in the room.
at work. 3. Third, ask the person about what they expe-
Taking note of our senses rienced when carrying out the exercise. What
Thinking too much automatically shifts the per- were they thinking about when they described
son’s focus from the present moment (what we the colours? How did it make them feel?
are doing, what is going on, who we are with) to Practise with another example, such as getting
the negative or worrying thoughts that are going them to focus on what their body is touching
round and round in their head. Sometimes a per- (e.g. the chair) and describe the texture and
son who thinks too much can even seem selfish surface. Highlight to the person how this tech-
or self-absorbed, as if they are only interested in nique breaks the cycle of only being able to
what is going on in their head. focus on thoughts.
We can teach the person to refocus attention Distracting
on what is happening outside their head by help- Distraction from think-
ing them to pay more attention to what their sens- ing too much can help
es are telling them about the immediate environ- to shift the person’s
ment, for example, sounds, smells, sights, tastes focus so that they
or touch. To teach this strategy to the person, do can notice something
the following. new or different in the
1. First, explain the purpose of this strategy: environment. Some
helpful activities to ex-
‘We will be learning a technique today that can plore with the person
be helpful when thinking too much is a prob- include: physical ac-
lem. It is a way you can practise keeping your tivities (brisk walking,
fast-paced household chores), activities that shift
location (visit a neighbour, take a walk) and activi-
Perhaps
ties that are engaging (watching a funny movie,
his friends got him into
trouble? Perhaps
talking with a close person). This kind of approach
the teacher was can also be combined with the strategy of ‘getting
Perhaps having a bad day and active’ (5.13).
it was his own fault? shouted for no It is possible to plan such activities in advance
reason? by identifying the situations in which the person
commonly thinks too much and thinking of some-
thing they can do to distract themselves when in
that situation.

Step 3. Learn how to challenge thoughts

that are negative or worrying
Thinking worrying thoughts makes us more wor-
ried, and thinking negative thoughts makes us feel
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TABLE 5.5 EXAMPLE THOUGHT DIARY
Day Time What am I doing? What am I thinking? How do I feel?
Monday 8am Having I’m lonely Mood 2 out of 10
breakfast
Tuesday ____ ________ ________ ________

more sad and negative about life. But people with his own fault? Perhaps his friends got him into
mental health problems can get into the habit of trouble? Perhaps the teacher was having a bad
thinking negative or worrying thoughts without day and shouted for no reason? Could these be
even realising it. We can help people to get out of possible explanations?’
unhealthy thinking habits in the following ways.
‘OK, now that we have tried to think of differ-
1. Get the person to notice when they are ent explanations for why your son might have
slipping into unhealthy thinking been told off at school, how convinced are you
now that the negative thought that you are a
Ask the person to keep a diary of the thoughts
that are going around in their head and the bad mother is true? Tell me on a scale of 1 to 10
way they made them feel on a score of 1 to 10 (1 not true at all, 10 definitely true).’
(1 is worst) using the scale from p. 78. Also ask Usually, by going through this process, the
the person to note what was happening at that person is able to see that there are other ways of
time (to try and identify triggers for unhealthy seeing the situation that are more positive or less
thoughts). For example: worrying. This, in turn, means that the thoughts
have a less negative effect on the way that they are
Wednesday afternoon: Thinking about what a feeling (don’t make them feel so sad or anxious).
failure I am as a mother
Mood: very sad (crying) 1 out of 10 Step 4. Practise and learn
Situation: Son came back from school and
Progress is much faster if the person practises try-
mentioned that he had been told off for being ing out these techniques at home. Ask the person
disruptive in class. to practise at home by developing a plan for when
and how long they will practise. The time and
2. Get the person to challenge the unhealthy
place can be linked to the settings in which the
thoughts
person is most likely to be thinking too much, but
Ask the person to consider how realistic or ac- it can also be helpful if the person starts to prac-
curate the worrying or negative thought is. Try tise at times that are not the most challenging in
this approach: order to build their basic skills. Also, remember to
ask about what might get in the way of practising
‘How convinced are you that your negative
and solutions that might help.
thought that you are a bad mother is true? Tell
me on a scale of 1 to 10 (1 not true at all, 10 Step 5. Review, encourage and support
definitely true).’
Follow the general advice about how to review,
‘OK, let’s think of it another way. If your friend
encourage and provide support 5.9.2.
told you that she was thinking she was a bad
mother because her son was naughty at school,
what would you say to her?’ 5.14.3 Challenges
‘You have assumed that you are the reason for When a person is very low in mood or worried, or
your son getting told off. Can you think of other when the thoughts are extremely distressing, they
reasons that he got told off? Perhaps it was may struggle to use this type of counselling. In

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such cases, it may be better to try a medication 5.15.2 How to use ‘improving
first and come back to ‘thinking healthy’ when the
person has improved. relationships’
‘Thinking healthy’ may be difficult for some You can identify which area of the person’s re-
people to understand. Other counselling strate- lationships is acting as a trigger for their mental
gies, such as ‘problem-solving’ or ‘getting active’, health problem by asking:
may be more suitable for such people.
Keeping a diary of thoughts and feelings is ‘Please tell me about these problems you have
not possible if the person cannot read or write. been having with the relationship with your…
However, you can still try to get them to identify (husband, mother, boss, etc.).’
patterns between the situation that they are in,
the thoughts going around in their head and how Then try to identify which of the four catego-
they feel (their mood). A visual chart can also be ries the person’s relationship problem fits into. It
used (p. 78). is important to note that people may have prob-
lems in one or more category, in which case you,
along with the person, need to decide which area
5.15 Improving relationships† to focus on first. You can say:

Problems in relationships can act as triggers for ‘Based on what you have told me, it seems
many mental health problems. For example, the that your health problems are related to what
ways people interact and communicate with oth- has been going on in your life, in particular, the
ers can affect their mental health. Some depressed grief you are experiencing following the death
people have difficulty asking others for help, and of your mother. What I suggest is that over the
this makes them feel isolated or overwhelmed by next few weeks we focus on this problem and
their problems. Others have difficulty saying ‘no’ identify ways you can cope with it better. As
to other people’s demands or requests and thus we do this, you will find your health problems
find themselves doing things they do not want to improving.’
do, feeling pressured and becoming ‘cranky’.
Or:
5.15.1 When to use ‘improving ‘Your health problems seem to be related to the
relationships’ stress you are experiencing due to the frequent
When counselling a person who is distressed, if quarrels with your husband over your wanting
you identify that the person’s distress is related to find a job. We will, over the next few weeks,
to relationships with significant people in their discuss how you can deal with this better so
life, you can use this strategy to help the person that the situation improves and you feel better.’
find better ways of dealing with their relationship
The techniques to deal with each category of
problems. These relationship issues usually fit
relationship problem are described below.
within one or more of the following categories:
●● serious disagreement with someone impor- Disagreements
tant in the family, or in a social or work setting One source of stress for many people is the chal-
lenge of communicating effectively with other
●● grief – death of a loved one
people in their lives. You can teach the person
●● any life change, bad or good, that has led to some simple communication methods in the ses-
relationship stresses (e.g. change of residence, sion and then ask if they are willing to practise
marriage, loss of job, birth of a new baby) these at home. There are three steps.
●● loneliness and social isolation that results in 1. Problem solve
feeling cut off from others.
The first step is helping the person to identify
†
With Neerja Chowdhary. clearly what they want or do not want. For
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a. ○○ avoid using words such as ‘always’ and
Your mother is NOT
welcome in this house!
‘never’, for example, ‘You never listen to me’
or ‘You always shout when things don’t go
your way’.
3. Practise
The third step is creating opportunities to prac-
tise these skills in action. You can do this in the
session by acting out the situation with the
person. For example, say, ‘I will be your daugh-
ter. I am calling you on the phone now. Hello
Can we discuss about mother, I can’t visit you this weekend. We are
your mother coming to stay?
really busy. Maybe I will come next weekend…
OK?’ The person is then asked to respond us-
b. ing the communication skills described above.
If the person doesn’t respond, she may require
more coaching; you could say, ‘So, what if you
were to say…’ and then continue acting out
the scene with the person so she has an op-
portunity to practise saying those words.
Grief
Finding the right words for better relationships. Some people struggle to cope with the loss of
their loved one to the extent that it affects their
example, a woman who is feeling hopeless mental health (10.4). You can help the person
about a conflict with her daughter may be en- who is in mourning by helping them to come to
couraged to identify what exactly she would terms with their loss and re-establish interest in
like from her daughter (e.g. wanting her to visit everyday life and activities. It is helpful for you to:
more often). The steps described in the section ●● encourage the person to talk and express their
on problem-solving (5.11) can be used here. sadness about the loss
2. Communicate ●● ask the person to describe the events just prior
The second step is teaching the person how to to, during, and after the death
communicate clearly and effectively. Often, it ●● discuss their relationship with the person who
is helpful to: died
○○ focus on the current quarrel and not talk ●● discuss both positive and negative feelings
about all the mistakes the other person has that the person had about the loved one who
made in the past; died (‘Every relationship has rough times.
○○ separate the other person from her behav- What was your rough time’?)
iour – using the words ‘Your words were ●● discuss how the future looks without the de-
very hurtful’ leads to more constructive ceased, including the unrealised plans and the
discussion than using the words ‘You are an change in the person’s social/family status af-
unkind person’; ter the death
○○ acknowledge the other party’s expecta- ●● encourage reaching out to other people who
tions; the daughter could say: ‘I know you are supportive and encourage the person to
feel like I am not paying attention to you’; get involved in activities that are pleasurable
○○ use ‘I’ statements about how the mother or relaxing (10.4.3).
feels and what she wants; for example, she
Life change
could say ‘I feel angry when you behave like
Changes in a person’s life may increase stress
this’ rather than ‘You make me angry’;

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owing to the effects they have on important rela- I can’t
tionships. For example, a promotion at the work- understand it – all these years I was
place, while a positive event, can mean a change looking forward to retirement and now I
in interactions with colleagues and less time with am miserable.
friends and family owing to increased work pres-
sures. More commonly, the life change is due to
negative events such as becoming unemployed.
You can help the person who is going though such
a life change in the following ways.
●● Discussing positive and negative aspects of
the old role. People may exaggerate the posi-
tive aspects of the old role and minimise the
unpleasant aspects. It is important to draw
Does the person have trouble starting and/or
their attention to both to help them to be more
maintaining relationships?
realistic.
●● Express their feelings about the change, such ‘What are the problems that come up in your
as guilt, anger and fear at the loss. interactions with…?’
●● Discuss the positive and negative aspects of
the new role. Explore opportunities that exist ●● Act out the social situation that the person
in the new role. finds difficult and give feedback and advice.
●● If no positive aspects can be identified, help ●● Encourage social interaction, and have the
the person determine what is within their con- person describe how the experiments from
trol. Even in the most negative circumstances, the previous week went.
people will be able to identify something that
‘This is a good time to try and work on your re-
they can do to feel better, for example, learn-
lationships. We can talk about what goes right
ing to make the most of their time when faced
with a serious medical illness. or wrong when we meet next week.’
●● Help the person develop new skills that they ●● If the person contacted an old friend and ar-
will need in the new role, for example, help- ranged to see them, you can ask:
ing them to manage the change effectively by
finding a new job, meeting new people. ‘Describe how it went. How did you feel? What
●● Help the person identify supportive people to did you say?’
help them manage the new role.
Each such description provides an opportu-
Loneliness and social isolation
nity for you to refresh in the person’s mind the
Sometimes, distress can occur when the person
positive steps they have taken, provide en-
experiences loneliness due to difficulty in making
couragement and try acting out interactions
friends, or in sustaining friendships, owing to poor
that have not gone well.
social skills or feeling depressed. Your role is to
encourage the person to form new relationships
(5.18.1). This can be done by: 5.15.3 Challenges
●● Exploring current social interactions by asking Some relationship problems may not respond
about family and friends, e.g. to attempts by the person to improve communi-
cation. In such circumstances, it is necessary to
‘How often do you see them?’ ‘What do you work with the person to help them accept this
enjoy about seeing them?’ and use the problem-solving strategy (5.11) to
define what changes need to be made in the re-
●● Finding out the problems in social interactions. lationship. Some people may have problems with

It isn’t
worth it.
5.16 Controlling anger
5.16.1 When to use ‘controlling
anger’
Anger can be justifiable and an important emo-
tion for action against an injustice. But some peo-
ple find it difficult to control their anger. They get ●● equip the person to be able to cope better with
angry for no good reason, or with only the slight- anger-arousing situations.
est reason (too quick to anger) or to an excessive
degree. A person may seek help for anger when Start by explaining that anger is a normal emo-
it affects their relationships or leads to problems tion and that there are socially acceptable and
at work, or even gets them into trouble with the unacceptable ways of expressing anger. Ask the
police. person to tell you about a recent angry episode.
Anger and irritability can be a sign of depres- What was the cause? How did they feel when they
sion, especially in men, adolescents and the el- were angry? What did they do when they were an-
derly. In that case, treat the depression first. gry? What were the consequences of the anger for
Anger has a two-way relationship with drug them?
use, especially with alcohol. A person who has dif- Help the person to identify how angry feelings
ficulty controlling their anger may drink alcohol to make their body react. The most important step
try to calm themselves down, but alcohol can also in controlling anger is recognising the first signs of
make people more likely to react with excessive anger. These may be feeling hot in the head, angry
anger. If a person has both anger problems and a thoughts, heart beating fast, fists clenching and
drug use problem, try to tackle both at the same feeling tense all over the body.
time (9.2). Ask the person for examples of when someone
A person who is experiencing psychosis and used an angry tone with them, and compare these
believes that people are trying to harm them may episodes with how the person felt when someone
get angry, although the anger is understandable used a calm tone with them. Explain to the person
in relation to the person’s beliefs. A person who is about the ‘cycle of anger’. With the cycle of anger,
manic may also be irritable and quick to anger. In a person is already experiencing anger before any
both of these cases, treat the underlying mental provocation comes along. They are tense and
disorder first. ‘looking for a fight’. Even a neutral comment can
be quickly misinterpreted, the person’s anger gets
out of control and leads to an angry outburst (an
5.16.2 How to use ‘controlling ‘explosion’). The consequences of the angry out-
anger’ burst make the person feel worse and more likely
to continue in an angry frame of mind.
Step 1. Educate the person about anger
The goals of controlling anger are to: Step 2. Motivate the person to control
●● identify the person’s difficulties managing their anger
anger
A person may have mixed feelings about trying
●● increase the person’s understanding of the to control their anger better. It may have become
factors that trigger anger a habit that they no longer notice. They may feel

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●● Wait until your mind feels calm and only then
I’m so
continue what you were doing.
angry, I want to hit him!
●● After the anger has passed, plan to tell the per-
son your thoughts to try to reduce the conflict.

Step 4. Keep a record of angry episodes

Ask the person to keep a record of angry episodes
before the next appointment. Ask them to take
note of what caused the episode, the angry be-
haviours they expressed and the consequences.

Case 5.1
justified in their anger and blame everybody else. Rafael describes an episode in the past week
They may have the idea that anger is not some- when he was at work. His boss came into the
thing that can be controlled. Approaches de- room and looked across at what he was doing.
scribed in ‘motivating people to change’ (5.17) Rafael immediately felt angry that his boss
may be a necessary first step. Some helpful mes- seemed to be singling him out. ‘Why should
sages that might encourage a person to work on he look at me?’ In response, he shouted across
controlling their anger are as follows.
the room ‘What are you looking at?’ in a hostile
●● Anger is damaging to your health and to your voice. When the boss said nothing Rafael got up
life. Learning how to control it is an important from the seat, walked over to his boss and stared
way of improving your life. into his eyes, threatening ‘What is your problem?’
●● Anger can be controlled. Some people say ‘I He could feel his heart pounding and felt like
just cannot control what I do when I get angry’ striking the boss, but his co-workers pulled him
or ‘I just see red’, but this is not true. You can away from the confrontation. He has now been
learn to control your anger better.
given a warning from his boss and is in danger
of losing his job.
Step 3. Teach techniques to delay or
avoid an angry response Step 5. Review, encourage and support
Discuss with the person the different techniques Review the episodes with the person and use a
they could use as a way to either delay their angry problem-solving strategy (5.11) to find alterna-
response or avoid it altogether. tive, more socially acceptable ways of reacting to
●● Ignore or walk away from the provoking situa- these triggers. It is very helpful for the person to
tion (e.g. if you become angry while talking to role-play different ways of reacting. It helps them
your wife, leave the room she is in). to get the feel of how to do it. You can also identify
●● Attempt breathing exercises (pp. 75, 76). potential problems and find ways around them.
●● Count backwards. For example, you could ask the person
‘Looking back, how do you think you could have
●● Replace aggressive responses (staring, making
behaved differently?’ If the person cannot think of
demands, threatening gestures, using harsh
any alternative behaviours, go through the tech-
tones) with alternatives (non-threatening eye
niques described in step 3 and ask them which
contact, appropriate gestures, a calm tone of
one they would feel comfortable trying. In case
voice, gently requesting a change in the other
5.1, Rafael says he could have counted backwards
person’s behaviour).
when he first noticed his boss looking at him. He
●● Using ‘positive self-talk’ during a conflict situ- could then tell himself, ‘He is not just looking at
ation (e.g. ‘keep cool’, ’don’t get too angry, it me’. If he still felt angry, he could leave the room
isn’t worth it’). to cool off for a few minutes (he could make the

Increased likeli- Suppression of Post-explosion

hood of reacting post-explosion feelings of guilt,
angrily in future feelings remorse, irritation

Cycle of anger.

Managing anger:
a. Be aware of your feelings
of anger.
b. Leave the room or place
where you are beginning to
feel angry.
c. Return only when you feel
calm and able to solve your
difficulty without losing your
temper.
a. b. c.

excuse that he needs to use the toilet) or he could 5.16.3 Challenges

try finding out what the boss wants without being
confrontational, for example, saying ‘Good morn- Other people may think the person has an anger
ing, is everything OK? Do you need anything from problem, but the person themselves may believe
me?’ that the real problem lies with others. This may
Now practise this with the person. Ask the per- make them hostile towards you and reluctant to
son how he feels as he does the role play. Does work at controlling their anger. Always take care
he feel in control of his anger? Try to find ways to of your own safety (2.2.1). Try techniques to
stop the anger building up in the first place. That motivate the person to change (5.17). If that
means helping the person notice the signs that he doesn’t work, just make the person aware that
is starting to get angry. you are available to help them if and when they
At the next appointment, don’t forget to ask the are interested to try to control their anger.
person ‘Did it work?’ and, if so, ‘Why did it work?’
If it did not work, ask ‘Why not?’ If the person’s ap-
proach to anger management did not work, try to 5.17 Motivating for change
generate new solutions together. Keep encour-
People commonly have mixed feelings about
aging the person by acknowledging successes
changing their behaviour in the ways that doctors
with positive feedback. If the person’s efforts to
would like them to do, for example, reducing alco-
manage his anger have failed, reassure them that
hol intake, taking more exercise, stopping smok-
they have at least tried and that together you will
ing, taking their medication as prescribed or cut-
come up with alternative solutions, practise them
ting back on fatty foods. It is not because people
through role play and review their efforts.

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are stupid or because they are deliberately defy- them whether there are any negative sides to the
ing medical advice. On the contrary, people often behaviour. For example:
continue to behave in a certain way because, as
well as the downsides, there are some benefits ‘Can you tell me what you like about drinking?
to them of continuing with the behaviour. People What are the good things about drinking for
may also have given up thinking that they can do you? Now can you tell me about any downsides
anything to change their behaviour. A counselling of your drinking?’
approach that can be very helpful in this situation
is ‘motivating for change’. If the person cannot tell you any downsides to
drinking, you might need to prompt them about
common areas affected by drinking. Make a list of
5.17.1 When to use ‘motivating for all of the reasons that the person gives you.
change’ Then ask the person to weigh up the benefits
and disadvantages to continuing drinking. Listen
This is especially useful for people with an alco-
for examples where the person’s values and what
hol or drug use habit, but also for those who have
they care about most in life are affected by their
other unhealthy behaviours or lifestyles affecting
ongoing drinking and try to highlight this incon-
their health, such as poor diet and lack of exer-
sistency in a non-judgemental way:
cise, or when a person does not wish to take med-
ications which are needed for a mental health ‘So, it is really important to you to be involved
problem. in your children’s upbringing, but drinking alco-
hol all the time interferes with that.’
5.17.2 How to use ‘motivating for
change’ Step 3. Don’t get into conflict. Be
Step 1. Express empathy prepared to let the person change at
Use your communication skills of warmth, active their own pace
listening and a non-judgemental attitude. This is Don’t get into conflict when the person resists
necessary so that the person can trust you and changing their behaviour. It is not easy to change
feel comfortable to speak openly. our habits. Trying to force people to change or
trying to make them feel guilty is almost always
Step 2. Support the person to make counterproductive. Change can only happen if the
their own arguments for changing person decides to change. This can be difficult for
health workers to understand. To us it might seem
Instead of trying to convince the person of why
obvious that a man who has breathing difficulties
they should change, try to get the person to con-
should stop smoking cigarettes. We may mistak-
vince themselves. Ask the person to tell you all of
enly believe that this is a simple decision and we
the reasons that they continue with the behaviour
just need to tell the person strongly. But this does
and the things that they like about it. Then ask
not work.

Step 4. Help the person to believe that

they can change
Talking positively about change can help to bring
change about. So, when a person says ‘I have
managed to lose weight in the past, so maybe
I can do it again’, make sure you give them en-
couragement. ‘Yes, you have done it before’. If the
person does not talk about change, try to ask a

question that will get them talking about change. 5.17.3 Challenges
For example:
The most common challenge is that, despite your
‘You have told me while we have been dis- efforts to use this method, the person does not
cussing your drinking that your liver is being want to change. They are simply not ready for
affected, and that your drinking is causing you this, in which case you should not be judgemen-
some problems both at home and at work. tal. Instead, reassure the person that your door is
Has that made you think about changing your always open for them to return at any time should
drinking at all?’ they wish to restart the process. If a person is de-
‘Is there anything that you have tried in the pressed, they may struggle to have enough self-
belief and hope to try and change. In that case, it
past, on your own, to change your drinking?’
may be necessary to treat the depression first or
‘Is there anything about your drinking that you
tackle their negative thoughts (5.14). Similarly,
want to change?’ if a person fails to change an unhealthy behaviour,
Then follow up by asking whether the per- or if they relapse, despite having tried hard to stop
son has any ideas about how they could change. it, they may lose hope in their ability to change. It
The purpose of this is to convince them that they
are the best person to know what could work
for them. Help the person to think through their That’s
plans for change to make them sure that the goals impressive. Tell me, how
are SMART (4.5). did you manage not to
drink for 5 days?
Step 5. Review, encourage and support
Meet with them regularly to review progress and
continue working in partnership. Setbacks are
inevitable and your role is to help the person to
learn from their mistakes and be encouraged to
keep trying.

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is important to reassure the person that such an 5.18.2 Get back into a routine
experience of ‘failure’ is very common and that
most people who persist with the effort will ulti- When a person develops a mental health prob-
mately succeed. lem, they may withdraw from the world and
stop following the normal routines of day-to-day
life. This is not the person’s fault. It is a result of
Section III: Social interventions the mental health problem. Even so, withdraw-
ing usually has the effect of making the problem
5.18 General principles of social worse. Explain this to the person. Encourage the
person to start following personal and household
interventions routines, such as getting up at the same time as
other people, maintaining personal hygiene, eat-
5.18.1 Increase social support ing with other people, and spending some time
Mental health problems frequently disrupt a per- outside the house every day. Physical exercise
son’s social activities and their support networks. and getting some fresh air may also help the per-
Our social contacts, including with our fami- son to feel mentally better. Try to get the person to
lies, friends and neighbours, are vital for mental start doing activities that they used to enjoy, even
health, for example, giving us opportunities to if they don’t feel like doing anything. If you have
be distracted from difficulties, to feel part of our more time, you can use a ‘getting active’ strategy
community, to be able to draw support to solve (5.13), but even if you only have a few minutes,
problems, and to have the chance to enjoy being explaining the value of these simple things can
with other people. For some people, religious in- help.
stitutions can be an important source of support.
Ask the person who they usually go to when
they need support. If they say that there is no one 5.19 Specific social interventions
to support them, then ask about who has sup- Most social interventions aim to support the per-
ported them in the past. It is unusual for a person son to realise their potential in a way that is de-
to have never had anyone to turn to. fined by their values and priorities. Recovery, for
Encourage the person to slowly start to in- many people, may include improving functioning
crease their contact with people who support and skills for independent living, meeting basic
them. Remember that mental health problems needs for food and shelter, promoting livelihoods,
can be a barrier to seeking the very support that improving social skills, addressing stigma, dis-
a person needs. The person may be feeling de- crimination and abuse, and supporting the per-
moralised, fearful of negative attitudes, or wor- son to integrate back into society (befriending).
ried about burdening others with their problems, These specific social interventions are discussed
or they just might not feel like speaking to others. in the next section. Support groups can promote
The steps used in problem-solving can be applied recovery for individuals, but also serve as a force
to address this challenge (5.11). For example, to mobilise and strengthen groups of people with
start with something small and manageable, such mental health problems and their family mem-
as asking a trusted friend whether they can come bers to advocate for a better deal.
around for a chat and a cup of coffee.
Explain to the person that increasing their
contact with other people may be tiring for them
at first and may not immediately make them feel
better. The important thing is to keep doing it.
Gradually, they will notice that it is helping them
and, as their mental health improves, the social
contact becomes easier and more enjoyable.

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5.20 Improving functioning and
skills for independent living
5.20.1 When to use ‘improving
functioning and skills’
Mental disorders and disabilities can under-
mine the person’s ability to care for themselves
independently. They may not do anything use-
ful with their day, either sitting doing nothing or
wandering around aimlessly. This lack of produc- on a combination of work, rest, leisure, self-care
tive activities is not good for recovery. When the and sleep. Focus on activities that the person and
mental disability is long-standing, the person family value, as well as those which are pleasur-
may have lost their job and not adapted to new able to the person. The activities also need to
roles, or may be isolated from society owing to be graded appropriately for the person’s current
stigma, or may be overprotected by the family so level of functioning and should not be too long in
that they are not encouraged to do anything with duration.
their time. Even when acute symptoms subside, The person’s preferences form the focus of the
the person may have got out of the habit of do- activities in this step, but the family plays a criti-
ing things for themselves or have lost confidence cal part in encouraging and supporting them to be
in their abilities. A process of re-learning and re- able to achieve the plans.
freshing of daily living skills may be needed. In all
cases, it is important to work with the person and, Step 2. Set recovery goals
wherever possible, with the family to re-establish In ‘principles of treatment’ (5.9, 5.18) we dis-
some routine to each day and to get the person cussed how to set recovery goals with the person.
doing things again. The key is to identify goals that are valued by the
person and which can be worked towards in a
5.20.2 How to use ‘improving step-wise fashion.
A person’s recovery goals might be in the area
functioning and skills’ of personal hygiene, education, work and liveli-
If the person is willing, work with family members hoods (5.21), relationships, managing money,
as well. Family members are your co-therapists. using public transport, living independently, deal-
They can play a critical part in supporting and ening with stigma (5.23), social skills (5.22) or
couraging the person to move towards more inde- coping with symptoms.
pendent living.
Step 3. Work towards recovery goals
Step 1. Make an activity schedule For the selected recovery goal, follow the steps
Explain the benefits of having the day structured used in problem-solving (5.11). Thus, the
with activities. This approach helps to give the first step is to break down the activities lead-
person something to do, improves their self ing to achieving the goal into smaller steps. See
confidence, enables them to contribute to the life the following examples of steps towards greater
of the household, distracts them from unpleasant independence:
symptoms, helps to improve concentration and ●● improving hygiene: e.g. being washed by fam-
memory, improves problem-solving skills and ily, being helped to wash, washing with verbal
promotes greater independence. prompting, washing independently without
With the person and family, make a structured prompting
plan for how the person will spend the day. Start
●● managing money: being given the ex-
from the time that they will get up. Try to agree
act amount, being given more money and
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accompanied to buy something, being given 5.20.3 Challenges
a monthly allowance to manage expenses
independently In psychosis, the person may experience problems
of motivation, concentration and reduced capac-
●● using public transport: short trip with family,
ity to carry out activities. Check that all symptoms
longer trip with family, family only buys ticket,
are treated as well as possible. Also ensure that
person buys ticket and travels independently.
side-effects of a medication are not interfering
Discuss potential challenges and how they will with functioning (e.g. owing to over-sedation).
be overcome. Agree on a specific (SMART; 4.5) Expectations from family members (and from the
target to achieve before the next appointment. person themselves) may also be low, which can
Tell the family to support the person’s motivation be a barrier to progress; this is why you should
by providing them with positive feedback when- make efforts to engage family members as early
ever they make an effort to do a step of the task, as possible.
even if it is not successful.

Step 4. Review, encourage and support 5.21 Meeting basic needs and
When you review the person, always ask about promoting livelihoods
progress towards the goal, give encouragement,
There is a two-way relationship between poverty
trouble-shoot problems and set new goals in a
and mental health (13.11). One way is through
spirit of positive expectation that they will be
mental disorders and disability putting people
achieved.
at risk of falling into poverty (or worsening pov-
erty) for a variety of reasons: the mental health

TABLE 5.7 TACKLING UNDERLYING CAUSES OF POVERTY

Problem Solution
Too acutely unwell to work Good clinical care to maximise symptom control
Lost opportunities for family Good clinical care to maximise symptom control
members to work
Expense of treatment Good clinical care to maximise symptom control
Drawing on community resources, social welfare funds, charity,
other community-based organisations
Residual disability from mental Improve functioning and skills for independent living (5.20)
health problems
Poor social skills Improving skills for social situations (5.22)
Stigma and discrimination Interventions for stigma/discrimination at the individual (5.23)
and societal (13.8) levels
Support groups (5.26)
Low education and poor skills for Find out opportunities for training and refer the person
work Make links with employers who are open to the idea of vocational
training
Support groups (5.26)
Limited employment opportuni- Make links with employers and community-based organisations
ties who may be able to assist people who need extra support to stay in
work

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Miss out on social
Lose confidence Avoid social situations support and enjoyment of
being with people

Difficulty with social

Sad mood and isolation
situations

A vicious circle of social skills problems and mental health problems.

a. b. c.

Strengthen social skills by (a) identifying a social event, (b) taking the first step of speaking with one person, and
then (c) building up to joining a group.

who has always felt socially awkward may iden- understand what some of the social skills prob-
tify the following social difficulties: lems might be. Following the example of the man
1. knowing what to say in different situations with depression, start by acting out the situation
(least difficult) where the man is buying something in the local
shop. While you are acting out the social interac-
○○ buying something in the local shop
tion, take note of the positive aspects of communi-
○○ family coming round to my home cation and also the difficulties which are revealed.
○○ friends coming round to my home For example, you might notice that the man has
○○ attending a group meeting overly intense eye contact, tends to mumble and
○○ attending a wedding doesn’t use any ‘small talk’ (e.g. greetings, rou-
tine questions and comments). Instead, he starts
2. putting across my view in a group meeting telling the shopkeeper straight away about his
without getting angry physical ailments in great detail. But, on the other
3. making new friends hand, you notice that he was polite and respect-
4. starting a conversation with a woman who I ful. Gently tell him what you noticed, starting with
like (most difficult). the positive aspects. Find out whether he agrees
or does not agree with your observations and ask
Step 3. Practise a specific social skill which of the weak areas he would like to work on
first.
Choose one of the least difficult social problems In this case, the man selects ‘small talk’. Give
that the person identified. Then act out that him some examples of ‘small talk’ that would be
situation with the person so that you can try to
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appropriate in this situation. For example, first 5.23 Enabling people to respond
greet the shopkeeper ‘Good morning’, then ask
‘How are you today?’ Advise the man not to start to stigma and discrimination
talking about his physical health concerns if the During your assessment of the person you may
shopkeeper responds ‘Fine thank you, how are identify that they are experiencing stigma (nega-
you?’ Explain that the question is not meant to be tive attitudes towards them due to their mental
answered literally but is just a way to greet some- health problems), discrimination (unfair actions
one. Once the shopkeeper has responded, the taken against the person) or abuse (actions that
man can ask for the item that he wants to buy. He violate the person’s human rights). The role of
could consider asking a general question: ‘How the health worker in advocating for the human
is business these days?’ He could also comment rights of people with mental health problems is
on something that has happened in the news or discussed in Part 4 (13.8). In this section we are
in the local community. Practise with the man so concerned with actions that the health worker
that he can try out some of these ideas. can take to help the individual person.
The impact of stigma, discrimination and
Step 4. Set goals for that skill abuse on a person may be profound, for example:
Ask the person to set a goal for trying out the new ●● undermining self-confidence, leading to isola-
skill, for example, to test out small talk at least tion and withdrawal, making the person fear-
twice in the next week. ful of rejection from others
●● being denied equal opportunities, such as for
Step 5. Review, encourage and support jobs or education
See the general advice in 5.9.2. For improving ●● living in fear of harm, such as shouting insults,
skills, review with the person how the test of the being restrained
new skill went. Try to obtain specific details of the ●● being denied fundamental rights, for example,
interaction and the extent to which the person felt of freedom of choice regarding how to lead
that it was successful. The person’s family mem- one’s life
bers may also be able to give useful feedback if
●● being emotionally, physically or sexually
they accompanied him. When asking the family to
abused.
give feedback, make sure they also consider posi-
tive aspects as well as anything that didn’t go so The goal of the approach in this section is to
well. If the person faced challenges, try acting out help the person to consider how these negative
the scenario again and find ways to overcome the experiences affect their life and how they can re-
challenge. If it went well, select a more difficult spond so that their quality of life is improved.
social situation and set a new goal.
How to deal with stigma?
5.22.3 Challenges Step 1. Discuss experiences of negative
This approach to improving social skills works comments, discrimination and abuse
better with people who have an awareness of the
social problems that they are facing and are moti- Ask the person about experiences of stigma,
vated to change. For a person who has less appre- discrimination and abuse. Discuss what hap-
ciation of their social difficulties, the method will pened and how it made them feel about them-
need to involve the family and focus on skills that selves. Show empathy for the impact of negative
bring some clear benefits for the person so that experiences.
they may become more motivated to persevere.
Step 2. Encourage the person to think
about themselves in a positive way
Explain to the person that even if it is not possible

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to control the way that other people see them, Step 4. Overcome the isolation resulting
they should still see themselves as valuable. Tell from stigma, discrimination and abuse
the person that the mental health problems are
not the only important thing about them, and that ●● Help the person to weigh up the advantages
they can recover and have a meaningful life. Ask and disadvantages of isolating themselves
them to list all the valuable things they contribute from society. On the one hand they may mini-
to their family and community. mise exposure to stigma, but on the other
hand this means that they are missing out on
Step 3. Deal with negative comments, the benefits of living in a community and not
discrimination and abuse living life to the full.
●● Address difficulties in social skills (5.22).
●● Discuss how the person dealt with the situa- Occasional symptoms should not be a block
tion at the time. For example, what they did to social interactions. If the person is more
when someone called them an insulting name. unwell, a priority is for them to receive effec-
Discuss whether the way they responded was tive treatment. When community members
helpful or not. see the person doing usual activities again,
●● Discuss other ways the person could respond. this will help to reduce their ignorance and
For example, it may be useful to practise ex- prejudice towards people with mental health
plaining the mental health problem to others. problems.
You could suggest that the person tries saying, ●● Explain that people may notice at first if the
‘I have an illness like other illnesses. I am tak- person starts going out more, but they soon
ing medication which makes me better’. stop noticing as everyone gets used to them
●● Getting into a fight or trading insults is not being around. Not only that, people’s fears
a good way to respond to abuse. If needed, about a person with mental health problems
teach strategies to control anger (5.16). decrease as they get to know someone who
●● When the person has experienced discrimina- has recovered.
tion, for example, being excluded from liveli- ●● Concealing mental health problem because
hood opportunities in the community, use of fear of the consequences may be a burden
a problem-solving strategy (5.11) and en- on the person. Discuss with them about where
courage the person to involve the family and and when they might consider telling others
relevant community members in addressing about their mental health problems with-
the issue. out feeling shame or facing discrimination.
●● For criminal acts, for example, physical or Remember that it needs to be the right people,
sexual assault, speak with the person about right place and right time. The person should
involving the family and the police. feel and understand that whether to disclose
their mental health problems is their choice.
I have an illness like
any other illness.
5.24 Supporting families
5.24.1 When to use ‘supporting
families’
Family interventions are helpful for people with
long-term mental disability, such as psychosis,
dementia or developmental disorders, who are
living with their family. They could also be used
for non-family members who have ongoing, close,
day-to-day involvement with the person.
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There are three main aims with this method:
Aren’t you Why should I
1. to equip the family to address problems worried about what other be worried? He is my
constructively people might say if you take son and the same as
2. to involve the family in supporting recovery of him to the wedding? all my other children.
the person
3. to promote more healthy communication
within the family (to improve quality of life and
reduce symptoms and relapse).
Supporting families is also important, and is
covered in Chapter 12 (12.6).

5.24.2 How to use ‘supporting

families’ Try to obtain detailed and specific information
Step 1. Assess the situation (e.g. about the daily routine) and observe how the
family talks about (and to) the person as well as
When assessing the family, remember that differ-
what the family says. When assessing communi-
ent family members may differ in their attitudes
cation, look out for the following unhealthy com-
and communication, and that the family may
munication patterns:
vary over time with respect to their strengths and
problems. Families are dynamic, so it is not help- ●● not allowing the person to speak
ful to label a family as ‘a problem family’. Your role ●● family members not expressing their needs
is to draw on the strengths of the family and help and expectations clearly or contradicting each
to address the current weaknesses in a supportive other
way. ●● negative remarks about the person’s behav-
If you ask family members directly about their iour, e.g. ‘He just sits in his room all day long’
attitudes towards the person and their communi- (critical tone)
cation styles, you are not likely to get a very realis- ●● negative evaluations of the person which are
tic understanding. The family member may want not linked to a specific behaviour, e.g. ‘I don’t
to paint a rosy picture and may feel defensive want to be with her anymore’ or ‘He is not
about expressing negative feelings. Therefore, good at anything’
start the assessment with indirect questions that
will allow the family members to feel more com- ●● over-concern, indicated by self-sacrificing be-
fortable and will still give you the information that haviour, exaggerated emotional responses or
you need. By demonstrating empathy and good extreme overprotectiveness, e.g. ‘I am the only
listening skills (2.1.1) you can also encourage one who understands him’ or ‘I can’t leave her
the family to speak frankly about the issues. This alone even for a minute’.
is a necessary first step in order to help the family Healthy family communication typically com-
and the person. prises warm and positive remarks, showing ap-
Ask the family: propriate levels of sympathy, concern, empathy
●● What problems are you facing because of your and enjoyment of the person’s company, e.g. ‘He
family member’s problems? is very loving towards his sister’ or ‘She tries to
●● What is the person’s daily routine? help to the best of her ability’ or ‘I know he finds it
difficult to cope with the side-effects’.
●● What level of duties and responsibilities is the By the end of the assessment you should have
person given? a clear understanding of:
●● What are your hopes/expectations of the ●● any knowledge gaps, misunderstandings or
person? negative attitudes regarding the cause of the

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mental health problem and its effect on the and misconceptions about the impact of the
person mental disorder or disability on functioning
●● the degree to which family members have re- and realistic expectations for recovery. For ex-
alistic expectations about recovery ample, for the family who comment that the
person is ‘lazy’, it is necessary to explain that
●● the problems facing the family and the highest
this behaviour could be related to the mental
priority problems to solve
disability (e.g. a person with chronic psychosis
●● the family’s strengths (e.g. coping strategies, may lack motivation and drive to do tasks) or a
attitudes, understanding) side-effect of medication (e.g. sedating effects
●● healthy and unhealthy communication within of antipsychotic medications), or because the
the family. person does not have any routine to their day
or meaningful activities to do.
Step 2. Problem-solving ●● For the family who are impatient with the
Some of the common problems experienced by person’s lack of progress in resuming work
families who have a member with a long-term or other activities, it might be helpful to com-
mental disorder or disability are: financial hard- pare mental disorder and disability to a physi-
ship, handling suicidal behaviour or violence, the cal illness. If someone breaks a leg, even after
person refusing medications, coping with the per- it has healed, they still have to slowly regain
son’s sexuality, substance use, marital difficulties their strength and ability to use their leg fully.
(when the spouse is the person with the mental Similarly, even when the obvious signs of men-
disorder), and missed opportunities due to need tal disorder have gone, the person still needs
to provide care. Use a problem-solving strategy time to get well. With a broken leg there can
(5.11) to support the family in identifying the sometimes be permanent disability; this can
main problems; focus on one priority problem, also be the case with mental disorder. In that
identify potential strategies to overcome it and case, the person has to have time and support
then test out the strategies (Table 5.8). to learn a new way of living with the disability.
●● For the family who are excessively negative
Step 3. Supporting recovery about the person’s chance of recovery, a differ-
ent approach is needed. You can explain that
Provide information mental disorder does not mean the person
●● Give the family information to address gaps will never be able to function again, although

TABLE 5.8 EXAMPLE OF A PROBLEM-SOLVING STRATEGY IN PRACTICE

Define the problem ‘Son’s threatening behaviour towards mother’
Summarise Worse when her son is unwell but also triggered whenever she asks him to do
anything.
Define solutions How can her son’s mental health be optimised? Can he be brought in for
review more regularly?
How has the mother handled this behaviour in the past? What helped? Who
else is available to support her? Can she involve community elders to speak
with her son? Can she call on the police if needed? What would stop her get-
ting help? Has she explained to her son that she is sometimes frightened?
How does the mother communicate with her son (Step 1)?
Agree on solution Mother decides to ask community elders to speak with her son, as well as to
to be tested agree a way that neighbours can help if she is in trouble.
Test it out and review Son respected community elders and has not been threatening since they
spoke to him.

they may not get back to their previous level

Step 4. Communication
of functioning. The family may also worry that Provide information
giving the person tasks and responsibilities
●● If the family appears to have communication
might make them unwell again. You can ex-
problems, explain to them about the link be-
plain that gradually giving the person tasks
tween the family’s way of communicating and
and involving them in activities is actually im-
the mental health of the person (and the rest
portant for their mental health. It is also the
of the family too). Start by giving information
only way that the person can start to regain
about healthy forms of communication and
skills and become more functional.
noting which of these strengths you have ob-
Get the family involved served in the particular family. Then explain
Work with the family to find concrete ways in about unhealthy forms of communication.
which they can support the person to recover. Describing the ‘do’s and don’ts’ of communi-
Be guided by the recovery goals set by the per- cation may be helpful (Table 5.9).
son (5.20) and the steps to achieving recovery ●● Discuss with the family about the specific un-
(5.20). healthy communication patterns that seem to
●● Start by asking the person how they would be present in the family.
like the family to support them to recover.
Practise positive communication
If the person refuses family involvement,
explain to the family that they need to be ●● Agree with the family on how to improve their

TABLE 5.9 THE DO’S AND DON’TS OF COMMUNICATION

Do Don’t
Speak one at a time All talk at the same time
Address comments about the person to them Talk about the person but not to them
directly
Make sure that everyone in the family has an equal Leave out the person so that they have no oppor-
chance to speak. Give the person time to speak tunity to speak
Listen to what other family members have to say Ignore others and assume that they have nothing
to contribute
Express feelings honestly Make rejecting comments
Be specific when expressing unhappiness or anger Make general negative comments about the
about a behaviour person
Express positive feelings when the person makes Focus only on the negative
progress, however small

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TABLE 5.10 UNHELPFUL AND CONSTRUCTIVE WAYS OF COMMUNICATION
Unhelpful ways to Constructive communication Message
communicate
‘Why are you so lazy and slow?’ ‘Don’t worry how long it takes.’ The person’s difficulty with func-
tioning is not their fault.

‘You’re a mental patient, you ‘Can you help me with the weed- Mental disorder doesn’t mean
can’t do anything.’ ing? But let me know if you need a person will never work again,
a rest.’ but they may need to start
slowly and with support.

‘Yes, yes, I’ll get your food ‘We’ll all eat together in an hour.’ Try not to make the whole
straight away.’ family routine revolve around
the person with mental health
problems.

‘How many times do I have to ‘It’s hard for me to understand It is not helpful to confront delu-
tell you? There is nobody try- the things you say, but I am wor- sions. Express loving concern
ing to harm you. It’s all in your ried about how upset you are.’ without colluding with the false
head.’ belief.

‘He will have some of the meat ‘What would you like to eat?’ Allow the person to speak for
stew and some potato.’ themselves and make any choic-
es that they can for themselves.

5.24.3 Challenges Step 1. Train the befriender

It may not be possible to get the key members of The befriender needs to have a clear understand-
the family to attend the clinic (e.g. because they ing of their role. They are expected to:
are at work) or to cooperate with your efforts. ●● provide emotional support by being friendly
Some family members may be against the idea and warm
of a medical approach to treatment for mental ●● provide the person with any information they
disorders, while others may actively discriminate might need, for example, about community
against the person. For uncooperative families, events
try to use counselling strategies to improve their
●● support the person with activities, includ-
motivation to change (5.17). If you are con-
ing support with their health care such as ac-
cerned about a family acting in an abusive way
companying to the clinic or reminders to take
towards the person and not being receptive to ad-
medications
vice and support, speak with your seniors and try
to involve other members of the family who are ●● give the person company, for example, to go
more receptive or respected members of the com- for a walk.
munity who could try to engage the family. Befrienders also need to be trained in recog-
nising the early signs of a relapse or worsening of
the mental health problem so that they can take
5.25 Befriending appropriate steps to refer the person if needed.

5.25.1 When to use befriending Step 2. Introduce the person to the idea
Befriending is most useful for people with mental of befriending
disability who have become isolated from society It is important that the person understands that
and have no social support networks. The person ‘befriending’ is not the same as a ‘friendship’.
should be stable and not behave in a way that Befriending is usually time-limited, although the
might put others at risk if meeting one-to-one. length of time varies and needs to be agreed for
The befriender could be a community volunteer each individual befriender–person pair. It is pos-
or a community-based worker (not necessarily a sible for the relationship with the befriender to
health worker), or a person with a mental disorder evolve into a lifelong friendship. It is also very

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important to obtain agreement from the per- 5.25.3 Challenges
son for this method, as it does involve sharing
information about their health problem with a Finding community-based workers or volunteers
stranger. who can befriend over an extended period of time
may be challenging. The person with a mental
Step 3. Plan and carry out the health problem may express symptoms which are
distressing to the befriender (e.g. accusations or
befriending resentment), or they may have unrealistic expec-
Careful selection of the befriender is important, tations (e.g. of being given money). Befrienders
as well as careful matching of befriender to the may suffer mental health problems themselves
person. The befriending relationship is not so pro- from time to time and you should pay close atten-
tected by professional boundaries as the relation- tion to this relationship in these circumstances. A
ship between a health worker and the person they further challenge is to handle the person’s expec-
care for. For example, the befriender may share tations that this is a new friendship, rather than a
details of their personal life with the person. Try time-limited period of friend-like support.
to minimise any possibility of exploitation by ei-
ther side.
The befriender is not a counsellor. They are 5.26 Support groups for mental
expected to meet up with the person in a com-
munity location, for instance, in a tea shop, and
health
converse with them on neutral topics, such as
sports, news stories or television programmes,
depending on their common interests. If the per-
son discusses symptoms (e.g. expresses distress
about something), the befriender should listen
attentively and ask if the person has been taking
their treatment (and, if not, encourage them to do
so) and suggest that the person goes to the clinic
for a review. The frequency of contact will depend
on the person. Weekly is good at the beginning
while the befriender and person are getting to
know one another. The meetings can be as short
as 20 min or as long as is comfortable for both.

Step 4. Review, encourage and support 5.26.1 What are support groups
Ask the person how the befriending is going when and when to use them?
you review them; congratulate them on their suc-
cess and help trouble-shoot where necessary. Support groups are groups of people who meet
For example, some people struggle to maintain a regularly to share and discuss issues of common
conversation; the health worker may suggest that interest. Members of a support group share some
they might do an activity with the befriender that characteristic with each other. In dealing with
does not involve conversation, for instance, go to mental health problems, there are two types of
a movie together. The person will still have some support groups.
social contact but without any pressure to talk 1. Groups consisting of persons suffering from
more than is comfortable for them. the same type of mental health problem. The
best example of such groups are Alcoholics
Anonymous groups where individuals with
drinking problems meet regularly.

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may be eligible to participate in the group to The group leader can conduct meetings in the
attend that meeting to find out more about following ways.
the group. 1. Welcoming all members and asking each per-
2. Helping provide a space for meetings. son to introduce themselves and what they
Ideally, support groups should meet in the hope will be achieved in the group.
homes of the members. However, this may 2. Stating the purpose of the group, by bringing
not always be possible. In these situations, the together what each member has suggested.
health worker may offer a room in the clinic
3. Sharing information which is relevant to the
during hours when it is not too busy. This way,
members of the group.
members can meet in a safe place and com-
bine their participation in the support group 4. Asking members to share their concerns on any
with a consultation with the health worker if issue which is relevant to the group. Members
they so wish. may respond by providing information, shar-
ing their own experiences and expressing sup-
3. Facilitating the group. The notion of self-
port. The discussion between members forms
help groups is unfamiliar to many people. The
the core activity of the group.
health worker can have a guiding role in help-
ing getting a group going by participating in 5. Summing up at the end is a way of ensuring
the first few meetings. that the group discussions come to some kind
of sensible conclusion. The date and time of
The first meeting the next meeting is agreed.

The first meeting is an important time to set the Keeping the group going
agenda for the group. What sorts of activities
will the group get involved in? How often would Group members should regularly review how the
it meet? (Box 5.11, Box 5.12) The next impor- group is getting on. A health worker may attend
tant issue is selecting a group leader who can en- occasional meetings of the group to provide in-
courage participation by other members. Often, formation and advice on how to keep the group
the person who took the lead role in helping set going.
up the group becomes the group leader and,
sometimes, the health worker can play the part 5.26.4 Challenges
of group leader for the first few meetings. Once
Common difficulties which may occur in keeping
members are comfortable in running the group
groups going are the convenience of the meet-
themselves, one of the members can be selected
ing place, difficulty in finding time to attend the
by the group to be the leader. The leadership posi-
groups, finding the discussions unhelpful and
tion may change with time.
feeling marginalised in the group. Identifying
these difficulties is important if solutions are to
BOX 5.11 GROUP RULES
help the support group work properly.
There are some basic rules in every group.
○○ What goes on must be kept confidential.
○○ You should be prepared to listen to others
and, when you feel comfortable, share your
own experiences.
○○ Do not make judgements or criticise others.
○○ Respect every other member’s situation. What
is right for one person does not have to be
right for the others.

Q: How many members can take part? Q: How much will it cost?
A: There is no perfect number. Most groups start A: It should not cost anything to be a member of
off very small. If the group gets too large, then it a support group. The only expenses may be those
is obviously helping many people. Smaller groups required to host the group (e.g. snacks and drinks)
can then be worked out based on factors such as and all members can contribute towards the cost
area of residence or age of the participants. of these.
Q: Where should the group meet? Q: How long will the group last?
A: Anywhere convenient with enough space and A: As long as its members feel that it should go on.
privacy. Ideally, the meeting place should be the Successful groups have no time limit at all. For ex-
same each time. Some groups may move around ample, Alcoholics Anonymous run for an indefinite
by taking place in the homes of different members period of time. Participants may change over time;
on different occasions. some may stop attending, while new members
may join.
Q: How often should the group meet?
A: The group itself should decide on how frequent-
ly they will meet. To make it easy to remember, it
helps to have a specific way of remembering the
day of the meeting, for example, the first Saturday
of every month.

5.27 Putting it all person with a mental health problem who you
see in your practice may need a different com-
together to plan care bination of these treatments, depending on the
In this chapter we have introduced you to a wide specific factors that have led to them developing
range of medications, counselling methods and a problem, their preferences and the availability
social interventions. In the rest of the manual, of treatments in your particular facility. See below
you will see how different combinations (or ‘pack- for a quick summary of principles when helping
ages’) of these treatments can be used to treat someone with a mental health problem.
different kinds of mental health problems. Each

chapter 5 summary box

things to remember when treating someone with a mental health problem
○○ Medications, counselling and social interven- ○○ Families can be important for ensuring the
tions need to be combined for each person with success of treatment, but always respect the
a mental health problem, depending on their wishes of the person with mental health prob-
particular needs lems in terms of how much family involvement
○○ Treatment often needs to be given over a they want.
period of a few months, sometimes longer. It is
critical, therefore, that the person becomes an
active partner in their own care in order to get
the best results.

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notes

Parts 1 and 2 of this manual discussed the general issues that apply to all mental health problems and
treatments. Part 3 will take you through the common types of clinical problems associated with mental
health problems. A problem-solving strategy is used. This means that mental distress, disorders and
disabilities are discussed according to how you would approach a person presenting with a particu-
lar kind of problem. Diagnoses are not used as the starting point, since this would assume that you
will already know what the problem is. Instead, we begin with clinical problems that you are likely to
encounter and then work our way to finding out how you can help the person with the problem. It is
important that you are familiar with Part 1 before you use the problem-solving strategy used in Part 3.
The clinical problems associated with mental health are grouped into six major groups. Chapter 6
covers emergency presentation where an immediate response is required. The approach to assessing
the emergency and providing intervention is laid out in flow charts which you can refer to quickly. You
can copy the charts and put them up on the wall so that anyone can find them easily if they need them.
Chapter 7 covers the non-emergency response to the most disturbing and worrying clinical prob-
lems that you will encounter. The most common causes of such severe behaviour changes are the
psychoses.
Chapter 8 deals with physical symptoms such as tiredness, aches and pains, and dizziness. These
are among the most common of all health problems in general health care, but often no ‘medical’ or
physical explanation can be found for them. The most common causes for such symptoms are depres-
sion and anxiety disorders. Common problems affecting any community are alcohol and drug depend-
ence. These are discussed in Chapter 9, along with dependence on prescription medications, tobacco,
gambling and the emerging problem of internet addiction.
Chapter 10 examines problems arising from loss and violence. Violence can do a great deal of harm
to mental health. Losing someone through death (bereavement) is also a trauma, especially when the
loss is sudden and unexpected. The most common mental health problems associated with these ex-
periences are depression, anxiety and post-traumatic stress disorder (PTSD). There are a number of
important mental health problems in childhood, many of which can affect the child’s ability to com-
plete education and to relate to others in the family. Childhood mental health problems can also lead
to problems in adjusting in adolescence. These issues are the subject of Chapter 11.

This chapter contains 11 flow charts to assist you

with assessing and treating the most common
mental health emergencies. The first flow chart
Try to learn these emergency flow charts so
that they are easier to use in an emergency situ-
ation.
(6.1) is a master flow chart for acutely disturbed After addressing the emergency, you can then
behaviour. By following this flow chart you can refer to other sections of the book (as indicated)
work out which of the other flow charts you then for the further non-emergency management of
need to use for the specific cause of acutely dis- the problem.
turbed behaviour (flow charts 6.2 to 6.10). These flow charts can be photocopied and dis-
As you can see from the master flow chart, played in a place where they can be easily seen in
when a person has acutely disturbed behaviour it an emergency. If you do this, always display the
is important to first of all check airway, breathing master flow chart (6.1) alongside the other flow
and circulation, and provide immediate resuscita- charts.
tion if needed. The next step is to work out wheth- The following symbols were used in the flow
er the disturbed behaviour has a physical cause (if charts:
so, go to flow chart 6.2), or is caused by substance BP, blood pressure
use (intoxication or withdrawal) or poisoning i.m., intramuscular
(flow charts 6.4–6.8). i.v., intravenous
Only after excluding those causes of disturbed p.o., orally
behaviour should you start to consider mental p.r., rectally.
health causes. This is the case even if the person
has a known mental health problem: you still
need to exclude these other causes of disturbance
first. If the disturbance is due to a mental health
problem, the next step is to decide whether it
is related to a mental disorder or disability (e.g.
psychosis, mania, dementia, developmental dis-
ability) (flow chart 6.9) or is due to mental distress
(flow chart 6.10). The last flow chart (6.11) covers
the emergency management of a person having
a seizure.

Be safe: involve others and remove dangerous objects

Airway, breathing, circulation: immediate resuscitation

Is there an acute medical cause?

Yes
○○ Does the person know the time, place and who people are?
Flow chart 6.2
○○ Abnormal pulse, BP, breathing rate or temperature?
Delirium
○○ Any head injury?
○○ Low glucose or hypoxia?
No

Is it due to poisoning or intoxication? Flow chart 6.3

Suicidal poisoning Suicidal/poisoning
○○ pesticide poisoning: pinpoint pupils, increased secretions, reduced
breathing rate, high/low BP Flow chart 6.4
○○ overdose of tricyclic antidepressant: increased pulse, low BP, reduced Yes Alcohol intoxication
breathing rate, dilated pupils
Flow chart 6.5
○○ alcohol intoxication or benzodiazepine overdose: smells of alcohol, has
Opioid/benzodiazepine
access to benzodiazepines, slurred speech, disinhibited
overdose
Opioid overdose: injection sites, pinpoint pupils, low breathing rate
Stimulant drug intoxication (e.g. cocaine, amphetamine): dilated pupils, Flow chart 6.6
excited or disordered thinking, paranoia Stimulant intoxication

No
Flow chart 6.7
Is it due to substance use withdrawal? Yes
Alcohol/benzodiazepine
○○ Recently stopped opioids, alcohol or benzodiazepines
withdrawal
○○ Restless and agitated; sweating, vomiting
○○ Increased pulse and BP Flow chart 6.8
No Opioid withdrawal

Is it a mental disorder or disability?

○○ Person hearing things that are not really there? Suspicious?
Yes
Flow chart 6.9
○○ Does the person believe that they have special powers?
Acute mental disorder
○○ Has the person got lifelong slow development?
○○ Has the person got chronic memory problems?

No
Yes
Is it mental distress? Flow chart 6.10
○○ Has the person recently experienced a traumatic or distressing event? Acute mental distress

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6.2 Emergency flow chart: delirium
Confirm: the person is confused (doesn’t know the correct time or place or
doesn’t recognise people) but is not intoxicated with alcohol or drugs

Monitor airway, breathing and circulation and resuscitate if needed.

Then treat any underlying physical health problem

Optimise the environment

○○ Quiet with adequate, low-level lighting
○○ Accompanied by someone known to the person
○○ Remove dangerous objects
○○ Calm and vigilant health care staff

If the person has disturbed behaviour

○○ Try to calm the person: give reassurance, explain what is happening, try to understand and address
their concerns

If the disturbed behaviour persists AND is:

○○ interfering with essential medical procedures
○○ putting the person at immediate risk of harming themselves or others

Give low-dose antipsychotic medicine

Offer oral medicine first:

haloperidol 0.5–2.5 mg p.o. or risperidone 0.25–1 mg p.o.
If refuses, restrain safely and give:
haloperidol 0.5–2.5 mg i.m./i.v. or olanzapine 2.5–10 mg i.m.
How to restrain: make sure you have
enough people and hold the person down
firmly using hands. Always prepare the
injection before you restrain someone.

Monitor pulse, BP, breathing rate and temperature every 15 min

Review response after 30 min. Repeat if needed

Refer urgently if possible

Person expressing suicidal ideas or plans

or who has attempted suicide

Refer for urgent hospital

treatment
○○ Signs of poisoning or intoxication
○○ Loss of consciousness or extreme lethargy
○○ Bleeding or injury from hanging, gunshot Yes
Pesticide poisoning
wounds, stabbing, deep cuts or burning
If unable to transfer, give activated
charcoal if the person:
No ○○ is conscious
○○ is within 1 h of taking poison
○○ gives consent.
○○ Do not leave the person alone Do not induce vomiting or use gastric
○○ Do not keep the person waiting lavage

Manage imminent suicide risk

Imminent risk of suicide? ○○ Remove any means for self-harm
(e.g. poisons, guns)
○○ Current thoughts or plans to commit suicide
Yes ○○ Ensure continuous observation
OR recent suicidal thoughts and plans, together
○○ If possible, consult with a mental
with:
health specialist or refer
○○ severe mental distress or hopelessness
○○ Inform family about suicide risk
○○ extreme agitation or violence
○○ Identify and treat mental, physical or
○○ uncommunicative or socially withdrawn
substance use disorders
behaviour
○○ Advise family on need for support
○○ Follow up within 1 week

See chapter 7 (7.6) in Where There is No Psychiatrist (2nd edn) for full assessment

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6.4 Emergency flow chart: alcohol intoxication

Confirm alcohol intoxication: smells of alcohol, slurred speech, disinhibited,

agitated or aggressive

AQ. if
Assess airway, breathing and circulation: give immediate resuscitation if needed needed?

Check that no physical problem is ALSO present

(e.g. infection, head injury, stroke, low blood glucose, hypoxia, liver failure)
 Treat the physical problem

If methanol poisoning is suspected, refer urgently for hospital treatment

Try to avoid medications if at all possible

If disturbed behaviour AND the patient is risking the safety of themselves or others
haloperidol 2.5–5 mg (oral, i.m. or i.v.)

Monitor airway, breathing and circulation

Place on side to prevent choking if the person vomits

Observe until the effects of alcohol wear off

See chapter 9 in Where There is No Psychiatrist (2nd edn) for full assessment

For opioid overdose: look for injection sites, pinpoint pupils, low breathing rate,
whether known user of opioids

For benzodiazepine overdose: look for history of taking benzodiazepines,

slurred speech, whether disinhibited, agitated or aggressive

Airway, breathing, circulation: immediate resuscitation

If breathing rate < 10 per min

OR
oxygen saturation < 92%

If opioid overdose:
○○ give naloxone 4 mg subcutaneous, i.m. or i.v.
○○ observe for 1 to 2 h after administering
○○ if long-acting opioid overdose (e.g. methadone), transfer to hospital

If benzodiazepine overdose, transfer urgently to hospital for support with breathing

See Where There is No Psychiatrist (2nd edn) for full assessment of suicidal
behaviour in chapter 7 (7.6) and substance use problems in chapter 9

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6.6 Emergency flow chart: stimulant intoxication

Look for features of stimulant intoxication:

dilated pupils, excited or disordered thinking, paranoia, disturbed behaviour

○○ Give diazepam 10 mg p.o.

○○ If person refuses, give i.v. only if aggressive behaviour is associated with imminent
risk of harm to the person or others

If symptoms persist after 20 min, give further diazepam 10 mg p.o. or i.v.

If paranoia and other psychotic symptoms persist:

haloperidol 2.5 mg p.o., i.m. or i.v.
OR chlorpromazine 75 mg p.o. or i.m.
OR olanzapine 10 mg p.o.
OR risperidone 2 mg p.o.

Monitor BP, pulse, breathing rate and temperature every 2 to 4 h

Transfer urgently to hospital if the person has:

○○ chest pain
○○ abnormal heart rhythms
○○ if the violence is unmanageable

Be alert for suicidal ideas and actions as intoxication wears off

See chapter 9 in Where There is No Psychiatrist (2nd edn) for full assessment
of substance use

Identify alcohol withdrawal: history of heavy alcohol drinking or recently stopped, restless and agitated;
sweating, vomiting, increased pulse and BP

Any physical health complications?

Yes
○○ Treat physical problem
○○ Low glucose, head injury, infection, stroke,
○○ Refer to hospital
liver failure

No
Yes
Signs of alcohol withdrawal-related delirium? ○○ Treat for physical withdrawal
○○ Confusion, fear, seeing or believing things ○○ Consider haloperidol 2.5–5 mg p.o., i.m. or
that are not real i.v. up to three times per day
No

Signs of Wernicke’s encephalopathy? Yes

○○ Give thiamine 100 mg i.m. or i.v. three
○○ Confusion, unsteady walking, eyes not
times per day for 3 to 5 days
moving together

Treat for alcohol withdrawal

Treat immediately with oral diazepam 10 mg p.o. (5 mg if liver is damaged and monitor carefully)

If no improvement after 1 h, give another 10 mg diazepam p.o.

Use up to 40 mg in 24 h. If more is needed, refer to hospital

Give oral thiamine 100 mg (once per day for 5 days)

For alcohol withdrawal-related seizures

treat with diazepam (or another benzodiazepine) only

See chapter 9 (9.1) in Where There is No Psychiatrist (2nd edn) for further
management of alcohol use disorder

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6.8 Emergency flow chart: opioid withdrawal

Identify opioid withdrawal: history of using opioid and recently stopped, restless and
agitated, sweating, vomiting, increased pulse and BP

Give reassurance
Opioid withdrawal is unpleasant but not life-threatening

If specialist support is available, treat with opioid replacements

(methadone or buprenorphine)

If no specialist support is available, consider:

clonidine OR lofexidine 0.1 to 0.15 mg p.o. (up to three times per day)

Treat specific symptoms as needed, e.g.:

○○ loperamide 2 mg p.o. for diarrhoea
○○ domperidone 10 mg p.o. for vomiting
○○ paracetamol 1 g p.o. for muscle pain
○○ promethazine 25 mg p.o. for insomnia

Oral or i.v. rehydration as needed

See chapter 9 (9.2) in Where There is No Psychiatrist (2nd edn) for further
management of substance use disorder

Identify symptoms of psychosis, mania, dementia or developmental disability

Treat in a quiet place and remove dangerous objects

If trying to calm the person is unsuccessful, offer oral medicine first:

○○ antipsychotic medicine: haloperidol 2.5 mg p.o. OR chlorpromazine 75 mg p.o.
OR olanzapine 10 mg p.o. OR risperidone 2 mg p.o.
○○ AND/OR diazepam 10 mg p.o. OR lorazepam 1–2 mg p.o.
○○ Do not use medication to treat behavioural disturbance in a child
○○ Avoid benzodiazepines for dementia
○○ Use lower doses in elderly and people with medical conditions

If the person refuses oral medicine, only treat against their will if there is an immediate
risk of harm to them or to others
Restrain the person in a safe way (see flow chart 6.2)

Antipsychotic: haloperidol 5 mg i.m. OR olanzapine 10 mg i.m.

OR chlorpromazine 25 to 100 mg i.m.
AND/OR diazepam 10 mg i.v. or p.r. OR lorazepam 1–2 mg i.m.
AND/OR promethazine 50 mg i.m.

Wait for 30 min

If disturbed behaviour persists, repeat the dose

Monitor pulse, BP, breathing rate and temperature every 30 min

Refer to hospital if still no response

See chapter 10 in Where There is No Psychiatrist (2nd edn) for further

management of aggressive/violent behaviour

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6.10 Emergency flow chart: acute mental distress

Person who has recently experienced a traumatic or stressful event and is distressed

○○ Speak to the person in a calm voice

○○ Find a quiet and private place
○○ Do not force the person to speak about their experiences
○○ Offer your support through listening

If the person has been the victim of a physical or sexual assault, follow local guidelines
for physical examination and reporting to police

Only if the person cannot be calmed and remains extremely distressed, give
diazepam 10 mg p.o.

Screen for suicide risk and manage the risk (see flow chart 6.3)

Identify someone who can be with the person while they remain acutely distressed

Offer an appointment to review within 1 to 2 days

Emergency assessment Emergency treatment

BP, temperature, breathing rate Check airway, breathing and circulation:
Signs of head or back trauma or focal deficits Immediate resuscitation
Signs of intoxication: pupils dilated/pinpoint Protect from injury
Signs of meningitis (stiff neck, rash) Put person on side (recovery position)
Do not put anything in their mouth

If pregnant or <1 month For all other seizures If possible medical

postpartum problem or drug use

○○ Insert an i.v. line, take blood and give fluids

If no history of epilepsy, slowly (30 drips/min) Screen for:
suspect eclampsia ○○ Glucose i.v. (adults 5 ml of 50% glucose, ○○ pesticide or tricyclic
○○ Give magnesium children 2–5 ml/kg of 10% glucose) antidepressant
sulphate 10 g i.m. ○○ Diazepam i.v. 10 mg slowly (child: 1 mg/year poisoning (flow chart
○○ Give 5 g (10 ml of 50% of age) 6.3)
solution) i.m. deep in ○○ If cannot get i.v. access: give diazepam ○○ stimulant intoxication
upper outer quadrant p.r. (same dose as above) OR intranasal (flow chart 6.6)
of each buttock with midazolam (adult 10 mg, child 0.2 mg/kg) OR ○○ alcohol or
1 ml of 2% lignocaine buccal or i.m. midazolam benzodiazepine
in the same syringe. ○○ DO NOT give i.m. diazepam withdrawal
If seizure does not stop after 10 min, give second (flow chart 6.7)
○○ If diastolic BP is
dose of diazepam/midazolam and If head injury or infection
>100 mmHg: give
REFER URGENTLY TO HOSPITAL of brain or meningitis
hydralazine 5 mg i.v.
DO NOT give >2 doses
slowly (3–4 min). If i.v.
is not possible, give Manage the seizures as
For people who have: for ‘all other seizures’
i.m. if diastolic BP
repeated seizures without regaining
remains >90 mmHg,
consciousness OR REFER URGENTLY TO
repeat dose at 30 min
seizures that don’t stop with 2 doses of HOSPITAL:
intervals until diastolic
diazepam ○○ If head or neck injury:
BP is around 90 mmHg.
○○ consider conversion disorder (triggered by DO NOT move neck
○○ Do not give more than
emotional stress) (8.6) because of possible
200 mg in total.
○○ administer oxygen cervical spine injury.
○○ Refer woman urgently ○○ check need for intubation/ventilation Log-roll person when
to hospital and follow Give: phenytoin 15–18 mg/kg i.v. (through moving.
local guidelines different line to diazepam) over 60 min ○○ Brain infection or
for management of OR phenobarbital 10–15 mg/kg i.v. (rate of 100 mg/ meningitis: manage
pregnancy, childbirth min). A good i.v. line is essential. the infection according
and postpartum care. If seizures continue: give the other drug (if to local guidelines.
available) OR additional phenytoin 10 mg/kg i.v.
(through different line to diazepam) over 30 min.
Monitor for respiratory depression

If seizure resolves, see chapter 7 in Where There is No Psychiatrist (2nd edn) for further management

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8 Symptoms that are
medically unexplained

8.1 The person with unexplained

physical complaints
Physical complaints are the most common rea-
sons for seeking help from a health worker.
Many symptoms, such as fever or cough, can be
explained by medical problems. However, there
are some complaints for which it is often difficult
to find any medical reason. This chapter is about
such complaints. Common examples are:
●● headaches
●● tiredness
●● aches and pains all over the body
●● burning or crawling sensations on the skin
●● chest pain
Unexplained physical complaints often affect multiple
●● heart beating fast (palpitations) parts of the body.
●● dizziness
●● When you are anxious, you may breathe much
●● low back pain faster, which leads to changes in the levels of
●● abdominal pain oxygen and carbon dioxide in the blood. These
●● sex-related or menstrual pain changes can produce symptoms such as dizzi-
ness, palpitations, tingling or numbness of the
●● gynaecological complaints such as vaginal
fingers and toes and a choking or breathless
discharge
sensation (a ‘panic attack’) (8.2.1).
●● bowel problems
●● When you are depressed, it is common to feel
●● difficulty breathing. physically exhausted, which can be caused by
the poor sleep or low mood associated with
8.1.1 How are physical complaints depression.
relevant to mental health? ●● Alcohol can produce physical complaints
because of its effects on various body organs
There is a strong relationship between mental if used in a harmful manner (9.1).
health problems and physical complaints, for a
●● People may feel that if they tell the health
number of reasons.
worker that their main problem is emotional,
●● Worry and tension can make you tense your they may not get help. Thus, they focus on the
muscles for long periods. This makes muscles physical complaint as a way of getting your
tender and painful. A good example of this is attention.
the ‘tension’ headache as a result of tensing
●● Many languages describe emotional pain in a
up neck muscles when one is worried.
physical way. For example, in English, one can
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say ‘my heart is heavy’ to describe a sad mood. 8.1.3 How to deal with this problem
Thus, the physical symptom is simply another
way of expressing mental pain. Questions to ask the person
●● Painful illnesses, such as arthritis, can make ●● When did this start? (The longer the symptom
a person feel unhappy and worried. Here, duration, the more likely it is related to a mental
the pain is caused by a physical illness, but health problem, but also, the less likely the per-
it affects the person’s mental health. Feeling son is to fully recover.)
depressed can make the pain less bearable.
●● Do you have tension in your life? Are you think-
●● Some mental disorders can lead to physi- ing too much about things? Have you been
cal health problems or make them worse, for feeling like you have lost interest in things re-
example, depression or anxiety can increase cently? Have you been feeling tense, worried
the risk of developing heart disease. or scared recently? (Ask questions for depres-
●● In one particular type of anxiety disorder, the sion and anxiety 3.9.)
key symptom is excess worrying about physi- ●● Do you drink alcohol? (If yes, follow further
cal health. Typically the person is convinced questions on problem drinking 3.9, 9.1.)
that a completely harmless physical sensation
●● What do you feel has caused your symptoms?
indicates a very serious illness, and demands
(The person’s views on the illness can be a valu-
medical intervention. They may fail to be reas-
able way of assessing whether it is a mental
sured even after a detailed medical examina-
health problem.)
tion and tests.
●● The medications used for some mental dis- Things to look for during the interview
orders can also produce physical symptoms,
such as dryness of mouth with certain types ●● A worried or unhappy look on the face.
of antidepressants (Box 5.2 and Table 14.1). ●● Any signs of physical illness and weight loss.
These multiple ways in which mental and
physical health are linked together form the basis What to do immediately
of the slogan ‘No health without mental health’.
●● Make sure that the person is not suffering from
a physical illness before you assume that it
8.1.2 When to suspect that is caused by a mental health problem. Carry
physical complaints are related out a physical examination and any necessary
laboratory investigations. If in doubt, consult a
to mental health problems colleague. (For tiredness 8.4; for sex-related
You should think of a mental health problem par- physical complaints 8.5.)
ticularly in a person who: ●● Reassure the person that there is no life-
●● has been examined and has had tests which threatening or serious physical illness. This
rule out other medical causes does not mean that they are not suffering from
●● has several seemingly unrelated complaints some other type of health problem.
●● has complaints which do not fit into any pat- ●● Explain the link between emotions and physi-
tern that you associate with a physical disease cal experiences. Be clear that mental health-
●● has an established medical disease but whose related symptoms are just as real as symptoms
physical complaints seem excessive that are caused by physical health problems, it
is just the cause that is different.
●● whose complaints are associated with prob-
lems in their personal life. ●● Explain that there is no need, at present, for
further tests or investigations.

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and ultimately help them recover through under-
standing the link between the complaints and
mental health or social difficulties and the coun-
selling strategies you have provided.
If the person develops new physical symp-
toms, do not automatically assume that they are
mental health-related. Take the new complaint
seriously and investigate as needed, but do not
be tempted to order investigations if you do not
think there is a physical cause.
Laboratory tests should be used to rule out medical
causes of physical symptoms. When to refer
●● Try to avoid using labels such as ‘mental’ since ●● If you are not sure about the possibility of a
the person may resent this. After all, many physical illness, you should refer for a further
people (and health workers) do not associ- opinion.
ate complaints such as headache with mental ●● Many people with long-standing medically
health problems. Instead, you could say: unexplained physical complaints have social
and personal problems which may be diffi-
‘Your symptoms are being made worse by your
cult to resolve in a clinic. Refer such people to
worries and tension. You have been worried other agencies (Chapter 15).
about your husband’s drinking problem. This
could be giving you a headache and making There is
your heart beat fast.’ nothing really wrong. It is all in
your head.
●● Use the counselling strategies of relaxation
exercises (5.12), problem-solving (5.11),
getting active (5.13) or improving relation-
ships (5.15) as appropriate.
●● For a person who is drinking alcohol at a harm-
ful level 9.1.
●● For a person with irrational anxiety about their
physical health, take the approach as for other
types of worrying (8.2.4).
●● Do not prescribe vitamins or painkillers unless
there is clear evidence of malnutrition or a
This headache is
painful physical illness. really causing you trouble. It is caused by muscle
●● Consider antidepressant medication (Box tension. I can help you to reduce the tension.
5.2 and Table 14.1) if the person has symp-
toms of depression, particularly if they also
have suicidal ideas, weight loss or sleep dis-
turbance, or if they have panic attacks (8.2).

What to do later
Review the person after 1 week and see them reg-
ularly until the complaints have resolved. This will
help reassure the person that their complaints
are being taken seriously, build their trust in you

8.2 The person who worries, 8.2.1 Fear and panic

is fearful or panics When we worry, we become scared that some-
thing unpleasant might happen. This is the basis
Worrying is thinking too much about unpleasant of the emotion of fear. Fear is an important part of
things which are happening or may happen in learning in life. For example, when a student fears
the future. Typical worries are related to money failing his examinations, he may study harder for
problems, relationship difficulties, children’s fu- them. However, when fear is out of proportion
ture and health. Worrying itself is common and a to the situation, it can cause extreme distress,
normal part of life. However, when worrying be- leading to the feeling that the person may die or
comes persistent, out of proportion to what is ac- something terrible might happen to them or their
tually happening in a person’s life, and begins to family. When this happens, fear can become a
interfere with daily activities then it is unhealthy. mental health problem.
Excess worrying can become a problem and actu- Panic attacks are attacks of extreme fear.
ally prevent the person from thinking clearly and Typically, the attack comes out of the blue with-
solving real problems. Depression and anxiety are out any warning. It is associated with such severe
important causes of such excess worrying. physical symptoms (the heart beating fast or dif-
ficulty breathing) that the person is terrified that
they may be having a heart attack, are about to
Worrying all the die or go mad. Many people will have one or
time is exhausting – it is no surprise that two panic attacks at some point in their lives.
you feel tired. If we can reduce your worry
However, sometimes panic attacks become more
then you should have more energy
again.
frequent. When they occur regularly, for example,
once a month or more often, then this signals a
mental disorder (‘panic disorder’).

8.2.2 Being scared of specific

situations (phobias)
Some people get scared of a specific situation
even though the situation is not dangerous. Typi-
cally, the person with these fears will avoid the
situation in order to prevent getting scared. These

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My son
is not studying He will fail He will
hard. his exams! never get a job.

We all have worries in our lives, but if a person does not find a solution for her worries, then she may become sick
with worrying.

He struggles Let me He now has

with maths and needs talk to him about extra help and is doing
some help. his study. better.

But if she thinks about the possible solutions, then she can do something about her worries and feel better.

A panic attack.

a. Sometimes when a person is worried (b) he

may get palpitations of the heart.
c. This can make him even more worried.
d. He may think he is having a heart attack.
e. He becomes terrified that he will die and
consults a health worker. a.

e. c.
d.
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fears are called phobias. Many people have one ●● work difficulties
phobia or another, for example, of spiders or ●● money problems, such as being in debt
snakes. However, some people have phobias of
●● sickness in the family.
everyday situations, such as:
●● crowded places, for example, buses or markets The experience of trauma and violence (10.1)
can also give rise to anxiety and panic, as can alco-
●● open places (anywhere out of the house)
hol and drug problems (including medications
●● social situations, for example, meeting people. such as sleeping pills 9.1, 9.2, 9.3). Some people
If a person has a fear of these situations and worry for no obvious reason and some may have
starts avoiding them, it will severely affect their a lifelong history of being tense or shy.
life, for example, if they are unable to go to work or
to the shops. Often the person experiences panic BOX 8.2 ADVISING A PERSON WITH A PHOBIA
attacks in these situations. When phobias become
so severe, they turn into mental disorders. A phobia is when a person experiences fear, often
panic attacks, in specific situations and begins to
8.2.3 Why do people worry or have avoid them. A person with a phobia should take
the following steps.
panic attacks or phobias? 1. Teach the person that the way of overcoming
Some of us worry when we are under stress. Ex- this fear is by exposing themselves to this situ-
amples of life difficulties that can lead to fear and ation until the fear subsides (‘facing the fear’).
anxiety are: This is the way they can become confident
●● relationship problems, such as marital con- that there is nothing to fear about the situa-
flict, conflict with parents tion.
2. Explain that avoiding the situation only
●● loss of someone close, for example, due to
makes the fear worse. Exposure must be done
death
consistently to build up the person’s confi-
●● loss of a job dence and overcome the phobia. They can be
●● physical illness taught to deal with the fear during exposure
by breathing exercises (as with panic attacks)
BOX 8.1 ADVISING A PERSON WITH A PANIC
and by reassuring themselves in their minds
ATTACK
that the fear is temporary.
Panic attacks are attacks of severe anxiety which 3. Identify the situations which lead to fear and
result from rapid breathing. A person who is af- then grade these situations in a list from the
fected by panic can be taught the following steps. least fearful to the most fearful.
1. To recognise that an attack is beginning when 4. Expose the person in steps starting from
they begin to experience the fearful thoughts the less fearful situations; once they have
or the physical symptoms. mastered this situation and can face it with
2. To immediately remind themselves that they no fear, encourage them to move to the next
are breathing too fast and they should take situation. For example, a house-bound person
control over their breathing. could be encouraged to take a short walk to
3. To breathe in a slow, steady, controlled the neighbour’s home as the first step. This
manner (in a way similar to the breathing step is practised daily until no more fear is
rhythm in relaxation exercises). The breathing experienced. The person must not leave the
should be continued in this manner until the situation under any circumstances. After over-
symptoms of the attack subside. coming this fear, they should move on to the
4. To reassure themselves in their mind that the next step, which could be walking further, say
symptoms are due to breathing too fast and to the post office. Finally, the person will need
that nothing dangerous will happen. to walk to the market.

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My heart is It doesn’t matter
beating fast… I must be whether I have anything to
having a heart attack. I will not go to say… this is a wedding and
the wedding today. What if people are there to enjoy the
someone asks me a question company of their friends. Why
and I have nothing to say? should anyone be judging me on
what I say or don’t say?
a.

My heart is beating
a. b.
fast. This is because I am tense,
and when a person is tense, the heart
always beats fast. I need to relax and a. A worrying thought.
my heart will relax as well. b. A reassuring alternative.

8.2.4 How to deal with ●● Have there been any problems in your life re-
cently? For example, problems in your mar-
this problem? riage/relationship or at work? (Finding out
Questions to ask the person about such problems is an important step in
making the link between life difficulties and
●● How long have you felt like this? (The longer worry.)
the duration, the more severe the problem is ●● Have you lost interest in daily life? (Ask ques-
likely to be and the harder it may be to recover tions about depression (3.9.)
fully.)
●● How did the symptoms begin? ( Symptoms Things to look for during interview
which begin following a stressful event are of-
ten short-lived and the person is more likely to A worried or tense look is typical of a fearful
fully recover.) person. A sad or emotionless face may suggest
depression. Some anxious people are very rest-
●● Are you using sleeping pills or alcohol? (If yes, less and fidgety, for example, constantly wringing
ask about alcohol problems 3.9, 9.1 and de- their hands or shifting in the seat.
pendence on sleeping pills 9.3.)
●● Have you been avoiding any situation because What to do immediately
of your fear? If yes, what situation? How has
this affected your life? (These are questions for ●● Reassure the person, specifically about the
phobias.) following:
●● Does your fear ever get so bad that you feel ○○ the symptoms are not a sign of serious
you might collapse or die? If yes, how often? physical illness (it is important that this
(These are questions for panic attacks.) reassurance is only given if you have com-
●● Have you been affected by violence in the pleted a thorough physical examination
past? (This is to identify trauma-related anxiety and appropriate laboratory tests)
10.1.)

a. First, try going with a friend

to a shop and asking for an
item.
b. Once you can do this
without feeling anxious, when
a. b. with a friend, try asking a
stranger for directions.
c. When you feel comfortable
doing that, try going to a shop
and asking for an item by
yourself.
d. Once you can do that, try
going to a restaurant and have
a tea all by yourself.
c. d.

a. b.
Steps in overcoming phobias
II. Getting used to travelling on
a crowded bus

a. Walk to the bus stop and

wait for the bus but don’t get
on.
b. Once you can do this
without feeling anxious, take
a bus at a time when it is not
crowded.
c. When you can do this
without fear, take a bus
journey with a friend when it is
crowded.
d. When this no longer causes
anxiety, take a bus journey
alone when it is crowded.
c. d.

○○ the symptoms are not a sign that the person ●● The most useful counselling strategies for
is ‘going mad’ panic attacks are relaxation exercises (5.12).
○○ if relevant, the symptoms are not a sign of ●● Other useful counselling strategies are those
witchcraft or spirit possession. related to thinking healthy (5.14) and prob-
●● Explain that worrying is the cause of the symp- lem-solving (5.11).
toms and that the symptoms can make the ●● Give specific advice on panic attacks or pho-
person even more worried. The way to break bias as shown in Box 8.1 and Box 8.2.
this cycle is to reassure oneself when the
symptoms start that they are only the result of
worrying.

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When to use medication Box 5.2 and Table 14.1 for information on
how to use antidepressants.
Two types of medication can be used.
1. Short-term (1 to 2 weeks) prescription of When to refer
benzodiazepines (Box 5.8 and Table 14.5)
should be restricted to special situations, such ●● If you are concerned that the symptoms may
as when: be the result of a physical illness, such as
○○ the person’s anxiety is so great that they are asthma or a health problem.
not able to listen or understand your advice ●● If there are serious life difficulties which could
○○ the person is very tense following a severe be helped by some other agency, for example,
life event such as the death of a spouse the police or women’s groups (Chapter 15).
○○ the person is so tense that they have not
slept well for many days and are now tired – Your symptoms
a good night’s sleep may help them recover are because of attacks of anxiety. These
faster are quite common problems and are not signs
○○ you are starting an SSRI antidepressant for of a dangerous illness. They occur because you are
an anxiety disorder (see below); the person tense or worried about something and this makes you
breathe faster than normal. When you breathe faster,
may need 3 to 5 days of a benzodiazepine
this produces changes in your body which make
medication while their body gets used to your heart beat fast and make you scared
the medication. You could use diazepam that something terrible is about to
5 mg twice daily. happen.
2. Antidepressant medication can be very useful
in these situations:
○○ if there are repeated panic attacks
○○ if the person has depression (7.4)
○○ if the worrying lasts more than 4 weeks
despite your explanation and breathing
exercises
○○ if the person’s life is severely affected (e.g.
not going out of the house at all).

section 8.2 summary box

things to remember when dealing with a person who is worried, fearful or
panics
○○ When worry and fear start affecting a person’s ○○ Treatment consists of advice about the cause
daily life, then they become a mental health of symptoms, relaxation exercises and coun-
problem. selling on how to overcome the mental health
○○ Panic attacks are attacks of severe anxiety. problem.
They are often mistaken for a medical problem, ○○ Antidepressant medication may help people
especially a heart attack, because of the severe with persistent and disabling anxiety problems.
physical symptoms.
○○ Some people avoid situations which make
them scared (phobias). Common situations
which cause this fear are crowded places and
social situations.

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BOX 8.3 ADVICE ON HOW TO SLEEP BETTER

○○ Keep to a regular sleep routine: ○○ Try relaxation exercises before sleeping

○○ go to bed at a fixed time (5.12).
○○ Avoid exercise in the evenings, but exercise in
○○ wake at the same time no
the daytime may help.
matter how much sleep you
○○ Avoid daytime naps.
have had during the night
○○ Worrying about not being able to sleep worsens
○○ use an alarm clock if you the sleep problem.
have difficulty waking at a ○○ Make your sleeping environment ‘sleep
fixed time in the mornings. friendly’: keep the room dark using curtains or
○○ Do not use alcohol or sleeping medications to use eye masks. Close your windows if it is noisy
get to sleep. outside or use ear plugs.
○○ Do not smoke before sleeping; coughing can ○○ If you cannot fall asleep, do not lie in bed; get
keep you awake. up, read a book or relax for 15 to 30 min and
○○ Empty your bladder just before sleeping. then go back to bed.
○○ Avoid tea and coffee in the evening; these are
stimulants and can keep you awake.

●● Educate the person about how to sleep better ●● If you must use medication, monitor the per-
(Box 8.3). son closely.
●● If you identify an underlying mental health ●● Give 1 week’s supply of a sleeping medication,
problem which may be causing sleep prob- for example, diazepam 5–10 mg at night or
lems, treat this as indicated in other sections lorazepam 1–2 mg at night. Ask the person to
of this manual (the likeliest underlying men- return in a week.
tal health problems are alcohol problems and ●● If the person is feeling better, stop the medica-
depression or anxiety). tion. Do not prescribe sleeping pills for more
than 2 to 3 weeks. The prescription should be
When to use sleeping pills for 1 week at a time so that you can review the
Sleeping pills are most commonly benzodiaz- person each week.
epines (e.g. diazepam, lorazepam, nitrazepam ●● Consider alternative medications which also
and so on (Box 5.8)). They are among the most produce sleepiness but are not addictive, for
commonly used medications in the world. This example, antihistaminic medications used for
fact alone shows us how frequent complaints of colds and allergies (e.g. promethazine).
insomnia are. Other medications used for sleep ●● If there is no underlying mental disorder, do
are the ‘Z medications’ (zopiclone and zolpidem), not use sedating antipsychotic medications to
which are similar to benzodiazepines. However, treat sleep problems.
sleeping medications produce an artificial sleep. ●● Give advice about how to sleep better.
They are all addictive so that once a person be-
comes used to taking them, they will not be able ●● For people who are overweight, give advice
to sleep without them (Box 5.8, 9.3). on weight loss, for example, through diet and
The best way to avoid such problems is to fol- exercise.
low these rules. ●● For guidance on how to help a person who has
●● Do not prescribe sleeping medications for been using sleeping medications for a long
people with long-standing difficulties with time 9.3.
sleep or with a history of problem with alcohol
or drugs.
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When to refer ●● Insomnia which does not respond to the
advice above and is causing severe difficulties
●● Physical illness which is causing pain or other to the person’s daily life.
discomfort.

section 8.3 summary box

things to remember when dealing with a person with a sleep problem
○○ Sleeping problems are very common. Insomnia ○○ Simple changes in lifestyle are the best way of
is a health problem if it has been present for at restoring healthy sleep.
least 2 weeks and is causing difficulties. ○○ If using sleeping pills, never use them for more
○○ Depression, alcohol problems, excessive use than 2 to 3 weeks at a time.
of sleeping medications and painful physical ○○ If insomnia is part of a mental health problem
illnesses can cause insomnia. (for example, depression), treat that problem
first.

8.4 The person who is 8.4.2 When to suspect that

tired all the time tiredness is the result of a
Tiredness is one of the most common reasons mental health problem
for feeling unwell. Tiredness can present in many Never suspect a mental health problem until you
ways. One way is feeling fatigued all the time. have confidently ruled out the common physical
When this is severe, even minor activities such as illnesses. Suspect a mental health cause for the
dressing oneself can seem too difficult. Another tiredness:
common way of expressing tiredness is ‘feeling ●● when there is no evidence to suggest a physi-
weak’ or ‘having no energy’ to do things. Tired- cal disease, such as lack of any signs of a
ness is often accompanied by a strong desire to physical disease or the absence of abnormal
sleep (though often the person cannot sleep) or to findings on tests
just lie down.

8.4.1 Why do some Physical health

people feel tired?

Many people feel tired because of viral or other
common infections. In such cases, the tiredness
will have started only a few days earlier. Whenever
tiredness has been present for less than 2 weeks,
you should treat it as if it is probably caused by
an infection. If tiredness lasts more than 2 weeks,
it becomes ‘chronic’ tiredness or ‘chronic fatigue’.
Box 8.4 lists the most common causes of chronic Mental health
tiredness. Lifestyle

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BOX 8.4 THE COMMON REASONS FOR 8.4.4 How to deal with this problem
CHRONIC TIREDNESS
Questions to ask the person
Physical health problems
○○ Moderate or severe anaemia ●● Since when have you been feeling tired? (If
○○ Chronic infections including tuberculosis, more than 2 weeks, the tiredness is chronic.)
hepatitis and HIV/AIDS ●● Have you been feeling physically sick in any
○○ Diabetes other way? For example, have you been cough-
○○ Cancer ing? Losing weight? Do you pass blood in your
○○ Chronic diseases such as rheumatoid arthritis, stools? (These are examples of questions for
kidney disease chronic physical health problems.)
○○ Chronic undernutrition ●● Have you been feeling under stress recently?
Are you thinking too much about things? Have
Mental health problems
you been feeling like you have lost interest in
○○ Depression or anxiety
things recently? Have you been feeling tense,
○○ Alcohol and drug problems
worried or scared recently? (Ask questions for
○○ Poor sleep
depression and anxiety 3.9.)
Lifestyle problems ●● Do you drink alcohol? Do you use drugs? Do
○○ Overwork, especially manual labour you use sleeping pills? (Ask questions for these
○○ Underactivity – doing too little can lead to types of habit problems Chapter 9.)
feelings of tiredness
●● Tell me about the activities you did on an av-
erage day in the past week. (This will give you
●● if there are other features of a mental health an accurate idea of the impact of tiredness on
problem such as multiple physical complaints, daily activities.)
sleep problems or suicidal feelings
●● if the tiredness is out of proportion to the Things to look for during interview
physical illness (e.g. a person may be anaemic,
Carry out a proper physical examination,
but the tiredness is so extreme that the anae-
in particular:
mia alone cannot explain it).
●● a sickly appearance
●● fever
8.4.3 Why tiredness is not
●● abnormal pulse rate
the same as laziness and blood pressure
People who feel tired find it very difficult to get ●● abnormal respiratory rate
any work done. For some women, this can be a
●● signs of anaemia such as a ‘washed-out’ or
great problem and can cause conflict with their
pale tongue, eyes or fingernails
partner or in-laws. When a health worker tells the
family that ‘there is nothing wrong with her’ be- ●● signs of weight loss such as thinning of the
cause they cannot find any physical illness, the muscles of the arms or legs.
family assumes that the woman is pretending to
be tired. Even health workers may think that the Tests and investigations
woman is lazy. Similarly, a man who feels too tired Because tiredness can be a sign of serious physi-
to work but has no obvious illness may be critical illness, it is helpful to do tests for common ill-
cised or ridiculed by family members and neigh- nesses:
bours. Remember that tiredness is often a sign of
●● haemoglobin levels for anaemia
a mental health problem. Just because there is no
obvious physical illness, it does not mean that the ●● white blood cell counts for infections
person is pretending to be sick. Tiredness is not ●● urine sugar for diabetes.
laziness.
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What to do immediately ●● Tell the person to keep in regular touch with
friends and relatives. If they are religious, rec-
●● Make sure the person is not suffering from a ommend regular visits to places of worship.
physical illness.
●● Relaxation exercises and problem-solving
●● Explain to the person and the family that counselling strategies can help (5.12, 5.11).
the tiredness is real and is being caused by a
●● In cases where nothing else seems to be work-
health problem. There is no need to specify
ing, you can try an antidepressant medication,
that this is a mental health problem since this
such as fluoxetine (Table 14.1).
may have a negative effect on the family’s sup-
port to the person. Instead, you can say that
When should tonics or
‘When we are under any type of stress we can
feel tired’. vitamins be used?
●● Explain that there are no specific medica- Tonics and vitamins are commonly used by people
tions for tiredness. However, if the tiredness is who feel tired. This is because many people feel
caused by excess stress, medications for stress that tiredness is the result of not having enough
may be given. vitamins or other nutrients. However, most peo-
●● Give dietary advice. Ask the person to eat ple with tiredness do not have problems which
more fruits, green vegetables and eggs, and will improve with tonics or vitamins. It is not help-
drink milk. ful to give tonics or vitamins to a person who is
not anaemic or who does not have features of
●● If the person is not sleeping well, give advice malnutrition. Dietary advice, such as eating more
on how to sleep better (8.3). green leafy vegetables, eggs, fish or lentils, is far
●● If the person has an alcohol or drug problem, better than tonics. Do not be fooled by the drug
give appropriate advice (9.1 and 9.2). company marketing materials which recommend
●● If the person is depressed or anxious, suggest tonics for anyone who complains of feeling tired.
ways of dealing with this (7.4 and 8.2).
●● Gradually increasing activity levels is often a When to refer
helpful way of overcoming tiredness. See the If you suspect that the tiredness is due to a serious
figure below for an example of how to do this. physical illness, such as tuberculosis or cancer, re-
The most effective counselling strategy is get- fer to a hospital. A reliable indicator of such an ill-
ting active (5.13). ness is weight loss.

Getting active
a. A person who is so tired that he does a.
not feel like getting out bed should first
try a simple, enjoyable activity such as (b)
watering the garden. b.
c. When he can manage this, he can then
try something more demanding, such as
walking to the market and shopping.
d. When he can manage this, he may be
ready to return to work.

c.
d.

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section 8.4 summary box
things to remember when dealing with someone who feels tired all the time
○○ Tiredness is not always the result of an illness. ○○ There are no specific medications for tiredness;
If a person has been working too much without vitamins and tonics will not help the tired per-
the chance for proper rest, the body will get son unless there is clear evidence of anaemia or
tired. vitamin deficiency.
○○ Tiredness has both mental and physical causes. ○○ Gradually increasing activities, antidepressants
Always exclude physical causes before consid- and problem-solving can be used for a person
ering mental health problems. with tiredness.
○○ Depression, anxiety and alcohol problems are
mental health problems which can cause tired-
ness.

8.5 The person with 8.5.1 Sexual problems in men

sexual problems† There are two common types of sexual problems
in men:
Sexual health is that aspect of health that is re-
lated to the sex organs and to sexual behaviour. ●● impotence: this is when the penis does not
Sexual health includes the prevention of sexually become or stay hard and erect, so that the
transmitted diseases and unwanted pregnancies, man cannot have sexual intercourse;
the enjoyment of sex as part of intimate relation- ●● premature ejaculation: this is when the man
ships, the acceptance of different levels of sexual ejaculates (passes semen) so quickly that nei-
desire across individuals and greater control over ther partner is able to enjoy the sexual act.
one’s sexual decisions. In this manual, only com- The most common causes of these sexual
mon sexual behaviour problems are described. problems are:
For a discussion on infectious diseases which
●● tension about sex, typically when a man is
affect the sexual organs, refer to other manuals
having sex for the first time with a particular
(Chapter 18).
person or when there is anxiety after having
Sex can be an important aspect of intimate
experienced occasions when the penis did not
relationships, although not everyone desires it.
become hard;
Sex is such a personal and private aspect of our
lives that it is rarely discussed with others. It is dif- ●● misconceptions about the size of the penis
ficult for people to get hold of trustworthy infor- or mistakenly thinking that there can be bad
mation. As a result, there is a lot of ignorance effects of having had sexual intercourse with
about what is ‘normal’ sexual behaviour and little a woman during her menstrual periods or of
understanding that there is a wide range of ‘nor- masturbation;
mal’. People also know little about the types and ●● ignorance about healthy sexual function
causes of sexual problems. Sexual problems are is one of the main reasons for the ‘dhat syn-
basically problems that men and women have drome’ seen in men in Asia (Box 8.5);
that interfere with their sexual health. ●● depression and tiredness: it is difficult to
enjoy sex when one is unhappy or tired;
●● alcohol problems: drinking heavily can make
a man impotent;
†
With Pramada Menon and Suvrita. ●● loss of interest in sex;
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●● cigarette smoking, which can affect the blood vagina) is dry or when a man tries to have sex
supply to the sexual organs; before she is ready, or when he forces sex on
●● diabetes, which can affect the nerves and her;
blood supply to the sexual organs; ●● loss of interest in sex.
●● some medications, such as antidepressants Women’s sexual problems are commonly
and medications for high blood pressure; caused by:
●● growing old: as with all bodily functions, sex- ●● lack of control over sexual decision-making:
ual function can also become impaired with this means the woman cannot choose when
ageing; she wants (or does not want) to have sex;
●● more rarely, past experiences of sexual abuse ●● tension or fear about having sex;
can affect sexual health in the future.
●● depression and tiredness: it is difficult to
enjoy sex when one is unhappy or tired;
8.5.2 Sexual problems in women ●● loss of interest in sex, which can happen if the
Common sexual problems in women are: woman does not find the partner attractive;
●● pain during sexual intercourse: this may ●● infections in the sexual organs;
occur if the woman’s sexual passage (the ●● sexual abuse in childhood (11.5) and
unhappy or painful sexual experiences can
BOX 8.5 THE DHAT SYNDROME make enjoyment of sex difficult;
●● some medications, such as antidepressants,
‘I am feeling weak because I pass semen in can reduce desire for sex.
my sleep’
Men in some parts of Asia believe
that semen is a source of physi-
BOX 8.6 GENDER AND SEXUAL PROBLEMS
cal strength. Young men may
become concerned when In many places, women do not have the same
they notice that they are control over their bodies and sexual lives as
‘losing’ semen by passing their male partner. A woman may not be able to
it in their underwear dur- choose whether she has sex and when. She may
ing the night, or when passing have to have sex whenever her partner desires,
urine or stool. They may become and yet may not feel free to ask for sex when she
very anxious about their desire to masturbate. If desires it. While there may be little a health work-
they do masturbate, they suffer guilt and tension. er can do from a clinic to change this social prob-
Many men will complain of tiredness, aches and lem, there are things that can be done to reduce
pains, impotence and even suicidal feelings. sexual problems. For example, the health worker
Typically, they will blame these complaints on can explain to a woman that her desire to have
the passing of semen in their urine. The health sex or her desire to stimulate herself are healthy
worker must spend time explaining male sexual- behaviours may help counter the beliefs that this
ity. An example which helps is that of a glass of is shameful. Or, the health worker can explain to
milk to which more milk is being continuously a woman that she has the right to protect herself
added all the time. Once the glass is full, milk will from an unwanted pregnancy and teach her how
begin to dribble out of the glass; the same hap- to do this. A woman who wishes to enjoy sex but
pens with semen in the body. Education about finds that her vagina is too dry can be advised to
masturbation being a healthy sexual behaviour use butter or some other oily substance to make
is important. If the person has become stressed her vagina wet. As a health worker, there is much
or depressed, treat as directed elsewhere in this you can do to change negative attitudes about
manual (7.4, 8.2). gender (Chapter 13).

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BOX 8.7 SEX AND RELATIONSHIPS

Sex can be a way of expressing affection and love. Sexual problems can end up making relation-
Sex is the way through which a couple can have ships deeply unhappy or even terminate them,
children and start a family. Sex can be a way of sometimes due to the partners finding new lovers.
experiencing physical and mental pleasure. If one On the other hand, sexual problems can be the
person has a sexual problem, the relationship with result of an unhappy relationship. Thus, if there is
their partner is also affected. Because sex is such a much fighting or conflict between two partners,
sensitive issue and is rarely discussed as a ‘health’ it is unlikely that they will have a satisfying sexual
issue, the problems tend to remain hidden. The relationship.
couple may suffer much unhappiness and guilt.
They may start blaming each other or themselves
in an effort to understand why they no longer
enjoy sex with each other. Sometimes, one partner
may accuse the other of being unfaithful. Sexual
problems can cause increasing tension in everyday
life between partners and lead to depression and
alcohol abuse.

The first couple is more likely to enjoy sexual

relations than the second couple.

8.5.3 Problem sexual behaviour beaten for behaving in this manner. Many people
who show problem sexual behaviour have either
Problem sexual behaviour is when a person a severe mental disorder or a disability such as
shows sexual behaviour at the wrong times, for psychosis, intellectual disability or dementia.
example, in a public place or in a manner which is Referral to a mental health specialist may be
threatening to others. The intent of the person is needed.
important here. A person might, for example, lack
a private space for masturbation and choose a se-
cluded public space instead. This is not a mental 8.5.4 How to deal with this problem
health problem: the person just needs advice and Special interview suggestions
support to find a more appropriate place for mas-
turbation. Examples of problem sexual behaviour ●● Allow some time to build rapport and trust.
which might indicate the presence of a mental Talking about sex is not easy. Don’t be in a
health problem are: hurry.
●● taking off clothes in a public place, for instance, ●● Never feel embarrassed to ask about sexual
someone who is ‘high’ in their mood (7.5) health: this is as important as physical or men-
and no longer cares about social norms; tal health for a person.
●● showing one’s sexual organs in a public place, ●● Interview the person in private first. If they
for instance, a person with intellectual dis- agree, invite the partner to join the interview
ability who is having difficulty fulfilling their later.
sexual needs; ●● Frank questions about the problem will help
●● an elderly person trying to have sex with their the person feel more comfortable in discuss-
partner even though they may not have had ing this sensitive subject with the health
sexual relations for several years. worker. It is also important to get a clear his-
tory of the problem.
When this happens, it causes great concern to
the family. Sometimes, the person is abused or
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Questions to ask the person BOX 8.8 MASTURBATION: A HEALTHY WAY OF
GIVING ONESELF SEXUAL PLEASURE
●● What is the problem? When did the problem
start? What have you done about it so far? Every person has a sexual life of their own. For
●● Tell me about your relationship. How long example, a person may have sexual fantasies or
have you known each other? How much do may stimulate their own sexual organs (mastur-
you love each other? Have you enjoyed sex bation). Some people who masturbate feel scared
with each other before? What sorts of things of being ‘caught’ or guilty that they are doing
do you enjoy doing? (It is difficult to enjoy sex something wrong. This can cause tension and un-
when the relationship is unhappy.) happiness. In some situations, women feel very
●● Do you masturbate? Are you having sex with guilty when they masturbate. Some people think
anyone else (other than your partner)? (If the it is a sign of moral weakness. However, it is im-
person only has a sexual problem with a spe- portant to stress that masturbation is a healthy
cific partner, then the problem may be because sexual activity for both men and women. It is
of a difficulty in their relationship.) a safe sexual activity and does not cause any
health problems. Impotence can be a problem
●● Have you been experiencing tension or think-
ing too much recently? Do you feel as if you when men who are masturbating cannot get their
have lost interest in daily life? (Ask about symp- penis to go hard.
toms of anxiety and depression 3.9.)
●● Have you had any infections of the sexual What to do immediately
organs?
Do some simple tests such as urine sugar and cul-
●● Are you taking any medications? ture to exclude diabetes or infections.
Ask a man the following For impotence
●● Do you suffer from diabetes, high blood pres- ●● Explain that this is a common problem and
sure or any other medical disease? that it is often short-lived.
●● Are you taking any medications? ●● Advise against cigarette smoking and drinking
●● Do you drink alcohol? alcohol before having sex.
●● Do you smoke cigarettes? ●● Discuss possible reasons the person may be
●● Do you get erections in the mornings? (Usually, tense or worried and explain the links between
if a man does not get any erections at all, then these emotions and impotence.
you should suspect a medical cause for the im- ●● Ask the person to try out sexual intercourse
potence.) in a slow and unhurried way and not to be
●● Ask men about their being in sexual contact disappointed if the sexual problem does not
with commercial sex workers; if so, this may resolve. Try again another day. As with all anxi-
make them feel guilty. Counselling and testing ety problems, facing up to what is causing the
for HIV and other sexually transmitted infec- anxiety is the best treatment.
tions is necessary. ●● If the problem persists, advise the man to
Ask a woman the following avoid sexual intercourse for 2 weeks. During
this time, encourage him to practise pleasura-
●● How much control do you have about having ble physical contact with his partner and social
sex? For example, do you feel sometimes that activities which do not involve intercourse.
your husband forces you to have sex?
●● Counsel the partner and encourage them
●● Have you had any difficult experiences of sex to be part of this treatment. It is especially
in the past? important for the partner to understand that
this is a treatable problem and not caused by
weakness.

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●● If the problem persists, you could consider intercourse so that his partner feels sexually
referral to a doctor to prescribe one of the excited and her vagina is wet. Explain to him
medications which are useful for this condi- the need to only have sex when both of them
tion, such as sildenafil or tadalafil. want to have sex.
For premature ejaculation ●● Recommend the use of vaginal lubricants such
as butter or oil or commercially available syn-
●● Explain that this is a common problem, most
thetic lubricants.
often caused by tension.
●● Ejaculation can be delayed by the squeeze For lack of sexual desire
technique or the stop–start technique. The ●● This is usually a problem when one partner
man is asked to recognise the sensation that has less desire than the other. Counsel both
he is soon going to ejaculate. The moment he separately and together, if possible. Reassure
feels this way, he should stop sexual move- both that the reason for this problem is often
ments immediately. Then, he must wait until because of marital problems rather than a
that desire has gone away before starting physical problem with the sexual organs.
sexual movements again. In the squeeze tech- ●● Explore marital problems between the part-
nique, just as the person begins to feel he is ners. Encourage them to discuss their feelings
going to ejaculate, he squeezes his penis with and concerns. Use counselling strategies for
his fingers. This reduces the urge to ejaculate addressing relationship problems (5.15).
and helps prevent it. These techniques help
●● Loss of sexual desire can be a symptom of
the man feel more confident that he can con-
depression. If depression is present, treat this
trol his ejaculation.
underlying cause first.
For women who have pain during intercourse ●● Suggest masturbation as a way of sexual
●● Explain that this is common and most often release for the partner whose sexual desire is
due to tension or because she is not sexually greater.
excited.
●● If she agrees, counsel the man to explain the
need for taking time to build up to sexual

b. a. When a man has a problem with

premature ejaculation, it is preferable
he has sex on top of the woman.
b. When he feels that he is about to
ejaculate, he should withdraw from
a. the woman and (c) use his fingers to
compress the penis at its base. When
the desire to ejaculate goes away, he
can once again continue to have sex.

When to refer places around the world nowadays it is seen as

normal and healthy, but in some it is seen as a
●● Any person showing problem sexual behav- mental health problem or even a criminal act. It is
iour that seems to be related to a mental very important that, as a health worker, you treat
health problem. same-sex relationships as another example of the
●● Any person whose sexual problems continue diversity of human relationships. Homosexuality
despite education and counselling. is not a mental health problem. Just as sexual
●● If you suspect that the sexual problem is problems can arise in a relationship between
related to a serious physical disease such as a man and a woman, so can they in same-sex
diabetes or a sexually transmitted disease. relationships. In reality, few people in same-sex
relationships will dis-
What to do later cuss this with health
workers because they
Review the person or couple after a week and then fear being criticised or
every 2 weeks to monitor how they are following mocked. As people who
your advice. Often, the explanation and the shar- are attracted to a person
ing of the problem makes people more relaxed of their own gender are
and this improves their sexual health. often persecuted, some
may suffer loneliness,
8.5.5 Same-sex relationships and guilt, fear and unhap-
piness. If you are sen-
mental health sitive to this situation
Homosexuality means sex between a man and a and can offer a space for
man (gay relationship) or a woman and a woman homosexual men and
(lesbian relationship). There are strong views lesbian women to dis-
about this sort of sexual behaviour. In many cuss their feelings in an

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atmosphere of trust, you may help them cope bet- with them. They may not be able to communicate
ter with their isolation and loneliness. their sexual feelings as well as others. For these
reasons, they may become unhappy and angry
8.5.6 Sex and intellectual disability and may show abnormal sexual behaviour. Such
people (and their families) need counselling to ex-
We often assume that a person with intellectual plain sexual behaviour. In particular, you can fo-
disability is ‘sex-less’. Just because someone has cus on masturbation as a way of achieving sexual
an intellectual disability, it does not mean that pleasure. Sometimes, however, the sexual behav-
they will not have sexual feelings and desires. Un- iour can become a problem and even dangerous
fortunately, because of the disability, they are less to others. Refer such people to a specialist mental
likely to meet a person who may want to have sex health service.

section 8.5 summary box

things to remember when dealing with sexual problems
○○ Sexual problems are often the result of an ○○ People will rarely complain of sexual problems;
unhappy relationship; they can cause further often their main complaint may be a physical
problems in the relationship. As far as possible, one (such as tiredness). It is good practice to
work with the couple. ask all people a simple question such as ‘How
○○ Some sexual problems are related to serious is your relationship with your husband/wife/
physical diseases, such as diabetes. partner recently?’
○○ Sexual behaviour that is considered to be a ○○ Depression, anxiety and alcohol problems can
problem to the community may be caused by a cause sexual problems.
severe mental disorder or disability. ○○ Many sexual problems are the result of igno-
○○ Confidentiality is very important; if a person rance about sexual performance. Education is
shares sexual problems that they do not want often the single most effective treatment for
the partner to hear about, you must respect sexual problems.
these wishes.

8.6 The person who 8.6.1 How can something so

suddenly loses their voice ‘physical’ happen because of
or other body function mental health problems?
The sudden loss of a function of the body, wheth- Imagine someone, often a young woman, who is
er a physical function such as the ability to move under a lot of stress. The stress could be related
a part of the body or a mental function such as to failing in an examination, to a broken love affair
memory or consciousness, can be terrifying for or to being forced to marry someone the woman
those affected and their family members. The does not want to. It may be difficult for her to
first reason you must think of is a brain disease, talk frankly about the cause of the distress with
particularly a stroke. This will need immediate her family. When strong emotions cannot be ex-
medical attention. However, such sudden loss of pressed freely, the mind may ‘convert’ them into
function can also be due to mental health prob- a physical symptom. This is what happens in con-
lems. When this happens, the condition is called a version disorder. The condition usually appears
‘conversion’ disorder. suddenly and is dramatic in nature. It has also

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Things to look for during the interview concerned about the symptoms themselves.
Focus instead on the stresses the person is
●● Obvious signs of brain disease, for example, facing.
signs of paralysis of the limbs (such as holding
●● The key to quick improvement is the person
them in a limp manner or with signs of thin-
talking openly about their worries or stresses
ning muscles).
and coming to accept that the symptoms may
●● Some people with conversion symptoms seem be related to these life difficulties.
to be not concerned about their symptoms
●● Encourage the person to find ways to solve her
even though they appear very serious. This
problems (5.11). Consider using counsel-
apparent lack of concern may give a clue to
ling strategies for relationship issues if needed
the psychological origin of the symptoms.
(5.15).
●● Advise against admission to hospital or pro-
Questions to ask the family or friends
longed rest. These may only convince the
●● How did it start? (A symptom which happened person that their illness is a serious physical
suddenly and without any previous signs of ill illness and may prolong the symptoms.
health is more likely to be a conversion symp- ●● Avoid prescribing medication except if there
tom.) are clear features of depression.
●● Has there been any stress recently? (Enquire ●● Counsel the family members who may be
specifically about exams, job problems and re- involved in the stressful circumstances which
lationship difficulties.) may have led to the symptoms.

Special interview suggestions When to refer

●● The person may have personal issues which ●● If the person has signs indicating a serious
are worrying to them, for example, being sexu- physical health problem such as high fever or
ally assaulted. They will not be comfortable paralysis of a limb.
to share these with you if their family or other ●● If the person is injured during an attack of the
people are nearby. symptoms or has not been taking food or flu-
●● Sometime the person will be completely mute. ids for 24 h.
They do not speak at all and may even appear ●● If the symptoms have lasted more than 1 week
not to be listening to you. Never get angry and do not respond to the efforts described
because of this. The person is mute because above.
they are under stress; they are not deliberately
trying to make your work harder.
Look, I understand
that you may have been worried about
What to do immediately
something recently. If you are able to talk to me
●● Make sure that the symptoms are not caused about this, I can help you find some way of solving
this problem. For now, I will go away and do my
by a medical illness; if they are, refer immedi-
other work and come back in an hour or so.
ately for emergency care.
I hope we can talk then.
●● Explain to the family that there is no life-
threatening illness. However, do not make
them think that the person is pretending to be
sick.
●● Symptoms often resolve quickly, within hours
or a few days. Use this time to establish a
rapport with the person. Do not appear too

section 8.6 summary box

things to remember when dealing with possible conversion symptoms
○○ Always think of physical diseases as the cause ○○ Most people with conversion disorder will
for sudden physical or mental symptoms. Only recover on their own. Helping the person to
if these can be ruled out should you consider talk about stress and problem-solve their life
conversion disorder. difficulties will help them recover.
○○ Common conversion symptoms are losing one’s ○○ Because of the sudden and dramatic nature
voice, paralysis, convulsions, loss of memory or of the symptom, family members are often
behaving in a confused manner. alarmed and worried. Explain to them what is
○○ Stress is the cause of conversion disorder. happening.

notes

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9 9.1 The person who drinks
too much alcohol
The person with problems
due to habits†

9.1.1 What is problem drinking?

Problem drinking begins with a level of drinking
that puts the drinker at risk of developing health
Alcoholic drinks are used in many cultures around and social problems in the future. This is called
the world. Some alcoholic drinks are ‘interna- hazardous or risky drinking.
tional’, such as beer and whisky. Other alcoholic Some people start showing signs of damage to
drinks are unique to the local culture, such as their health or personal lives due to their drinking.
chibuku in Zimbabwe, tella in Ethiopia and feni in This is called harmful drinking.
Goa (India). In some places, people brew alcohol People who drink too much do not always
at home. Illegally brewed alcohol can contain dan- drink every day. There is another type of drinking
gerous chemicals which can cause death. Most pattern which is also dangerous. This is drinking
people who drink alcohol do so once in a while, very heavily for a few days at a time. For example,
in the company of friends. some people only drink at weekends. However,
Some people drink when they drink, they can drink a large amount of
more regularly but alcohol. This is called binge drinking.
never drink more than A smaller group of harmful drinkers develop a
a moderate amount physical and psychological need to have a drink.
every day. There are This is called alcohol dependence (or addiction).
some people who drink If a person with dependence does not get a drink,
too much. This is when they will start feeling physically sick (e.g. shak-
you need to become ing of hands/body, getting drenched with sweat,
concerned.

BOX 9.1 DRINKING TOO MUCH: HOW MUCH IS TOO MUCH?

Using this chart you can calculate the amount of

alcohol the person is drinking. A person is drinking A single standard drink.
too much if:
○○ a man drinks more than three standard drinks a
day (or 21 drinks a week)
○○ a woman drinks more than two standard drinks
a day (or 14 drinks a week)
○○ he or she must have a drink in the morning
when they wake up
○○ he or she has one or more health or social A shot of A glass of A 330 ml A glass of
problems related to the drinking. spirits beer can of beer wine

†
With Abhijit Nadkarni.
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nausea); this is called a withdrawal syndrome. BOX 9.2 WHEN ALCOHOL SHOULD NOT BE
The withdrawal reaction is temporarily relieved by CONSUMED, OR ONLY WITH CAUTION
drinking more alcohol, thus keeping the depend-
ence going. Situations when alcohol is prohibited by law:
Drinking problems may not be easy to iden- ○○ a person who is under a specific age (which
tify. Sometimes, a person may be drinking too can vary from one country to another)
much (Box 9.1), yet managing to live normally. ○○ while driving (in many countries, drinking
The health worker must be concerned about such beyond a legally established safe limit is
people as well because, sooner or later, the drink- prohibited).
ing problems will affect their health. Some drink- Situations when alcohol use is not recommended:
ers say that they can ‘hold their drink’ very well, as ○○ while working with machines or tools
if this means that they do not have a problem. In ○○ if the person has repeated seizures (i.e. not
fact, when the body becomes used to the effects controlled by medications)
of alcohol, this is called tolerance. Tolerance is ○○ a pregnant or breastfeeding woman.
itself a sign of drinking too much. By the time
Situations in which alcohol should ideally be
health is affected, the problems are very serious.
stopped (or at least greatly reduced):
Thus, early detection of a drinking problem is an
○○ while taking medications for mental health
important part of health promotion and preven-
tion of illness. problems, diabetes or epilepsy
Box 9.2 describes situations where drinking ○○ if there is liver, heart or kidney disease or
alcohol is not recommended or should be done diabetes.
with great care.

a. b.

I need a drink

How alcohol dependence develops.

a. Most people who drink do so socially, with their
c. friends.
b. But sometimes the need to drink gets stronger
and the person may drink more, and drink alone.
c. Eventually, he needs a drink even when he wakes
up in the morning.

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9.1.2 Why do people ●● losing one’s job

drink too much? ●● neglecting family, leading to family break-up

●● legal problems.
Many people try alcohol for the first time when
they are adolescents or young adults. Easy availa-
bility of alcohol, seeking the pleasurable effects of 9.1.4 When should you suspect that
alcohol, peer pressure and a way to escape from a person has a drinking problem?
problems are common reasons to start drinking.
Many people with a drinking problem do not seek
Drinking can also start later in life, for example, in
help until their health is very bad. Even when they
middle age, particularly at times of stress. Most
do, the drinking problem is often undetected and
people who drink alcohol do so ‘safely’, i.e. at
untreated. In many communities, there are nega-
a level which is not causing harm to their social
tive attitudes towards people who drink, and
lives or health.
thus those who have drinking problems may feel
ashamed to talk about this to the health worker.
9.1.3 What does drinking too much The health worker may also feel that drinking is
do to a person and the family? a personal responsibility and not something that
the health worker should become involved with.
First, it seriously damages health. These are some It is important to be aware that many health
of the health problems which can result from problems are related to drinking and that prob-
drinking too much alcohol: lem drinking itself is a serious health problem.
●● blackouts, when a person has no memory of You should ask about the drinking behaviour of
what happened after a bout of drinking all people attending your clinic, especially those
●● withdrawal reactions, such as becoming tense with:
and shaky, and in severe cases becoming con- ●● unexplained accidents or injuries
fused and having seizures (7.10) ●● burning pain in the stomach area or vomiting
●● accidents, especially while driving or at the blood
workplace ●● relationship problems with family and friends
●● ulcers in the stomach ●● repeated sickness and absence from work
●● blood in vomit and/or stools ●● mental health problems such as depression
●● jaundice and anxiety
●● sexual impotence (8.5) ●● sleep difficulties
●● depression and suicide (7.4, 7.6) ●● sexual difficulties, such as impotence.
●● sleep problems (8.3)
●● delusions and hallucinations (7.3) 9.1.5 Drinking in women
●● brain damage Harmful drinking is typically seen as a ‘man’s
●● repeated sexually transmitted diseases and problem’. It is true that the majority of harmful
HIV/AIDS due to risk-taking behaviours drinkers are men. However, women can also have
●● tuberculosis a problem with alcohol. In many societies, harm-
ful drinking is becoming more common in women.
●● intellectual disability in the unborn baby (in
Drinking can affect women in ways unique to their
cases where women drink during pregnancy).
gender:
Social effects of problem drinking include: ●● women are more susceptible to the toxic
●● increased poverty due to reduced working effects of alcohol; this is why the ‘safe’ levels
ability and spending money on alcohol of drinking are lower for women (Box 9.1);
●● violence in the home (10.2) and community ●● drinking during pregnancy can lead to seri-
(13.11) ous problems in the unborn child, causing
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intellectual disability and Questions to ask the person
birth defects; this is why
drinking alcohol should ●● Have you been drinking alcohol recently? (If
be avoided during yes, ask the CAGE questions):
pregnancy; ○○ Have you ever felt you should Cut down on
●● because of the shame your drinking?
associated with drinking, ○○ Have people ever Annoyed you by criticis-
women do not discuss this ing your drinking?
with the health worker and ○○ Have you ever felt bad or Guilty about your
are less likely to receive help drinking?
for their problem;
○○ Have you ever had a drink first thing in the
●● because of the gender-related stresses women morning (an ‘Eye-opener’) to steady your
face, they are vulnerable to drinking as a way nerves or to get rid of a hangover?
of coping;
If the person says ‘yes’ to two or more of
●● women who have male partners who drink
these questions then you should suspect a drink-
heavily may suffer physical and emotional vio-
ing problem and ask more detailed questions on
lence from them.
drinking behaviour.
●● What type of alcohol do you drink (e.g. whisky,
9.1.6 How to deal with this problem beer)?
Emergency management of a person who is in- ●● How much do you drink every day? If only on a
toxicated with, or withdrawing from, alcohol is few days a week, ask: How many days a week?
described elsewhere (flow chart 6.4). Here we How much on those days?)
will discuss how to help people who have a drink-
●● How is drinking affecting your health? (This
ing problem that is not associated with an emer-
will help make the person realise how the drink-
gency.
ing is damaging their health.)
●● Have you tried to stop your drinking? What
Special interview suggestions
happened to your effort?
●● Spend a little time building rapport and ex-
plain that the information the person shares Things to look for during the interview
is confidential. People with drinking problems
are often relieved to discuss their drinking, if ●● Does the person look tense, nervous or fidg-
they feel they can trust the health worker. ety? (Can be signs of alcohol withdrawal.)
●● Do not take a moral view on drinking. Even ●● Breath smelling of alcohol.
if you feel that drinking is bad, your aim is to ●● Bruises, scars or other signs of injuries.
help the person. ●● Signs of liver disease, such as jaundice.
●● Always try to engage with a family member
(usually a spouse) after the initial interview Questions to ask the family or friends
with the person. The spouse can provide a
more accurate picture of the problem, may ●● Has the person been drinking alcohol
play an important part in the person’s recov- recently?
ery, and may themselves need mental health ●● Are you worried about their drinking? Why?
care owing to the stress of living with a person ●● Has the person been drinking in the mornings?
who has alcohol problems.
A ‘yes’ answer to the first question and any of
the others suggests the person may have an alco-
hol problem.

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What to do for the person them (e.g. if a man has told you that he has lost
with an alcohol problem many jobs then you can tell him how that is com-
monly seen in people who drink heavily). After the
Most often, health workers only treat the physical feedback you can ask the person, ‘Would you like
illnesses associated with problem drinking. Un- help with stopping or reducing your drinking?’
less you treat the drinking problem itself, the per- It is important to remember that even an as-
son will never fully recover. There are three stages sessment of the person’s drinking and its impact
to helping a person overcome a drink problem. followed by feedback can have a beneficial effect.
Stage I: Accept that there is a drink problem This process allows the person to reflect on their
This is an essential first step. Often, the person drinking behaviour and start to notice its effects
with an alcohol problem only comes to the clinic on their life. This can be a powerful motivation for
because of family pressure. The person may deny changing drinking behaviour.
they have a problem. It is important not to get A person who is forced into treatment without
angry with the person. Instead, talk about other accepting that they have a problem is less likely
issues (such as work and health) and try to get the to give up the habit. The most effective way of
person to make the links between drinking and its increasing the desire to stop is to use the counsel-
effects on their life. You can facilitate the process ling strategy ‘motivating for change’, whose prin-
as follows: using the details of the person’s drink- ciples are summarised below (5.17 for details):
ing that you have obtained earlier, you can now ●● discuss with the person the perceived benefits
give them personalised feedback about how and and the actual/potential harm of drinking
why the drinking may be harmful and how it may ●● encourage a balanced evaluation of the posi-
be related to any problems or issues that the per- tive and negative effects of alcohol, i.e. chal-
son may have told you about during the assess- lenge overstated benefits and understated
ment. Any feedback about the effects of drinking negative effects
should be given to the person only if it applies to
●● avoid arguing with the person; if they resist,
then phrase in a different way or change the
BOX 9.3 ‘CONTROLLED’ DRINKING topic
●● encourage the person to decide for themselves
If a person chooses controlled drinking, then
what they want to do about their drinking
there are some tips you can suggest to control the
amount of drink used every day: ●● if the person is still not ready to stop or reduce
○○ keep a track of how much you drink (e.g. by alcohol use, then ask them to come back any-
recording in a diary)
time to discuss further.
○○ keep at least 2 or 3 days in a week when you Stage II: Reduce or stop drinking
do not have any alcoholic drinks Should the person completely stop drinking (ab-
○○ alternate your alcoholic drinks with non- stinence) or simply reduce to the ‘healthy’ limit
alcoholic drinks (controlled drinking; Box 9.3)? There is no simple
○○ do not drink ‘straight’ alcohol; mix it with answer to this. You will need to consider the health
water or soda so one drink lasts longer and social situation and the history of drinking
○○ put less alcohol into each drink (e.g. drink before you and the person agree on a goal.
only single shots) In these situations, abstinence is the preferred
○○ never drink in the daytime goal:
○○ make each drink last longer (e.g. an hour) ●● if the drinking has caused serious health prob-
○○ eat before you have your first drink lems (e.g. repeated attacks of jaundice)
○○ do not drink to quench thirst; use water or ●● if the drinking has caused serious problems at
other non-alcoholic drinks work or at home (e.g. violence)
○○ reduce the time you spend in bars or with
●● if the person has tried controlled drinking
friends who drink heavily. before but has not been successful.
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BOX 9.4 HOME DETOXIFICATION There are many suggestions you can make to
help the person stay sober.
A potentially uncomplicated alcohol withdrawal
●● Alcoholics Anonymous (AA) is a worldwide
can be safely managed at home if a family
network of people who have become sober
member is willing to stay with the person for the
and who help each other stay sober. Anyone
duration of the detoxification. However, home
who has a desire to stop drinking can join. AA
detoxification is not suitable for someone who works through sharing personal experiences
has experienced seizures or severe confusion dur- and giving support at regular meetings. As a
ing a detoxification in the past and/or has existing health worker, you must keep relevant infor-
physical health problems (e.g. epilepsy, uncon- mation on the local AA or other alcohol sup-
trolled hypertension) or mental health problems port groups (Chapter 15).
(e.g. hallucinations, suicidality).
●● People with a drinking problem often use
If the person is suitable for home detoxification, alcohol as a way of coping with difficult life
they can be prescribed the chlordiazepoxide situations. Teach problem-solving strategies
regimen described in Box 9.5. It is important to (5.11) as a healthier way of coping. Widening
inform them that drinking alcohol while undergo- the social support circle, for example, through
ing detoxification with a benzodiazepine can lead religious groups, friends at work or neighbours
to severe problems with breathing and is poten- who are non-drinkers, can be a source of sup-
tially fatal. They will have to be monitored daily port in difficult times. Relationship problems
during the first few days through the course of the are often linked to drinking behaviour; give
detoxification, either at home or through visits advice on improving relationships (5.15).
to the clinic. While detoxification is in progress, ●● Advise the person to find alternative activities
monitor the following every day: sleep, nausea/ for leisure and relaxation. Prepare them on
vomiting, tremors, anxiety, agitation, uncontrol- how to deal with difficult moments when they
lable sweats, orientation, hallucinations, head- feel like having a drink (Box 9.6).
ache, pulse rate, blood pressure, temperature,
ataxia (poor coordination and unsteadiness), and Skills needed to stay sober
dehydration. If these do not improve with time, or or to control drinking
worsen, then refer to the hospital.
Sometimes people might face specific difficulties
in staying sober or in sticking to their controlled
Abstinence as a goal is easier to monitor and
drinking plan. We need to help the person to iden-
less likely to lead to a relapse (becoming depend-
tify these difficulties and together come up with
ent on alcohol again). Whatever the chosen goal,
strategies to overcome them. Some common diffi-
the person must agree to it. Thus, the goal is the
culties and the skills that will help overcome them
person’s choice, and it will need regular monitor-
are as follows.
ing in the months ahead.
If the person is a heavy drinker and is show- Drink refusal skills
ing signs of dependence, then suddenly stopping The person will need drink refusal skills in any sit-
drinking may lead to withdrawal symptoms (Box uation where they are offered alcohol. For exam-
9.5). Advise the person on these risks and how to ple, if offered a drink, they could say:
deal with these symptoms. If a person has tried ●● ‘No, I am recovering from a
to stop and developed severe reactions then it is drinking problem, so I am
better to refer them to a hospital where the with- not drinking any more’
drawal reaction can be monitored more closely. ●● ‘The doctor has told
Stage III: Staying sober me not to drink as
This is usually the most difficult phase of treat- I have
ment, because it lasts the rest of the person’s life- health
time. problems’

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BOX 9.5 ALCOHOL WITHDRAWAL AND ITS TREATMENT

Alcohol withdrawal occurs when a person who is ○○ Thiamine is a type of vitamin. Give 100 mg
physically dependent on alcohol suddenly stops i.m. injection and prescribe 1 week’s supply of
drinking. It usually begins within 24 h of stopping thiamine tablets (50 mg daily), multivitamins
drinking and lasts between 4 and 10 days. The and folic acid (1 mg daily).
worst period is usually the first 2 to 3 days. The ○○ A 4- to 6-day supply of chlordiazepoxide to be
more they have been drinking, the worse are the taken as follows:
symptoms. ○○ day 1: 25 mg four times a day
The common warning symptoms that a withdrawal ○○ day 2: 25 mg three times a day
reaction has started are:
○○ day 3: 25 mg twice a day
○○ tremor
○○ shakiness ○○ days 4 & 5: 25 mg at night
○○ poor sleep ○○ days 6 & 7: 12.5 mg at night.
○○ nausea ○○ Alternatively, you can use diazepam, in the
○○ anxiety same way, starting from a dose of 5 mg four
○○ irritability times a day.
○○ fever ○○ Prescribe the following medications as needed:
○○ restlessness. ○○ paracetamol 500 mg to 1 g (max. 4 g daily) for
As the symptoms worsen, the person may become headache/body aches
confused, hallucinate and have seizures. Treatment ○○ omeprazole 20 mg in the morning for gastric
in the general health care setting should include: acidity
○○ Education about the relationship between the ○○ domperidone 10 mg 3–4 times daily for nau-
symptoms and the withdrawal from alcohol. sea and vomiting.
○○ Full physical examination: if the person has a
fever, seizures, cannot drink fluids, is dehydrat-
ed, has a physical disease, or is hallucinating or
confused, refer them to hospital.

i.m., intramuscular.

a. b. c.

Abstinence is the goal:

a. when the drinking has caused serious health problems, e.g. repeated attacks of jaundice;
b. when the drinking has caused serious problems at work or at home, e.g. violence;
c. when the person has tried controlled drinking before but has not been successful.
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●● ‘I wouldn’t mind having a fruit juice/cold drink ●● going to a ‘safe’ place where alcohol is not eas-
or coffee instead’ or ily accessible (e.g. library, church)
●● ‘I have problems with drinking, so it will be ●● getting involved in non-drinking activities
really helpful if you don’t make such offers to ●● talking about the urge to drink with a friend or
me in the future’. a family member, as it helps to distract oneself
If the person’s companion still keeps insisting from the urge to drink and also to get some
on them having a drink, it is useful to change the help and support
topic. If even after changing the topic the com- ●● use of non-alcoholic substitutes
panion still keeps insisting on the person having ●● reminding oneself about the bad impact of
a drink, the person may need to leave their com- drinking every time there is an urge
pany. It is important for the person to maintain
●● many people have an urge to drink when
eye contact with the companion who offers them
they face problems in their lives; teach prob-
the drink when saying ‘no’ and speak firmly and
lem-solving skills (5.11) to help the person
convincingly.
address these problems rather than resorting
Handling drinking urges or ‘craving’ to drinking, which can only make the prob-
Drinking urges are thoughts or feelings that push lems worse
the person to want to drink alcohol. They may ●● finally, note that some problem drinkers can
keep returning to the person’s mind for quite a become depressed or anxious. Treat them as
long time after they have stopped drinking. Some you would any other person with these men-
strategies that a person can use to deal with urges tal health problems (7.4, 8.2). However, it is
are: equally important to help the person to man-
●● realise that the urge is time limited and wait age problem drinking, as the depression/anxi-
for it to pass away as it eventually does ety might not resolve when there is continued
heavy drinking.
BOX 9.6 DEALING WITH DIFFICULT TIMES
WITHOUT DRINKING When to use medications
There are moments when it is especially difficult There are two situations in which you could
to stay sober. We suggest some strategies you use medications. The first is to control with-
could try to deal with such times. drawal symptoms by using chlordiazepoxide or
diazepam. The second is to help the person stay
○○ If you drink mainly at night: try to keep your- sober. Medications such as disulfiram cause a
self busy, go to places you cannot drink, such strong reaction if a person drinks, and the fear
as a temple. of this reaction helps in keeping the person so-
○○ If you have the habit of going to drink with ber. Other medications such as acamprosate and
fellow workers after the day is over: try to or- naltrexone help reduce the urge to drink alcohol.
ganise a different social activity, such as going These medications should only be used by a men-
to see a film or some sporting activity. tal health specialist (Table 14.6).
○○ If you drink heavily only with certain friends:
avoid these friends. When to refer
○○ If you drink when alone: reduce the amount of
time you spend alone – you can join a support ●● For serious medical problems (e.g. vomiting
group (AA) or increase the time you spend blood, jaundice and serious accidents).
with your family. ●● For severe withdrawal reactions.
○○ If you drink when you are under stress: learn ●● When there is also a severe mental disorder
ways of coping with stress and solving your (e.g. psychosis).
problems rather than blanking them out with
alcohol.

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9.1.7 Living with a person who Family members often feel confused, are un-
sure of how to deal with the person and feel iso-
has a drinking problem lated. An important contributor to stress for most
Problem drinking affects all members of the fam- family members is their lack of knowledge about
ily. They experience significant levels of stress alcohol. You may help by providing information
and are at high risk of harmful effects on their about the alcoholic beverages that the person
mental and physical health. This might manifest might be consuming, safe and unsafe patterns of
as excessive worry, drinking, and issues related to dependence. Ex-
lack of sleep, diffi- plore existing support and help the family mem-
culty concentrating, ber build a stronger support system and improve
etc. Family members joint problem-solving in the family.
might cope by stand- Some relatives blame themselves; reassure
ing up to the drinker, them that they are not responsible for the drink
putting up with them problem. Support groups for relatives (e.g. Al
or withdrawing from Anon) are available in some places. The family
the drinker and gain- could be encouraged to unite around this cause
ing independence. and encourage the person to seek help.

section 9.1 summary box

things to remember when dealing with someone with an alcohol problem
○○ Ask all people, especially those with health ○○ Counselling about stopping or controlling
problems commonly associated with drinking the drinking habit, treatment for withdrawal
alcohol, about their drinking habits. symptoms, referral to Alcoholics Anonymous
○○ Harmful or problem drinking is when a per- and support to the family are the main manage-
son drinks alcohol at levels which are causing ment approaches.
physical, mental or social problems.
○○ Most problem drinkers come to health work-
ers with physical problems (such as stomach
ulcers) rather than the drinking itself.

9.2 The person who 9.2.1 Does everyone who takes

is abusing drugs a drug have a drug problem?
Drug abuse is when a person uses a drug repeat- No. There are different ways in which a person
edly without any medical reason and this use af- could use drugs.
fects their health and social functioning in a nega- ●● Trying once or twice is very common. It is typi-
tive way. As with alcohol, repeated use of drugs cally seen in young people.
which are addictive can cause dependence that ●● Casual use is the next most common type of
makes the person feel a strong desire to contin- drug use. This is especially true of drugs such
ue taking the drug, even though it may be caus- as cannabis (Box 9.7). Most people who use
ing them harm. When an addicted person tries to this drug do so only occasionally and their
stop the drug, they feel ill (withdrawal syndrome). daily lives or health are not affected.
There are many types of drugs which are abused.
●● Traditional use: this is the use of specific drugs,
Of these, alcohol, tobacco and sleeping pills are
as accepted by the local culture, on specific
described elsewhere in the manual.
occasions (Box 9.8).

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BOX 9.7 CANNABIS: A DRUG OF ABUSE OR A BOX 9.8 TRADITIONAL DRUGS
DRUG FOR RECREATION?
In many communities, the use of drugs is allowed
Cannabis or marijuana is smoked or eaten by for certain occasions. Examples include cannabis
communities around the world. It has many in some festivals in India and Africa, and
names depending on where you live; for exam- mescaline and peyote in Latin America. Some
ple, it is called mbanje in Zimbabwe, grass in the drugs, such as the khat leaf chewed by people in
USA and charas in India. It is the most common parts of East Africa, are used as part of social
illegal drug used today, but its use is now being interaction in everyday life. A common feature of
legalised in many parts of the world (in countries these drugs is that they are all derived from
including Uruguay or in some states of the USA). plants and are used strictly for the traditional
There are also some specific circumstances in ceremony or ritual. While most people who use
which cannabis may be used as a medication, for the drugs in this manner will have no ill effects,
example, to help reduce the nausea associated some may abuse the drugs as well. As societies
with chemotherapy for cancer. change, the use of these drugs outside their
The majority of cannabis users cannot be consid- traditional context is becoming more common;
ered as abusers, because the drug use is casual this may also lead to problems.
and controlled. However, cannabis may affect the
person’s health. This can happen in two ways:
○○ because cannabis is usually smoked, it can
damage the breathing passages and lungs
○○ people with severe mental disorders (psycho-
ses) can become more unwell when they take
cannabis; indeed, some very strong varieties
of cannabis (typically the marijuana grown
artificially) can cause brain damage and trig-
ger psychoses in vulnerable youth.
Always make an effort to dissuade the person
from smoking (as you should for anyone smoking
cigarettes), especially if they suffer from a severe severe, with the person feeling a strong urge
mental disorder. However, be sure to explain to to take the drug, fever, restlessness, confusion,
a concerned friend or relative the difference be- nausea, diarrhoea, anxiety and convulsions
tween cannabis and other, more serious, drugs. (flow chart 6.8).
●● Drugs which stimulate the brain: these
include cocaine, methamphetamine (also
●● Harmful use: when the way the drug is used
known as crystal meth), khat and pills such as
(e.g. smoked or injected) or the effects of the
ecstasy and ‘speed’ (amphetamine). In small
drug (e.g. hallucinations) can be harmful.
doses, these drugs make the person feel alert
●● Dependence: this is the least common type of and awake. In larger doses, the person feels
drug use, but is the type health workers should tense, panicky and restless. They may have dif-
be most concerned about. ficulty controlling their thoughts and may hal-
lucinate and become suspicious and confused
9.2.2 What drugs are abused? ( flow chart 6.6). The withdrawal reaction is
typically associated with hunger, fatigue and
●● Drugs that depress the brain: these include sometimes low mood; it is usually mild.
opium and heroin. In small doses, these drugs
●● Drugs which make the person hallucinate:
make a person feel relaxed. In larger amounts,
many depressant and stimulant drugs can
they make the person drowsy and unconscious
make a person hallucinate. Some drugs, such
(flow chart 6.5). The withdrawal reaction is
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BOX 9.9 DRUG ABUSE AND LIFE-THREATENING Crystal meth and cocaine are examples of
INFECTIONS party drugs that shift the body into overdrive
and make the user feel energetic and happy.
○○ Drugs like heroin and cocaine are sometimes Some of these drugs, such as rohypnol and
injected into the body. Because people who ketamine, have also been called ‘date rape
inject drugs may share needles and syringes, drugs’ because they have been used in situa-
and because drug users are more likely to tions of sexual assault. Because these drugs
engage in unsafe sex, they are at risk of HIV are colourless, tasteless and odourless, they
infection. Another serious disease which is can be added to drinks and used to intoxicate
associated with the same routes of infection or sedate others without their knowledge.
as HIV is hepatitis (types B and C). ●● Another category of drugs, more frequently
○○ Health workers must educate the person used by children living on the streets, involves
about the risks of these serious infections. If inhaling solvents like glue or paint thinner;
the person is unwilling to consider stopping these drugs produce effects of feeling happy
drug use, your goal is to try to get them to and stimulated, and can sometimes cause
switch from injecting drugs to some other hallucinations.
route of taking drugs which is less dangerous,
It is not uncommon for people to take several
such as swallowing pills. Substituting heroin
drugs at the same time, for example, with tobacco,
injections with buprenorphine tablets or
alcohol or sleeping pills. When used together, or
methadone syrup is a good example of such
in combination with alcohol, all of these drugs
a switch, which is best done under supervi-
pose an even greater threat to health and safety.
sion of mental health specialists (Table
14.6). If the person is unable or unwilling to do
this, then urge them never to share needles 9.2.3 How are drugs used?
and syringes. Recommend using disposable Drugs can be used in many ways. The common
syringes only. This will also reduce the risk of ways are:
skin and body infections which can occur with ●● smoking: cannabis, opium, cocaine and tradi-
dirty needles. Always give advice on safe sex tional drugs
behaviour. Suggest testing for HIV and hepa-
●● drinking, chewing or eating: pills, party drugs,
titis B after counselling. If the person is HIV
cannabis and traditional drugs
positive, you will need to refer to HIV services.
○○ If the person does not have either infection,
recommend hepatitis B vaccination.
○○ Finally, of course, complete stopping of the
drug is the goal, although this may often not
be possible at the start.

as LSD (lysergic acid diethylamide), are spe-

cifically used for this experience. LSD can have
an effect that lasts more than 12 h. Some per-
sons can become very excited, confused and
suspicious when taking these drugs. There is
no withdrawal state.
●● ‘Party drugs’: in recent years, certain drugs
have become popular among youth who
attend dance music events. They are called
‘party drugs’ and are typically produced in ille-
gal laboratories, using a variety of chemicals.
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●● sniffing or snorting the drugs through the ●● Accidents. When a drug abuser is intoxicated,
nose: cocaine and glue they may have accidents.
●● injecting: heroin and cocaine. This is the most ●● Social damage. Drug abusers spend so much
dangerous way of taking drugs (Box 9.9). time taking drugs that they are usually not
able to study, work or participate in normal
9.2.4 What does drug abuse everyday life.
●● Financial difficulties. Drugs cost money.
do to the person? Because drug abusers have limited sources of
Drug abuse causes enormous damage to the per- income, the drug abuse causes poverty.
son and their family. ●● Legal problems. In some cases, the drug
●● Mental health problems. Because drugs affect abuser may become involved in criminal
the brain, drug abusers can feel depressed and activities in order to obtain the drug. In most
tense. Some drugs can make the person suspi- societies, drug abuse itself is a crime and thus
cious and confused, whereas others can pre- the person may be imprisoned if caught using
cipitate a psychotic episode. drugs.
●● Physical health harm. Problems can arise ●● Death. Drug abuse can kill people through
as a result of the way a drug is abused. Thus, overdose, serious infections and accidents.
smoking a drug can damage the breathing
passages and lungs, while injecting a drug can 9.2.5 Why do people use drugs?
cause infections (Box 9.9).
●● Family problems. Drug abuse often leads to Most often, drug abuse starts in young people.
fights and problems in the family. One of the main reasons for starting drug use is

e. b.

The vicious cycle of drug abuse.

a. Drug use often begins when a

person has friends who use drugs.
b. He may first try drugs just as an
experiment, which makes him feel
‘high’ or ‘stoned’.
c. He enjoys it and uses the drug
more and more, until he reaches a c.
stage (d) when he feels sick every
time he doesn’t take the drug and
he must take the drug regularly (e)
to avoid feeling sick.

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peer pressure, which means because of friends 9.2.8 How to deal with this problem
who are also using drugs and who encourage the
person to use them. Curiosity and easy availabil- Special interview suggestions
ity are also important. A person may use drugs
●● Interview the person in private. Many drug
as a way of coping or dealing with stress, such as
users are taking the drug in secret and will
relationship conflicts and unemployment. One
not want to share their habit in front of their
other reason for drug use are chronic painful con-
family.
ditions (as opiates are also very effective painkill-
ers). Once the drug abuse has started, physical de- ●● Even if you have strong views about drug
pendence caused by the drug is the main reason abuse, you must not let them interfere with
for continuing drug abuse. your role as a health worker.

9.2.6 Why do drug users Questions to ask the person

seek your help? ●● Which drugs are you using? How often do you
take drugs? (This will tell you about the type
●● Because of health problems due to the drug and frequency of drug abuse.)
use. ●● How do you take the drugs? If by injection, ask:
●● Because they have run out of drugs and are Do you share needles? If yes, have you had an
now suffering withdrawal symptoms. HIV test or hepatitis B test?
●● Because they are fed up with their habit and ●● Have you tried to stop the drugs on your own?
want help to stop. What happened? (People who have tried to
●● Because their family or the police has told stop may be more motivated to accept your
them to seek your help. help.)
●● How is the habit affecting your health? Your
9.2.7 When to suspect drug abuse? family life? Your work?
●● Would you like to stop using the drugs? Why
●● If a young person develops problems in school now? (Being motivated is an important sign
or college, especially if they had no problems that the person may succeed in giving up the
before. habit.)
●● If a person starts neglecting their daily work or ●● Who are the people whom you trust and who
responsibilities. would support you now? (They may play an
●● If a person drifts away from their old friends. important part in helping the person stay off
●● If a person is repeatedly in trouble with the the drug.)
police.
●● If a person appears confused during interview. Things to look for during the interview
●● If a person has mental or physical health prob- ●● Signs of poor self-care.
lems which are related to drug abuse, such as
●● Signs of injection use, such as marks or
repeated accidents or skin infections on the
abscesses on the arms.
arms.
●● Signs that the person is intoxicated, such as
●● If a family member is worried about a change
looking drowsy or slurred speech.
in the person’s behaviour.
●● Jaundice may be a sign of hepatitis B or C.

Questions to ask the family or friends

●● Have you noticed any change in the person’s
behaviour or new friends? Since when?

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○○ joining community groups which help drug When to refer
abusers.
●● If the person is abusing large amounts of
For people who are not willing to stop now drugs, such as more than 1 g of heroin a day, or
●● Refer them to a community group which helps ●● is unable to stop the drugs despite your guid-
drug abusers. ance, or
●● Consider ways of reducing the drug abuse; for ●● has developed severe physical or mental
example, from smoking 0.5 g of heroin a day to health problems due to the drug abuse, or
0.25 g.
●● is injecting drugs and cannot stop this habit,
●● Move from more to less dangerous ways of or
using drugs, for example, from injecting drugs
to smoking them. ●● for methadone or buprenorphine substitution
treatment for opiates, in countries where this
●● Always offer the person a chance to come back is available.
and talk to you.
For people who relapse What to do later
●● Explain that this is common. Find out why they Giving up drugs is very hard and relapse is com-
relapsed and how they may prevent this from mon, so keep in regular touch with the person.
happening in the future. Only when the person has found new ways of
●● Give credit for whatever period of time the dealing with stress and has become involved in
person had managed to stay off the drugs. new activities will the chances of relapse fall. In
●● Start again as you would have the first time the general, keep in touch for at least 6 months. In
person came for help. some countries, it is necessary for health workers
to notify the legal authorities when they deal with
a drug user. You will need to be aware of these
rules and act appropriately.

section 9.2 summary box

things to remember when dealing with someone who has a drug problem
○○ The most common drugs which are abused ○○ Most illegal drug use is a temporary behaviour
are legal: tobacco and alcohol. This section is in young people.
about illegal drugs such as opium, cocaine and ○○ Motivating the person to change their behav-
heroin. iour, treatment for withdrawal symptoms,
○○ Regular drug abuse can be both a social and a counselling the family, regular follow-up and
health problem. The most serious problems are referral to community groups are the main
seen in those who inject drugs. treatments.

9.3 The person who can’t stop tion tables in Chapter 14). Problematic painkill-
ers are those that contain opioids, for example,
using prescription medications codeine, dihydrocodeine, tramadol and pethidine.
Sleeping pills and some types of painkillers are This chapter is about becoming dependent on
the most commonly misused legally obtain- these two types of medications. Usually they are
able medications. The most common sleep- either prescribed by health workers or bought
ing pills are diazepam, nitrazepam, lorazepam, ‘over the counter’ (without a prescription) from
chlordiazepoxide and alprazolam (insert trade pharmacists. Health workers themselves can be
names in your area for these drugs into medica- tempted to misuse these medications.

a. b. How a person becomes addicted to

sleeping pills.

a. A person who cannot fall asleep may

(b) start taking sleeping pills to help her
sleep.
c. She will sleep much better for a few days,
but as she continues taking the pill, the
effect it has on her reduces and she has
difficulty again (d).
d. e.

e. She now needs more pills to fall

asleep and (f) she can sleep only when
f.
she takes the pills.
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9.3.3 How should you deal with this ●● The withdrawal programme can be decided as
follows.
problem?
○○ Find out how much of the particular sleep-
Questions to ask the person ing pill or painkiller a person is taking each
day. If the amount changes from day to day,
●● How long have you been taking these medica- take an average figure for the previous 3
tions? (The longer the period, the greater the days.
possibility of dependence.)
○○ Reduce the medication immediately by
●● How often do you take them? (For sleeping one-quarter. For example, if a person was
pills, if they are taken during the day as well, taking four diazepam tablets a day, reduce
then the person is probably dependent.) it to three.
●● In a day, how many tablets do you take? (This ○○ The person should take this reduced
will give you an estimate of the total amount of amount for the next 3 or 4 days. After this,
the medication the person is taking each day.) reduce again by one-quarter or a practical
●● Do you drink alcohol? (When sleeping pills or amount (e.g. one tablet again).
painkillers are taken together with alcohol, ○○ Continue in this manner over a period of
their combined sedative effects can be very about 2 weeks until the person has been
strong.) taken off the pills.
○○ If the person gets severe withdrawal symp-
What to do immediately toms, go back to the previous dose and wait
●● Explain that when sleeping pills or painkillers for a week before starting the withdrawal
are used for a long time, they can produce a again.
dependence problem in the same way that ○○ If the person is taking short-acting sleeping
alcohol can. Strongly recommend not to mix pills like alprazolam, you may substitute
these pills with alcohol because of the dan- this with longer-acting ones like diazepam
gers of causing sedation and suppression of first and then gradually reduce as described
breathing. above. The withdrawal symptoms will be
●● Explain that many of the person’s symptoms less severe for long-acting medications.
(e.g. sleep problems and pain) are actually the
result of this dependence, rather than a sign
that more sleeping pills are needed.
●● Use motivational strategies (5.17) to help
the person decide to change their behaviour.
●● For people who are injecting opioid painkill-
ers, follow the treatment guidelines for opioid
dependence (9.2.8).
●● For someone who is using tablets, once you
have the person’s understanding, you can start
them on a gradual withdrawal programme.
This means that the person reduces the medi-
cation in small steps over a period of time so
that the withdrawal symptoms are reduced.
Typical withdrawal symptoms are tension,
worry, sleep problems and pains. Always warn
the person of the chance of withdrawal symp-
Withdrawal from sleeping pills should be done
toms so that they are prepared for them. gradually, for example, reducing by one pill, or a
quarter of the daily dose, every few days.
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●● Some people will get their pills from other When to refer
health workers (or even directly from phar-
If the person is taking large amounts of sleeping
macies) if they feel you are not prescribing
pills, if they are injecting the pills or using inject-
enough. If possible, be in touch with other
able opioid painkillers or abusing many different
local health workers and pharmacies and
types of drugs.
inform them of the need to avoid prescribing
pills to such a person.

section 9.3 summary box

things to remember when dealing with someone who can’t stop using
prescription medications
○○ Prescription medications like sleeping pills and ○○ Always try counselling for improving sleep or
opioid painkillers are readily available and can a sedating antihistamine for people with sleep
lead to dependence problems. problems.
○○ You should prescribe opioid medications only ○○ If using sleeping pills, do not ever use for more
to people who need them for pain relief. than 2 to 3 weeks.
○○ Dependence on sleeping pills and painkillers ○○ Before prescribing painkillers for aches and
can lead to the very complaints which the per- pains, make sure that you are not missing an
son had before starting the pills, such as sleep emotional cause.
problems, tension and pains. ○○ Education and gradual withdrawal is the treat-
ment for most people with this problem.

9.4 The person with tobacco dependent because tobacco contains nicotine, a
drug which produces addiction. However, just as
dependence with other drugs, many adolescent smokers are
The leaf of the tobacco plant has been used as a only experimenting and will not become depend-
drug for centuries. It can either be chewed (such ent on tobacco.
as gutka in India) or smoked (in the form of ciga-
rettes). 9.4.1 Why tobacco use is dangerous
People start using tobacco for the same rea-
Tobacco is one of the most important causes of
sons as they start drinking. Peer pressure in school,
premature death in the world. Despite the enor-
being influenced by advertising by cigarette com-
mous health damage, tobacco companies are ag-
panies, and a belief that smoking is fashionable
gressively marketing cigarettes, especially in low-
are common reasons for starting smoking. Once
and middle-income countries. Young people are
smoking has begun, the person quickly becomes
especially targeted.

Tobacco can be used in several

different ways: (a) flavoured
tobacco can be smoked as shisha,
(b) dried tobacco leaves can be
rolled into a cigarette, and (c)
tobacco leaves can be chewed.

a. b. c.

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The diseases most commonly associated with 9.4.2 When to ask about
tobacco use are:
tobacco use
●● cancers of the breathing passages and lungs
●● cancers of the mouth or tongue You should ask everyone about tobacco use. This
is because most tobacco-related diseases only
●● heart attacks, strokes and high blood pressure occur after many years of use. Thus, adolescents
●● serious lung diseases such as chronic bronchi- who begin smoking regularly will only show signs
tis and emphysema. of disease when they are in their 40s or 50s. By
Smoking tobacco harms others who do not then, it is usually too late to prevent the disease.
smoke in these ways. Suspect tobacco use:
●● The unborn child can be harmed when a ●● when you smell tobacco on the breath
woman smokes during pregnancy. The child ●● when you notice yellow-stained teeth or
may be born too early or too small. fingers
●● Passive smoking is when a non-smoker inhales ●● when you notice decayed teeth or a discol-
the smoke created by a smoker. Passive smok- oured tongue
ing can cause the same diseases in the non- ●● when you see a packet of cigarettes in the per-
smoker as actual smoking. son’s clothing
●● Children who live in families where smoking ●● whenever a person has breathing, chest or car-
occurs have a higher risk of suffering breathing diac complaints.
diseases such as asthma, and infants are more
likely to die during sleep.
BOX 9.10 WAYS TO CUT DOWN ON SMOKING

Here are some suggestions on how a person

could cut down smoking.
○○ Decide to smoke only once an hour. Then start
increasing this time by half an hour until it is
every 2 h and so on.
○○ Make it hard to get a cigarette. Do not keep
more than one at home at any time.
○○ If you always smoke with tea or coffee, try
a. b. switching to some other drink.
○○ If you can quit even for one day, you can quit
for another. Try it!
○○ Spend the money you save from smoking on
something you like but haven’t had money for
in the past.
○○ Exercise and see how much better it feels
when you are not smoking!
c. d. ○○ If you break down and have a cigarette, it’s
OK! It was good that you tried and you can try
Signs of tobacco use: again.
a. breath smelling of tobacco ○○ Tell your friends you are going to quit.
d. cough or other chest/cardiac complaints ○○ Talk to your doctor about the use of medica-
c. yellow-stained fingers tions to reduce cravings for tobacco.
b. yellow-stained teeth.

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When to refer mouth, persistent cough for more than 1 month,
chest pain and difficulty breathing in long-term
If you suspect cancers or heart disease caused by
smokers are all signs that a medical examination
tobacco. Changes in the colour of the tongue or
is needed.

section 9.4 summary box

things to remember when dealing with tobacco dependence
○○ Tobacco is an extremely harmful drug. ○○ The only way to detect the habit is by asking
○○ Tobacco users will rarely come with the habit as everyone about tobacco use.
the main problem. ○○ Motivating and educating the person are help-
ful strategies to stop tobacco use.

9.5 The person with a gambling continues until the person is in deep
financial trouble. Indeed, in these respects, the
gambling habit way that gambling can become an addiction has
Gambling is when a person bets money on a game similar mechanisms to drugs. When a person falls
where winning is mainly based on chance. Com- into this cycle, it is called pathological gambling.
mon examples of gambling include betting mon-
ey on horse races, card games, sports, lotteries 9.5.2 Gambling and health
and gambling machines.
Gambling can affect health in many ways:
●● work is affected because a person has irregu-
9.5.1 How does gambling lar hours and may sleep less because some
become a habit? gambling activities take place late at night
Unlike other drugs, gambling has no external ●● because the gambler cannot think of anything
‘chemical’ that can help explain why a person other than gambling, they can become irri-
becomes addicted. The expectation of winning table, have poor concentration and become
seems to be a major reason why people wish depressed
to gamble, even though most gamblers lose ●● the gambler may have financial problems and
much more than they win. They may borrow or may owe money to several people
steal money to gamble. But the cycle of loss and ●● some gamblers will get involved in theft or
crime to raise money
●● conflict with relatives is often the result of the
gambler not giving enough time and attention
to family responsibilities
●● gambling, drinking alcohol and smoking often
go together (e.g. gambling activities may be
held in a bar).

9.5.3 When to suspect

gambling is a problem
●● Whenever you see any person with a drinking
Gambling is often associated with other habits, such as problem, ask about gambling.
smoking and drinking.
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●● When a person has repeated problems with the urge to gamble with drink-
their family or with the police. ing in a bar, then they should
●● When a person has begun to show signs of avoid that bar. Similarly, they
increasing poverty. should avoid friends
they associate with
●● When a person withdraws from friends.
gambling.
●● Identify important
9.5.4 How to deal with this problem individuals in the
Questions to ask the person person’s life who
can understand
●● Have you been gambling recently? What type the problem
of gambling do you do? and support the
●● Have you lost time from work because of person dur-
gambling? ing this difficult
●● How has gambling affected your home life? phase.
●● How do you feel about your gambling? Do you ●● Identify all people the person owes money to,
feel guilty? and help the person develop a plan aimed at
repaying their debts. This will help them gain
●● How do you find the money to gamble? How
confidence that they will be able to resolve
much do you owe others?
their difficulties. It will also help prevent
●● Do you drink alcohol? (If yes, ask about prob- them from gambling more in an effort to raise
lem drinking.) money to pay their debts.
●● Have you thought about stopping gambling? ●● Hand over a large share of the salary to the
Would you like to do so now? spouse on pay-day so that the month’s income
is not gambled away.
What to do immediately ●● In some places there are special groups which
●● Discuss the nature of the habit. Most gamblers help people with gambling problems (such as
may not even be aware that the way gambling Gamblers Anonymous). Refer the person to
becomes a habit is similar to other kinds of them if they are available.
addictions. This awareness may motivate the If the person relapses or does not
person to consider stopping the habit. want to stop immediately
●● Discuss the negative effects of gambling on ●● Do not reject them.
the person’s life. ●● Ask them to come and see you again.
●● If there are any other addictions, treat ●● Discuss the possibility of giving up at each visit.
accordingly.
●● Attempt a reduction in gambling activity by
If the person wishes to stop now reducing the amount of time spent gambling
●● Identify other activities the person could do or setting an upper limit on the amount of
instead of gambling. These activities should money the person will gamble in a week.
be enjoyable to the person so that they are Some gamblers can become depressed or anx-
able to resist the urge to gamble. ious. Treat as you would any other person with
●● Identify the situations which make the person depression (7.4).
want to gamble. For example, if they associate

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9.6 Internet addiction Negative consequences of internet addiction
include sleep disruption (and its consequences,
Similar to gambling addiction, internet addiction such as daytime fatigue) due to late-night inter-
is a problem because of being unable to control net usage, relationship difficulties, academic un-
the impulse to use the internet, rather than an ad- derperformance, and depression.
diction to a chemical. It involves activities such as
The focus of treatment for internet addiction
excessive and compulsive gaming, and e-mail or
should be controlled use. Some treatment strate-
social media communication. The common fea-
gies that can be used to achieve that include:
tures of internet addic-
tion include: ●● encouraging the person to disrupt their com-
puter routine and reorganise the patterns or
●● excessive use, often
timing of use
associated with a
loss of sense of time ●● using activities that the person needs to do or
or a neglect of other places to go as prompters to remind them to
important activities log off
such as eating and ●● making a reminder card which lists the pros
sleep and cons of excessive internet use
●● anger or frustration when a computer is ●● cultivating alternative activities, especially
inaccessible those that had been neglected since the exces-
●● the need for better computer equipment, sive internet usage started.
more software or more hours of use.

section 9.5 & 9.6 summary box

things to remember when dealing with someone addicted to gambling or the
internet
○○ Gambling and internet use can become an ○○ Some of those addicted may be depressed.
addiction and lead to damage to a person’s ○○ Education about the nature of the problem,
mental and social health. motivating for change, identifying alternative
○○ Even though gamblers and people with internet recreational activities and problem-solving are
addiction rarely come forward for treatment, the best treatments.
many do recognise that they have a problem.

notes

10.1.1 How does trauma

affect health?
An incident that makes a person fear for their life Trauma can cause physical injuries such as a bro-
and causes them extreme distress is a traumatic ken leg following an accident or a burn after an
event. There are different types of traumatic explosion. Trauma can also have a deep effect on
events: a person’s mental health. Even a person who only
saw what happened (such as someone walking on
●● personal trauma:these are incidents which
the road and seeing a terrible accident) can expe-
threaten the person, for example, being raped,
rience these mental health effects. Many people
being a victim of crime, being involved in a
affected by trauma will experience some emo-
road traffic accident, or witnessing trauma in
tional distress in the following ways:
a loved one;
●● feeling numb, in a daze and disconnected from
●● war or terrorism: these are events in which
one’s surrounding and feelings
an entire community, or a subgroup in the
community to which the individual belongs, ●● forgetting one or several important parts of
has been exposed to violence; the event
●● disasters: e arthquakes, fires, floods and other ●● repeated thoughts of the event and re-living
natural disasters can cause trauma to individ- what happened to them
uals or large numbers of people at the same ●● irritability, sleep difficulties, nightmares, hav-
time. ing difficulty concentrating

The possible causes of post-traumatic stress disorder: crime, war, disasters.

†
With Maryam Shahmanesh.
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BOX 10.1 MENTAL HEALTH EXPERIENCES FOLLOWING TRAUMA

People with PTSD have three types of complaints: ○○ being on edge: sleep is disturbed, the person
○○ experiencing the trauma again and again: the feels irritable, has difficulty concentrating and
person re-lives the trauma is easily startled or scared, as if the trauma
through visions of the incident, could happen again at any minute; panic at-
nightmares and ‘flashbacks’ tacks and hyperventilation (i.e. breathing very
(thoughts of the traumatic event fast) can occur (8.2).
repeating itself); In addition, many people with PTSD feel depressed
○○ avoiding things: the person and lose interest in daily life, feel tired or suffer
avoids situations which aches and pains, and have suicidal feelings. Some
remind them of the resort to using alcohol or sleeping
traumatic event; they are medications to help them cope with
unable to remember things related to their symptoms.
the trauma and feel emotionally
distant from people;

●● feeling scared and avoiding anything that have experienced mental health problems in the
reminds them of the event past and those who have poor social support are
●● physical symptoms such as nausea, vomiting, more vulnerable to developing mental health
racing heart and feeling breathless problems, including PTSD.
●● children can experience bed-wetting.
10.1.3 How to deal with this
This is a normal response to a traumatic event
and usually lasts for no longer than 2 weeks. In problem
a few people, however, these experiences con- Questions to ask the person
tinue for months (even years) after the trauma.
If they begin to interfere with the person’s daily ●● What happened? How/when did it start? What
life (e.g. causing difficulties in relationships with happened to you? Who else was present? What
others) the person may have developed a mental did you do immediately afterwards? (These
disorder called post-traumatic stress disorder questions will help you get information about
(PTSD). Traumatic events can trigger other men- the traumatic incident.)
tal health problems as well, including depression, ●● How are you feeling now? (Intense symptoms
anxiety, and alcohol and drug problems. of distress are associated with greater risk of
developing PTSD.)
10.1.2 Why do some victims of ●● What have you done to help cope with your
violence develop mental health feelings? (In particular, explore the availability
of social supports, or the use of alcohol or other
problems? drugs.)
Events that lead to actual loss of life or events that ●● Ask about features of depression and anxiety
were life-threatening are more likely to lead to (3.9) as these are common mental disorders
mental health problems. Man-made events such following trauma.
as terrorist violence may be more traumatic than
natural events. Survivors of traumatic events in What to do immediately
which others died may feel guilty or blame them-
selves for not having done enough to save oth- For trauma associated with disasters, war or other
ers. People who have prolonged exposure to the humanitarian crises, the first principle is to pro-
trauma (e.g. childhood sexual abuse), those who mote safety and ensure that basic needs, such as

section 10.1 summary box

things to remember when dealing with someone who has experienced trauma
○○ Traumatic events include being a victim of ○○ Psychological first aid is the most helpful strat-
violence, rape or another criminal act, or being egy for distress immediately after the event.
involved in war, terrorist violence or major ○○ Sleeping tablets (benzodiazepines) and anti
disasters. depressants are very rarely useful in the imme-
○○ Most people experience distress following such diate aftermath of trauma.
events; only a small number develop PTSD or ○○ Counselling strategies are often of great help in
other mental health problems. recovery. Antidepressants are helpful if other
○○ The main features of PTSD are experiences of approaches have failed or if there are symp-
re-living the trauma, avoiding situations or toms of depression.
places that bring back memories of trauma,
and feeling fearful or on edge.

10.2 The woman who is being (such as mothers-in-law). Domestic violence can
take a variety of forms (Box 10.2).
beaten or abused by her partner Violence occurs in all classes of society.
Around the world, women experience violence at Violence severely damages a woman’s physical
the hands of other family members, most com- and mental health. In the most extreme situa-
monly their husbands or intimate male partners. tions, it can cause her death either through inju-
Less commonly, women may experience violence ries or by suicide. Many victims seek help for the
at the hands of other male relatives (such as sons) various health problems they suffer.
or other women with more power in the home

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BOX 10.2 THE WAYS IN WHICH MEN CAN ABUSE WOMEN

○○ By mocking, abusing and humiliating (e.g. ○○ By controlling resources in the home (e.g.
using foul language or running down the denying the woman money, health care or the
woman’s relatives and friends). opportunity to work).
○○ By threatening (e.g. threats of ○○ By forcing her to isolate herself (e.g. denying
killing or harming the woman, the woman the chance to meet her friends or to
threats of harming oneself (e.g. leave the house).
through suicide) if the woman ○○ By physical violence (from slapping to hitting to
leaves). kicking her. In more serious cases, the man may
○○ By forcing her to have sex. use a weapon or even try
(Some people think that to kill the woman).
because a
woman is married, she must
allow her husband to have
sex with her whenever he
wants. This is not true.)

10.2.1 How do women suffering 10.2.2 Why do some people beat or

domestic violence present to abuse their partners?
health workers? Intimate partner violence is very common and
Women rarely complain of domestic violence. For occurs everywhere in the world. Some men beat
that reason, it is important for health workers to their wives because they believe this is the ac-
be alert to the possibility of violence and to ask cepted way of dealing with conflicts. They may
about this issue when in doubt. The typical health have seen their fathers behave in a similar way
problems which women do complain of are: towards their mothers. Violence becomes a way
of keeping women ‘in their place’. Some people
●● multiple presentations with cuts, bruises say that some women ‘deserve’ it when they are
and other injuries, with vague or unlikely beaten because of what they do or how they be-
explanations have. What is important for the health worker to
●● suicidal behaviour or self-harm note is that there is no justification of any sort for
●● drug and alcohol misuse a man to be violent towards a woman.
●● unexplained chronic physical complaints such Violence, though mostly directed against
as headaches, sleep problems, tiredness, gas- women, can also be directed against other people
trointestinal symptoms, bladder symptoms in the family such as children (11.5), elders and
and chronic pain men. In same-sex relationships, men may be vio-
lent against their male partners and women may
●● reproductive tract symptoms, such as vaginal
be violent towards women. There are also cases
discharge and vaginal bleeding, and sexually
of women being violent towards male partners . A
transmitted infections
common theme in domestic violence is the need
●● adverse pregnancy outcomes such as miscar- for power and control. A person who wants to
riages and unplanned pregnancies exert power or control over another is more likely
●● repeated health care consultations with no to be violent towards them.
diagnosis Health workers should not think that the
●● intrusive male partner attending consultation. abuser is a ‘monster’. He may be in need of help

10.2.3 How to identify domestic 10.2.4 How to deal

violence with this problem
Many health workers are unsure whether they Special interview suggestions
should ask about violence, because they feel
there is little they can do about it. Some believe ●● Violence is a subject which causes embarrass-
that violence is not a health issue. In fact, violence ment, so discuss it in private.
is as much a health concern as dirty drinking wa- ●● If family members or the husband seem unwill-
ter, especially for mental health. As a rule, if you ing to leave, you can say you need to ‘examine’
suspect that violence is occurring in a woman’s the woman and thus need to be alone with her.
home, always ask her about it. All women who

BOX 10.3 MYTHS AND TRUTHS ABOUT INTIMATE PARTNER VIOLENCE

○○ Myth: A man can do whatever he wants to his ○○ Myth: She deserves it.
wife. ○○ The truth: No
○○ The truth: No person human being, man
has the right to con- or woman, ever
trol another person, ‘deserves’ to be a
let alone be violent victim of violence.
towards them.
○○ Myth: It’s a matter for their family. It’s none of
○○ Myth: He loves her too much to do something like our business.
this. Even if he does hit her, it is because he loves ○○ The truth: It is a matter for the whole com-
her. munity. If one woman is being beaten, then
○○ The truth: Hitting is others will be beaten as well.
never the result of love.
Many men who hit are ○○ Myth: How can she
possessive of their wives, leave him? What
but this is not love. will happen to the
children?
○○ Myth: He hits her because he drinks. ○○ The truth: If there
○○ The truth: Alcohol does not make a man is violence in the home, this can be far more
violent, but it can make an angry man more dangerous to the children’s well-being than
likely to become separation of the parents.
violent.

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BOX 10.4 WHY DO WOMEN STAY IN VIOLENT angry and the violence may get worse.
RELATIONSHIPS? ●● If the woman asks you to speak with her hus-
band, discuss the potential risks with her first.
There are many reasons women do not leave
If you both agree that engaging him may help
their violent relationships. improve the situation, invite him to meet with
○○ ‘No money, nowhere to go’: the woman is you (either together with the woman or sepa-
trapped by her money situation; if she leaves, rately, based on what she feels most comfort-
she may have no home to go to and no able with).
money.
○○ ‘How will the children manage without a Questions to ask the woman
father?’: if she has children, she may have
worries about their future. Step 1: Ask
○○ ‘What will he do if I go?’: she may be scared of Asking about violence in the home is a very sensi-
what he might do if she leaves. Some hus- tive matter and must only be done after you have
bands threaten (and do) kill their wives. built a rapport with the woman. In general, start
○○ ‘What will others think if I leave?’: she may off with a general question about the quality of
have little support in her situation; some the relationship or an opener to normalise the
women fear that her family will reject her and
question.
that she will be shunned by her community. ●● How is your relationship with your husband?
○○ ‘Let me try and change to make things better’: ●● Violence in the home is very common, so we
some women blame themselves for the vio- ask about it routinely.
lence. They may feel that they should change ●● Do you and your husband fight or argue? How
in order to make the situation better. often? About what?
○○ ‘This is what marriage is about’: some women ●● Are you in a relationship with someone who
may believe that violence is a ‘normal’ part hurts or threatens you? Is there anyone at
of living with a man. This is especially so for home who you are frightened of?
women who have seen their own mothers or
sisters being beaten. Remember never to pressurise the person to
talk.
●● Discussion of violence takes time. Do not be Step 2: Assess the extent of the problem
in a hurry to get the information. Do not take Based on the responses to these questions, you
sides. can be more direct.
●● Listen before you say anything on how to ●● Has your husband ever hit you? Or threatened
resolve the situation. to hit you?
●● Do not make judgements about whether the
woman is right or wrong in deciding to stay Being married can be
with or separate from her husband. quite difficult for some of us. Many women who
feel unhappy are suffering violence in their homes.
●● With the exception of situations where there Could this be happening to
is an immediate danger to the woman’s life, you?
do not be in a hurry to ‘save’ the
woman from her situation.
●● Take care to keep your discus-
sions confidential. If the man
finds out that his partner has
been speaking to others
about the violence she is
experiencing, he may get

most cases, he probably would not. But it still

As you may know, it is not
uncommon for a person to be emotionally, does no harm to ask.)
physically or sexually abused/harassed at As a rule, do not be afraid to ask about
some time in their lives. Has this ever violence. Most women are relieved when asked
happened to you?
about violence, because they are often scared or
embarrassed to bring it up themselves.

Questions to ask the family or friends

As for all people who seek help from you, never
ask questions of the family or friends without the
person’s permission. Having done so, these are
some important questions.
●● What do you feel she should do? (This will give
●● How is this situation affecting your feelings? you a sense of the views of the people who are
(Ask questions for anxiety, depression and sui- close to the woman. These often play an impor-
cidal thoughts 3.9, 7.4.) tant part in influencing the decision taken by
●● How are you coping with this violence? Have the woman.)
you told anyone else about it? Who? (Identify ●● If she were to leave home, would she be wel-
the woman’s social support and her ways of come to stay with you? Or with someone else?
dealing with the violence; check on the use of
alcohol or sleeping tablets.) What to do immediately
●● What about the children? (If there are children ●● If the woman discloses violence, offer support-
caught in the violence, make arrangements to ive statements such as ‘You are not alone’, ‘You
talk to them.) are not to blame for what is happening to you’.
●● What things have you thought of to change ●● Clearly document the woman’s history and
your situation? (If the woman has considered any physical injuries. Record details such as
separation, find out who she has talked to.) exactly what the woman said her partner did
●● What are your concerns about separation? (e.g. ‘Woman says partner hit her with a metal
Who would you go and stay with? (This is es- pan at least 6 times’) and the nature of injuries
pecially important when there are no women’s (e.g. ‘A bruise on the right shoulder area meas-
shelters in your area.) uring about 2 cm by 3 cm’). These records may
●● Does your husband know that you are talking be very important in the event of a police case.
to me about this problem? ●● Many women develop negative feelings about
●● Would you like me to invite your husband to themselves. Be comforting and reassure the
come to talk to me about this problem? (In woman that she is not responsible for the
violence.
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○○ Consider where she could go for refuge, for
example, neighbours – make sure that this
place will welcome her in an emergency.
○○ If there are weapons in the house, hide
them.
○○ Save money in case it is needed later.
○○ Leave copies of important documents, such
as identification cards and marriage certifi-
cates, with others.
○○ Devise a code word she could use with chil-
dren or relatives when she feels threatened
and wants help.
○○ The best course of action is to recognise
Carefully document the location and extent of bruising. when a situation is becoming dangerous
and leave the room immediately.
●● Treat symptoms of depression (7.4) or PTSD ●● Give information regarding resources for
(10.1). women in your community (Chapter 15).
●● Use problem-solving to identify practical
things the woman can do to address the causes When to refer
and consequences of the violence (5.11).
If the woman’s life is at risk and she has nowhere
●● While you should not make decisions for the to go, hospital may be the only safe shelter for her.
woman on whether she should continue living If available, refer her to a community-based group
with her husband, you should share your con- or programme for empowerment of women.
cerns if you feel that her life is at risk.
●● Involve people important in her life in plan- What to do later
ning for the future. This could include family
If the woman wishes, invite the husband for
or friends who have genuine concern for the
counselling to address the relationship problems
woman.
(5.15). The difficulty in helping people who
●● If the woman has legal problems, or wishes experience violence is knowing what to do if the
to make a police complaint, refer her to the situation does not change and the woman cannot
appropriate authorities. It can help if you write leave. You can consider the following options for
a note describing the health issues, since the the woman.
woman may not get a sensitive hearing from
●● Make a police complaint. Some men will back
the police.
off when the police get involved.
●● If you know the legal rights for women who are
●● Share the information with the wider family
victims of violence, then share this informa-
and hope that they will apply some pressure
tion with her. If you don’t know this, consult
to the husband.
a colleague or refer her to a woman’s support
group. For example, in some places police ●● Start planning for separation. Examine the
can question and warn a man who has been woman’s concerns about separation and
accused of violence, and judges can restrain a help her think of ways in which they can be
man from coming near the woman and force overcome.
him to make maintenance payments. ●● Refer her to a woman’s support group from
●● Discuss what the woman would do if violence whom she can seek advice.
occurred again. Help her plan her actions. ●● Sometimes the man may himself come to
Examples of how the woman can plan for her the health worker for some different reason –
safety are as follows. bring up the issue at this time.
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10.2.5 Working with men who are to try to get them to confess to the affair. Of
course, the affair is most often imaginary
violent (7.3).
The greatest difficulty in helping women whose ●● All violent men can benefit from advice on
husbands or partners are violent is that most how to control and deal with their anger
men do not seek help for this problem. They may better. You should advise on how to
fear humiliation, police or legal action, or social manage anger (5.16).
stigma. These are some suggestions on how to ●● Support groups for
work with men who do seek help because they men who have difficulty
are concerned about their violent behaviour. in controlling their
●● It is important for the health worker not to anger may help in
take sides in this situation and to try to help reducing the risk of
the man change his behaviour. recurrence, in the same way that
●● There are also some situations where a man Alcoholics Anonymous groups help
can become violent as a result of his mental individuals with drinking problems (5.26).
health problems. The first is men who drink ●● Confidentiality is very important when work-
too much and become violent when they are ing with partners as separate individuals. Both
drunk (9.1). The second is men who are very partners must feel secure that their conversa-
suspicious that their partners are having an tions with the health worker will not be shared
affair with another man and beat their wives with the other partner.

section 10.2 summary box

things to remember when dealing with women who are being abused
○○ Violence is common; suspect it in any woman ○○ Violence may escalate during pregnancy.
with unexplained injuries, vague physical symp- ○○ Always ask about violence if you suspect it.
toms, sleep problems or suicidal feelings. ○○ Encourage the woman to share her experience
○○ Violence can be physical, sexual or emotional. with family or friends she trusts.
Most victims of violence in the family are
women being abused by their male partners.

10.3 The person who has been Sexual assault and rape are among the most
terrifying experiences. In some places, the person
raped or sexually assaulted suffers the double blow of rape and then being
discriminated against by other members of their
In most countries, rape refers to forced sex where
community. Because rape involves both physical
there is sexual penetration of a woman by a man.
and mental violence, it is extremely damaging to
Sexual violence against children is discussed else-
the person’s health.
where (11.5).
Sexual assault and rape can lead to:
Sexual assault is a broader term, which
includes rape as well as other forms of sexual vio- ●● unwanted pregnancies
lence. This includes: ●● sexually transmitted diseases, HIV/AIDS
●● touching or grabbing parts of the body ●● physical injuries such as bruises, tears, cuts or
●● making sexually suggestive comments or fractures
movements ●● mental health problems such as PTSD and
●● sexually attacking a person in any way, depression
whether or not there is sexual penetration. ●● death.
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a. b. c. d.

The health impact of rape

a. Unwanted pregnancies.
b. Sexually transmitted diseases, such as HIV/AIDS.
c. Physical injuries, such as bruises, tears, cuts or fractures.
d. Mental health problems such as PTSD and depression.

Some people argue that it is not possible for ●● In the days and weeks after a rape, the person
a man to rape another person unless she cooper- may blame themselves, fear being killed or
ates, for example, by lying down and staying quiet harmed, feel dirty, have repeated thoughts of
during the rape. In fact, most women do put up the rape, or have nightmares and sleep prob-
resistance and many manage to escape the rap- lems. Physical complaints such as aches and
ist in this manner. However, a rapist can over- pains, loss of appetite and tiredness are also
come a woman by sheer physical strength, often common.
combined with emotional power. Sometimes, ●● Later, the person may develop a fear of people
the woman is so scared that she fears resisting and of situations similar to those in which the
because the rapist might hurt her even more. rape occurred. They may develop depression
Men can also be victims of sexual assault and (7.4), PTSD (10.1) or suicidal behaviour
rape by other men. Male rape is an even bigger (7.6).
secret than female rape. This is partly because
●● In the end, the majority of people recover, but
male victims rarely seek help.
not without having suffered ill effects for a
long time.
10.3.1 How do people react to
being raped? 10.3.2 Who rapes another person?
Typically, the person goes through a series of In the case of women, most often the rapist is
emotional reactions as a result of being raped someone she knows:
(10.1). ●● her boyfriend: this is sometimes called ‘date
●● Shock and anger are often the first reactions. rape’;
The woman may be tearful, shaking with fear ●● her husband: in many societies, having sex is
and anger, and unable to understand what she considered a ‘duty’ of a wife; however, if she
has just experienced. does not want sex and it is forced on her, it is
●● Some women may appear calm and con- sexual violence;
trolled; this does not mean that they have ●● a man in her social circle, such as an uncle or a
coped well with the rape. neighbour, or someone she works with.
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Rape can also happen by: Questions to ask the person
●● the police or soldiers
●● What happened? (In particular, ask about the
(especially when
time since the assault, the nature of the assault
women are cap-
and the nature of any injuries.)
tured by soldiers
or arrested by the ●● Are there times when your partner has sex
police – it is particu- with you when you do not want to?
larly terrifying because ●● When was your last menstrual period? Are you
the woman is being using any contraception? (Assess her risk of
raped by the peo- pregnancy.)
ple who should be ●● Did the rapist use a condom? (The risk of HIV
protecting her); and sexually transmitted infection is increased
●● the client, if the woman if the rapist did not use a condom.)
is a commercial sex ●● How are you feeling right now? (Ask about their
worker; mental health, in particular, symptoms of de-
●● a complete stranger (the pression, anxiety and suicidal behaviour.)
attack may happen on the street or in the ●● Have you told anyone about the rape? Who?
woman’s home). What was their reaction? (This will help you
For men, the rapist is usu- identify any support the person might have dur-
ally a person in authority, for ing this difficult period.)
example, a police officer,
soldier, priest or another What to do immediately?
man within a situation Physical examination
where men live close to one A physical examination is recommended especial-
another and relatively cut- ly if the rape occurred less than 24 h earlier. The
off from the rest of the person may be resistant to having such an exami-
community, such as nation. Reassure them that this is the main way
in prisons, the in which a rape can be proved for legal purposes.
army, board- The examination will include looking for injuries
ing schools or to the sexual organs or other body parts (includ-
hostels for men. ing the rectal region, especially in men), collecting
specimens to look for sperm, and tests for sexu-
10.3.3 How to deal with this ally transmitted infections including HIV.
problem Emergency contraception
Rape is a very sensitive issue. Take time to listen If there is a risk of pregnancy, emergency contra-
without pressurising the person to talk about ception should be offered to a woman who has
what happened. Give appropriate priority to ad- been sexually assaulted as soon as possible:
dressing the person’s health and legal needs. If ●● if available, levonorgestrel 1.5 g; if not avail-
the person would like to speak about what hap- able, a combined oestrogen–progesterone
pened, discuss it in private. Reassure them about course with anti-emetic cover can be given;
the confidentiality of their story. Do not ask for ●● emergency copper intrauterine device with
unnecessary details about the act. Men who are prophylactic antibiotics for prevention of sex-
raped (by other men) are especially unlikely to ually transmitted infections.
come forward with what happened owing to the
If the event was more than 5 days ago or the
stigma and humiliation attached to this experi-
woman is already pregnant, she should be offered
ence. Be especially sensitive when asking men
safe abortion in accordance with national law.
about sexual violence.

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Post-exposure prophylaxis (PEP) for HIV and ●● Encourage disclosure to a friend or relative,
sexually transmitted infections and spending a few days with someone the
●● Offer HIV counselling and testing as soon as person trusts. It is better if they are not alone.
possible after the event. ●● Refer the person to a support group who
●● Consider offering PEP to victims presenting can advise them on legal rights and provide
within 72 h of the assault, according to the risk assistance.
of HIV (which depends on the prevalence in ●● If the woman agrees, talk with the family. Some
the area, HIV status and characteristics of the men reject their wives if they have been raped.
assailant if known, nature of assault and num- Talk to the husband and try to change his reac-
ber of assailants). tion by pointing out that rape is a crime and
●● If PEP is given, HIV counselling and testing that it could have happened to any woman.
need to be done. Adherence counselling and ●● The person who has been raped or sexually
support for PEP must be provided. assaulted by a relative or close friend should
●● Offer prophylactic antibiotics for chlamydia, be encouraged to share this with their family
gonorrhoea, trichomonas and syphilis accord- to help them cope and prevent the rape from
ing to national guidelines. recurring.
●● Offer hepatitis B vaccination according to
national guidelines. When to refer
Caring for mental health Always refer for a physical examination to special-
ised medico-legal services (if such are available).
●● Offer psychological first aid (5.10) and
ensure that prevention of further violence has
What to do later
been specifically addressed.
●● Provide practical advice to address the per- ●● Look for signs of depression or PTSD (10.1),
son’s concerns, such as help with the decision drug and alcohol use or other mental health
about reporting the rape to the police. Ideally, problems; if present, manage them accord-
the event should be reported; however, fac- ingly (7.4, 8.2, 9.1, 9.2).
tors such as shame, the assailant being a close ●● Arrange follow-up for testing and manage-
relative or the fact that, in the case of men ment of sexually transmitted infections and
being raped, homosexuality may be a criminal pregnancy (if a woman) at approximately 4
offence may make a person hesitant to report weeks post-assault, and syphilis, hepatitis B
the rape. and HIV counselling and testing at 3 months
●● Explain the psychological reactions to the rape and (if received PEP) at 6 months.
so that the person knows that the fearfulness,
nightmares and sadness are typical reactions.

section 10.3 summary box

things to remember when dealing with a person who has been raped
○○ Rape and sexual assault are among the most ○○ When helping a person, the key is to provide
severe acts of violence that a person can experi- psychological first aid, ensure their physical
ence. They can affect the person’s physical health, document the event (including a physi-
health, sexual health and mental health. cal examination), advise on preventing preg-
○○ Rape can lead to unwanted pregnancies, sexu- nancy and sexually transmitted infections, and
ally transmitted infections (hepatitis B, HIV) and counsel on the mental health effects of rape.
serious injuries. Depression, suicidal feelings ○○ Provide support and correct documentation if
and PTSD are the common mental health the person chooses to file a police complaint.
problems. ○○ Link the person with support services.

Typically, three stages are described in the human Some people can blame themselves for not having
response to loss, although not everybody experi- done enough to prevent the death, or get angry
ences all of the stages or experiences them in this that the loved one left them. Crying, sleep prob-
order. lems, loss of interest in activities and in meeting
people, and even thoughts that life is not worth
‘It cannot be true’: the stage of denial
living can all be experienced in this stage.
This happens in the days
just after the loss. There is ‘It’s time to move on’: the stage of
a feeling that the news is reorganisation
false. The person you love This is the final phase of bereavement. For most
could not be dead. It is just people, it is the time when they accept the loss as
not possible. This stage of part of life and get on with the rest of their life.
shock is most obvious when Coming to terms with loss is a gradual
the person dies suddenly. process. Most of us will never stop
The person can feel numb, thinking of the lost person now and
as if in an unreal, dream-like again. What is important is that the
state. Activities such as the funeral can help the sadness we feel when we do think
person distance themselves from the loss. of the person does not interfere
with our ability to enjoy happy
‘I feel miserable’: the stage of sadness
moments in our life. The real sign
This stage usually begins once all the hectic activity that a person has moved on is
surrounding the final rites and funeral are over when they begin to make plans
and the bereaved person is back to their own usual for the future. A future without
life. The absence of the loved one is now noticed. the loved person, but still a future
Sadness, a feeling like searching for the missing with hope.
person and imagining that
they must still be alive are
common experiences. Some
people may even hear their
name being called or have
dreams of the lost one.

bereaved person feel supported by others. If died as a result of suicide or if their relation-
the person is religious, prayer may help them ship with the person was difficult. Ask them
cope with the grief (Box 10.5). about those types of reactions to make them
●● The needs of people who have been bereaved feel more confident that they can be frank and
through suicide need very sensitive attention, open with you.
because they may feel great anger or blame ●● If the person has suicidal ideas, assess and
themselves for the death. They may also be at manage as described elsewhere (7.6).
higher risk of attempting suicide themselves. ●● Do not give simple reassurances such as ‘it’s
●● A discussion of feelings of loss and sadness God’s will’ or ‘at least you have children’. Grief
may be helpful a few days after the bereave- is a universal human experience, and your
ment. The person may feel embarrassed to ability to listen quietly and allow the sadness
share some emotions, such as anger. This to be expressed is a treatment in itself.
is especially a concern when the loved one
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●● Do not give sleeping tablets (benzodiazepines) a week, following the principles of psycho-
unless the person is extremely distressed and logical first aid (5.10). The counselling could
unable to sleep. include discussion about their relationship
●● Encourage a gradual return to daily life and with the dead person (exploring both positive
work within 3 to 6 weeks. Work and other and negative feelings). Ask them to bring pho-
activities can themselves be helpful in raising tos or other items which remind them of the
spirits and making the person reorganise their dead person, as this can help provide a focus
life for the future. for the discussion.
●● If the person shows signs of depression, you
What to do if the bereavement is could encourage counselling strategies such
abnormal as getting active (5.13) or thinking healthy
(5.14), or prescribe an antidepressant
●● If the grief appears ‘abnormal’, you should (Table 14.1).
consider counselling the person at least once

section 10.4 summary box

things to remember when dealing with bereavement
○○ Bereavement or grief is the normal human ○○ Counsel the person about the loss and involve
response to losing someone you love through friends and family in providing support.
death. ○○ Counselling strategies for depression or anti-
○○ If grief lasts longer than culturally expected depressants may help if there are symptoms of
(usually more than 6 months), or leads to depression several months after the bereave-
severe depression or suicidal ideas, then it is ment.
‘abnormal’.

notes

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11 General approach to children and
adolescents
Problems in childhood and
adolescence†

as well as the intervention. Indeed, most young

people will be accompanied to the health worker
by an adult who may be a parent, a family mem-
Children and adolescents, whom we can col- ber or a concerned community member (e.g.
lectively call young people, can be affected by a teacher). This need for family (or broader)
many different types of mental health problems involvement has to be balanced against the inde-
(as can adults), which can range from ‘distress’ pendence and privacy of the young person. Some
to ‘disorders’ to ‘disabilities’. Distress can be general guidelines to follow while exploring a
broadly defined as a situation when a young per- young person’s problem are as follows.
son’s emotional stability is disturbed by factors ●● Create a place which is comfortable for both
which may be internal (e.g. the onset of puberty) the adult and the child. A box of toys to help
or external (e.g. arrival of a sibling or a problem with the developmental assessment (Box 11.1)
in the family) or a combination of both. Distress along with pen and paper are use-
in young people may be reflected in behaviours ful for young children.
(e.g. disobedient behaviour or acting as if they ●● Always be sensitive to the pres-
are a younger age) and may occur when the chal- ence of the
lenges the young person faces overwhelm their young person.
personal strengths or supports. Disorders, on the Be careful of
other hand, are a more defined group of condi- the language
tions, which can be recognised by a pattern of being used,
emotions, thoughts or behaviours which have even if the
an impact on the daily functioning of the young child is very
person. Disabilities in children are typically pre- young. Avoid label-
sent from birth or develop before the age of 18 ling the child with nega-
and affect the young person’s ability to learn and tive terms such as ‘naughty’ even if you don’t
live independently. They may last for most or all think that the child is listening.
of their life. ●● There may be situations when you would like
Although the young person may be identified to speak to the young person alone; if so, ask
as the one with the problem, it is almost always the family member if you can have some time
necessary to consider the family in the assessment alone with the child. When speaking to the
child, explain that you will not share any infor-
mation given to you, unless they give their
permission or unless there is an emergency
situation.
●● When speaking to the child, simplify your lan-
guage so that it is understandable; however,
do not talk ‘down’ to an adolescent (i.e. as
if they are a young child), as this may annoy
†
With Gauri Divan. them.

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TABLE 11.1 THE MILESTONES OF DEVELOPMENT
Milestone Age at which a child Suspect a problem
should achieve this if this milestone is
milestone delayed beyond
Responds to sounds/voice 2 months 3rd month
Smiles at others 2 months 3rd month
Reacts to peek-a-boo 3 months 6th month
Holds head steady 4 months 6th month
Babbles and laughs 4 months 8th month
Transfers toys between hands 6 months 9th month
Sits without support 8 months 10th month
Pulls self to standing 10 months 12th month
Can feed self, using fingers 12 months 18th month
Says at least one word appropriately 12 months 18th month
Looks for hidden object 12 months 18th month
Takes independent steps 12 months 18th month
Holds a pen and scribbles 18 months 24th month
Points to ask for and show things 18 months 20th month
Follows simple one-step requests 18 months 24th month
Says 8–10 words 18 months 20th month
Tries to wash own hands 24 months 30th month
Says two-word sentences 24 months 24th month
Points to two body parts 24 months 30th month
Knows own name 24 months 30th month
Jumps with both feet 3 years 36th month
Talks in three-word sentences 3 years 36th month
Eats/drinks by self 3 years 4th year
Follows simple requests 3 years 4th year
Avoids simple hazards 3 years 4th year
Draws a circle 3 years 36th month
Is toilet trained 4 years 4th year
Draws a simple face 4 years 5th year
Counts to five 4 years 5th year
Hops on one leg 5 years 5th year
Draws a person with a body 5 years 5th year
Wants to play with others 5 years 5th year

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If an adolescent: is also useful to ask the parent to describe their
●● is not able to learn at the same rate as other child’s abilities on their first birthday.)
students in class; ●● When did you first notice that your child was
●● has inappropriate emotional reactions and different from other children of their age?
sexual behaviours (e.g. masturbation in ●● Do you think your child has any difficulties
public). with their hearing? Seeing things? (Rule out
any sensory problems before you consider the
If an adult:
possibility of intellectual disability.)
●● has difficulties in everyday functioning (e.g.
●● For older children, ask about self-care abili-
cooking, cleaning);
ties, school performance and behaviour.
●● has problems in social adjustment (e.g. mak-
●● Does your child have any medical problems,
ing friends, keeping a job).
such as seizures?
Moderate to severe intellectual disability is ●● Were there any problems during the pregnan-
usually detected in a child by the age of 2 years cy? Were there any problems during childbirth,
owing to the significant delays in achieving for example, prolonged labour? Did the child
milestones. When intellectual disability is first have any problems during the first month or
detected in an adolescent or adult, it is usually so after they were born? For example, did they
mild and only emerges as a problem because the have a high fever or fits? Is there any family
person has to face new and increasing responsi- history of learning problems? (These questions
bilities as they grow older. help to identify the cause of the intellectual
disability.)
11.1.5 How to deal with this ●● What do you think the cause of the problems
problem is? (Some parents may think that evil spirits or a
curse has caused their child to develop slowly.)
Special interview suggestions ●● Does the child have any difficult behaviours
Just because a young person has intellectual that the family finds difficult to manage? (Ask
disability, it does not mean they are not able to about unexplained aggression, or behaviours
understand what is being said about them. Do which embarrass the family.)
not make the mistake of behaving as if the child is ●● Are there any challenges the parent or family
not in the room. Treat all children, no matter how faces with looking after the child, for example,
severe the disability, with dignity and respect. See do they need to discipline them differently
the general advice for assessment in the introduc- from other children, do they need to keep the
tion of this Chapter. child restrained because of any behaviours?
●● Ask to see any medical records of the child.
Questions to ask the parents
●● What are your concerns about your child’s de- Things to look for during the interview
velopment? (Get a clear story of which aspect The key to understanding the child’s level of
of the child’s development the parent is most development during the session is to:
worried about.)
●● Observe the child and their behaviour while
●● Are there similar problems in other children or you are talking with the parent. See the items
adults in the family? (Family history is impor- in Table 11.1 for things to look for depending
tant, since some disabilities are genetic.) on the age of the child. Note the child’s level of
●● At what age did your child learn to hold their attention and involvement with the interview.
head up? Sit with support? Stand with sup- Children with intellectual disability often have
port? Walk by themselves? Speak their first difficulty following the interview and their
clear two-word sentence? (In an older child it attention may shift frequently.

What to do immediately
The first, and most important, thing is to be abso-
lutely sure that the child has intellectual disabil-
ity. This diagnosis has a serious impact because it
means that the child has a problem which is not
curable. It is a label which can cause great unhap-
piness and worry, since the young person may
need lifelong support; so use it with care. Apart
from the history from the parent and examining
the child, you should also seek a teacher’s report
on school performance and refer for an assess-
A child with Down syndrome will have ment to a child or mental health specialist.
slanting eyes, low ears, a short neck If you are unsure of the diagnosis, support the
and a single prominent crease across family by describing the areas where the child
the palms.
appears to be delayed and give simple advice
which can help their child. This could be activi-
Children with intellectual disability are vulner- ties around stimulating language development
able to neglect (since the family may feel it is not (13.3) or helping the child to become more
worth wasting resources on them) or abuse (both independent in daily activities.
physical and sexual), and it is worth being aware The abilities a child has will be an important
of both these possibilities while talking to the par- indicator of how much progress they are likely to
ent or family members but also being alert while make in the years ahead. It is essential to reassure
examining the individual. Some signs to observe the parents that every child will be able to learn
for are: to some extent and to explain that they should

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focus on the child’s strengths. They should also be should receive the appropriate medication for
informed about what can be realistically expected these. Other than these special (and rare) situ-
of their child, although this may be better done by ations, there are no indications for the use of
a specialist after a formal evaluation. medications for the treatment of intellectual
●● Most children with mild intellectual disabil- disability. Occasionally, children with intellec-
ity will be able to go to school. Many children tual disability may exhibit disruptive behav-
may manage in a regular school, especially if iours, which should be managed by trying to
the teachers are sensitive to their needs and identify and deal with environmental causes,
are able to give them the extra attention and not by using medications. ‘Brain tonics’ or
encouragement that they need. Children who other medications that are supposed to help
need greater support can be helped in schools ‘mental function’ have no effect on the think-
which have resource rooms with special edu- ing abilities of the child.
cators. Most children will be able to care for ●● Be alert to insidious or sudden changes in the
themselves and will be fairly independent; young person’s behaviour which could be a
however, they will need more time to learn sign of the onset of a mental health problem.
the same skills as their peers. These children ●● Provide information about any special
may have difficulties in making friends as they schemes to help families with children with
grow older and in finding and keeping jobs. intellectual disability either through financial
●● Most children with moderate intellectual or educational help (Chapter 15).
disability can be supported in mainstream ●● Stay in regular touch with the family. Parents
schools that have resource rooms with special and families may go through cycles of dis-
educators so that they can benefit from indi- belief, denial, anger, loss and sadness when
vidualised attention. Others may need to be faced with a serious diagnosis such as that of
in special schools. They may need continued intellectual disability. The daily care of a child
prompting and help with daily activities. For with intellectual disability, especially when it
example, a child may learn to wash and go to is severe, can also add to the stress for a par-
the toilet on their own, but may need prompts ent. Refer parents to support groups in your
on how often they should go and reminders area (Chapter 15). Monitor and be aware of
to wash their hands when they are finished. the possibility of depression and anxiety in a
They will be dependent on their families for parent and provide care as described else-
social interactions. Most will not be able to where in this manual (e.g. 3.9).
hold regular employment, although shel-
●● If you suspect child abuse or neglect, handle
tered employment in workshops may be pos-
as described in 11.5.
sible (Chapter 15 for your local resources).
Inappropriate sexual behaviours may become
a problem in adulthood.
What parents can do
●● Children with severe intellectual disability are Explain to the parents that one can never be sure
likely to need one-on-one care for the length of the potential for a child with an intellectual
of their lives. They may have physical dis- disability, and hence the child should be given
abilities and medical problems. Bladder and chances to learn at every opportunity, for exam-
bowel control may not be achieved. Such chil- ple, by talking, playing and interact-
dren may not be able to cope, even in special ing with others. They may, however,
schools, although efforts should be made to need to use language which is
allow the parents a break from daily care. more appropriate for younger
children. As the child begins
The general principles of care of a child with to speak they should keep
intellectual disability are as follows. raising the complexity of
●● If the child has a specific medical problem, their own speech and
such as low thyroid function or seizures, they storytelling.
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BOX 11.3 GENERAL GUIDELINES FOR THE PARENT ON HELPING THEIR CHILD LEARN DAILY
ACTIVITIES

○○ Try to think of your child’s various strengths ○○ Avoid punishing the child for things they can-
and build on these (e.g. the child may be loving not do or mistakes that they make. It is best
and affectionate, they may like order, they may to ignore behaviours that one doesn’t want to
be good at following simple requests). see, since attention, even if it is negative, may
○○ Be realistic and patient in what you expect from encourage the child to keep doing it! If appro-
your child. priate, behaviour charts (Box 11.4) may be used
○○ Start with simple tasks and move to more com- to modify unwanted behaviours and reward
plex activities only after the simpler ones have positive ones.
been achieved. ○○ Involve the child in household activities, for
○○ Break down activities into smaller parts, which example, the child could learn to wash potatoes
should be taught separately. For example, while you peel them.
putting on a shirt can be divided up into the ○○ Make a special effort to teach the child social
following steps: lifting the shirt up and align- skills – such as learning to greet and say good-
ing it correctly, putting one arm in one sleeve, bye, to share toys and take turns, and to ask for
putting the second arm in the second sleeve, permission to use things which belong to oth-
closing the shirt over the chest, fastening the ers. The best way of teaching these skills is to
buttons from the bottom to the top. Try to act them out for your child. Explain clearly what
teach one step at a time, and wait for the skill to you expect your child to do and why, and praise
be learned before adding the next step. the child when it is done the right way.
○○ Praise the child whenever they succeed in ○○ Allow the child to do whatever they can do on
any activity, however small. Praise can be in their own, even though they may make mis-
the form of smiles, hugs, positive words and takes (or it may be messy!). This will make the
rewards such as a special treat for the child. child confident and self-reliant.

Help a child learn a skill by breaking it down into small steps.

Chapter 18 for more details.

Encourage parents to continue to focus on aware that their child with intellectual disability
their child’s educational needs, since schools are needs education as much as any other child. Refer
places where children learn social skills and make the family to local schools which support children
friends, as well as learn facts. Make the parents with special needs (Chapter 15).

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BOX 11.4 THE BEHAVIOUR CONTRACT

We all work towards gaining a reward or pleasure. The parent using the chart needs to understand the
This pleasure can be in the form of simple rewards following guidelines.
(e.g. praise, hugs, a pat on the back, all of which are 1. Keep the goals simple and objective. For exam-
given naturally) or more concrete rewards (e.g. ple, ‘eating breakfast’ instead of ‘behaving well’.
stars, points, stickers, tokens or even money for 2. Keep the initial goals within the child’s reach.
adolescents) when the pre-decided goals are For example, ‘finishing breakfast three times
attained. A ‘contract’ of behaviour between the every week’ instead of every day may give the
parents (and sometimes with teachers) and child child a sense of achievement.
may help by clearly defining what is expected from 3. The chart should be attractive and interactive
the child and by getting both sides to agree to the and could be made with the help of the child
plan. In return for good behaviour, the parents (e.g. the child can colour in a star or apply a
could agree to give a specified reward, while for sticker).
bad behaviour a specific action would be taken or a 4. The parents must be consistent and not be
privilege denied. This sort of contract can also help pressured to give rewards if goals are not
establish who has kept to their side of the deal and achieved.
who has not. The behaviour chart provides a visual, 5. The goals can be positive (e.g. ‘waiting for his
fun way of involving the child in achieving positive turn’) but consequences can be negative (e.g. if
behaviours and can be used for a range of mental the child doesn’t complete breakfast three days
health problems. each week, he will not get a favourite TV show
on the Saturday).
6. Keep the reward collection within a reasonable
time span (e.g. for young children it should be
at the end of the week; teenagers may be able
to wait 2 weeks).
7. Create a reward which will motivate the child
(e.g. something that will link into the child’s
hobby, an activity he enjoys or a simple treat).
8. Remember that not all charts work with all
children. If the parent is not achieving success,
take a break and start again.
ACTIVITY TO BE ACHIEVED:

...............................................................................................
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

I will get 1 point/sticker/star for every time I ……………... (desired behaviour)

When I collect ..... (number of stars/tokens)
I will ....................... (reward)

Child’s signature Parent’s signature

section 11.1 summary box

things to remember when dealing with a child with intellectual disability
○○ Intellectual disability is characterised by a ○○ Early detection is important because parent
significant delay in achieving the normal training can help the child to do better.
milestones of development, especially around ○○ The mild form of intellectual disability may not
understanding and learning from one’s experi- be detected until adolescence or even adult-
ences and also in developing language and hood.
physical skills. ○○ Parents should be supported with information
○○ Intellectual disability is not a disease, but a on how to care for their child and where to ac-
condition which lasts the entire lifetime of the cess special education.
person. ○○ Be aware of the potential of neglect or abuse of
○○ Intellectual disability is not curable but may a vulnerable child.
be preventable. Ensuring healthy pregnancies, ○○ Medications have very little role in intellectual
childbirth and early appropriate child care can disability except in the control of seizures and
help prevent some cases. severe mental disorders which may occur in
some individuals.

11.2 The child who has difficulties described earlier (Table 11.1). Children who have
difficulty communicating are often brought in for
in communicating help in the pre-school or primary school years.
Children are communicators from the day that
they are born. They cry to be fed, when they are 11.2.1 What causes difficulties in
cold or soiled, and for affection. Communication communicating in children?
itself is made up of understanding language
(which comes earlier) and spoken language There are a number of reasons for a child to have
(which develops later). Different skills of com- difficulties in communicating in a way which is
munication are achieved by different ages as appropriate for their age. The causes are:
●● hearing impairment or deafness
●● specific language delay
●● intellectual disability (11.1)
●● stammering or stuttering
●● autism
●● selective mutism.
Most of these disabilities and disorders do not
have a specific underlying cause but are due to a
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combination of genetic and environmental fac- ●● Has the change in the child’s communication
tors. Hearing impairment may be related to the come on very suddenly? (Children with selec-
exposure of the developing brain to certain medi- tive mutism often have a history of a sudden
cations that the mother took in pregnancy or due change in their communication due to an un-
to very severe jaundice after birth. Selective mut- pleasant experience such as arrival of a sibling.)
ism may be caused by a stressful event (e.g. start-
ing a new school). There may be a family history of Things to look for during the interview
speech problems for a child who stammers.
Interviewing children who have a difficulty in
communicating may not yield as much informa-
11.2.2 How to deal with this tion as observing the child when you are talking
problem to the parents. Give the child a simple toy to play
with while you are getting a history from the fam-
When a parent consults about a child who is not ily. Observe for the following.
communicating properly, a detailed history will
help to differentiate the conditions described ●● Does the child seem very shy and overwhelmed
in Box 11.5. It is particularly important to try to by the visit to you? Do they seem clingy to their
understand how well the child was developing parent and look at them for reassurance? (This
before the age of 3 years. is probably a child with speech delay, mild intel-
lectual disability or selective mutism.)
Questions to ask the parents ●● Does the child play with the toy in an unusual
way? (For example, spins the wheel of a toy car
●● When did you first become worried about way instead of rolling it along, flicking a doll’s eyes –
your child is communicating? unusual play can be a sign of autism.)
●● Are you worried that your child is not devel- ●● Does the child seem uninterested in what is
oping in other areas like other children of his happening around them? Does the child make
age? (Children with intellectual disability will very little eye contact with the parent during
have delays in other milestones). the session? Is the child happy to be on their
●● Is there anyone else in the family who has own while engaging with the toy? (All signs of
similar kinds of behaviour? (Stammering and autism.)
autism may have a positive family history.) ●● Does the child use any gestures? Are these ges-
●● Can you tell me about the first 2 years of your tures appropriate (e.g. a child with hearing im-
child’s life? (Ask particularly about any inci- pairment instead of speaking may look at the
dents around pregnancy and childbirth which mother and point at something they want)?
may cause intellectual disability or deafness.) (Unusual gestures are typical of autism.)
●● Does your child have any unusual behaviours? ●● Does the child exhibit any unusual behav-
(Children with autism may show odd behaviours such as rocking their whole body back
iours Box 11.5). and forth, walking on their toes, flapping their
hands? (Again, these are features associated
●● Does your child get upset if you change their
with autism.)
routines unexpectedly? How do they show this
distress? (Questions useful to identify autism.) For a child who can speak, call the child and
●● Is your child interested in what other children ask simple questions about their friends and what
do? Does your child play with toys appropri- the child likes to do. Listen to the answers.
Children with autism rarely ‘pretend
ately? ( ●● Does the child make good eye contact, though
play’, meaning they will not play with dolls or they may appear shy? (Suggestive of intellec-
kitchen utensils as if they are imitating grown- tual disability, selective mutism, stammering.)
up actions; they also are described as being ●● Does the child try to speak, but their speech
happier ‘in their own world’ rather than playing is not fluent in the way it is produced?
with children of their own age.) (Stammering.)
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BOX 11.5 THE DIFFERENCES BETWEEN THE COMMON CAUSES OF A DIFFICULTY IN
COMMUNICATION

Hearing impairment or deafness may be obvious Autism is a developmental disability. Children with
when it is severe. The parent will have noticed that autism show a wide variation in their difficulties.
the child does not respond to sounds as an infant Although all people with autism have difficulties
and makes no speech sounds as they grow older. with social communication, at the severe end, the
Milder forms of hearing impairment may be more child may have no speech at all or no interest in
‘hidden’. The child may appear inattentive, only communicating with others, while at the milder
respond to loud sounds and have an associated de- end the child may struggle to start and continue
lay or impaired speech. Most children with hearing conversations with peers. Children with autism will
impairment will use other forms to communicate also have restricted areas of interests and often
their needs (e.g. gestures) and their development become extremely focused on repetitive activities
in other areas will be as expected for their age. (e.g. they may get ‘stuck’ on a toy or a part of a
A child with intellectual disability will respond to toy, may be interested in non-play objects such as
sounds but they will have a delay in all areas of de- pieces of string).
velopment (Table 11.1); as a result, their speech Many children with autism will repeat words or
may be at the level of a younger child. phrases they have heard, and use these in a non-
Stammering is when there is a difficulty in the way meaningful way (e.g. repeating ‘Hello, how are you’
the child speaks, which results in their sentences or a jingle from an advertisement). Other children
being interrupted by a difficulty in saying specific may make up ‘nonsense’ words or use words in a
words. The lack of fluency in the speech may be be- way that sounds unusual (e.g. a high-pitched tone).
cause of simple hesitations, repetitions of certain Children with autism will not use gestures to com-
sounds or a lengthening of certain sounds. When municate their interests or needs (e.g. they will not
stammering is severe, there is a ‘blockage’ so that point to show a biscuit they want); they also rarely
the child is unable to say a whole word. Stammer- use social gestures such as those for ‘bye-bye’.
ing may be caused by underlying anxiety. Unclear Many children with autism are sensitive to sounds,
speech (e.g. lisping) is common below the age of 5 touch or lights and can find them distressing. Many,
and most children will outgrow it. but not all, children with autism also have some
degree of intellectual disability.
Specific language delay: a delay in language
milestones without any hearing loss or other devel- Selective mutism occurs when a child who is
opmental delays. Children will be late to talk and developing normally stops speaking altogether in
struggle to have fluent conversations, but they will front of strangers or at school, but still manages
use the language skills they have in appropriate to use gestures which are appropriate and speak
contexts along with gestures. normally in front of familiar or selected people.

●● Does the child ignore you unless you get their What to do immediately
attention by coming in front of them and then
The first thing to remember is that there are no
they are happy to speak with you? Is the child’s
medications for any of these conditions; discour-
speech difficult to understand? ( Hearing
age parents from giving their children medica-
impairment.)
tions, no matter who has prescribed them.
●● Does the child ignore you and seem as if they Each of the specific problems has a distinct
are ‘in their own world’? Do they carry on what approach. Except for stammering, it is a good first
they are doing even when you try to interact step to have a hearing assessment done on any
with them? Do they seem to repeat your words child with a difficulty in communication.
back to you without it making sense? Do they
●● For stammering the first step is to reassure
use unusual words which do not have any
both parents and child that this is no one’s
meaning to you? (Autism.)
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fault. Stammering can be worsened by anxi- complete blockages in word production will
ety and stress. Explain to the parents that need the input of a speech therapist.
allowing the child to complete their sentence ●● Selective mutism is often associated with
without rushing them will build their confi- a mild language delay, which should also
dence. Parents should talk to the child slowly be addressed. Explain to the parent that the
and patiently and not rush them for answers child’s reluctance to speak in specific social
or fill in words the child is struggling with. situations is probably due to them being anx-
Encourage the parent to create a time every ious. In such circumstances, it is better not to
day when they have a slow conversation with pressurise the child to speak. Instead, advise
their child on something they are interested the parent to use positive rewards to encour-
in, giving opportunities for the child to speak age their child to speak in specific social situ-
without being pressurised. Ask the parents to ations (Box 11.4). More severe mutism which
speak with the teachers to excuse the child is affecting a child’s academic progress should
from reading aloud or public speaking activi- be referred to a speech therapist.
ties while the child works at regaining their
●● In language delay, explain to the parent how
confidence. More severe stammering with
they should enrich the speaking environment

BOX 11.6 WHAT TO DO WHEN SPECIALIST INTERVENTION IS NOT AVAILABLE: ADVICE FOR
PARENTS

For any child with a language difficulty: enrich the In autism, the child’s communication difficulties
speaking–listening environment in which the child result in parent and child communication being
lives. As a parent, you can: ‘out of tune’. As a parent of a child with autism you
○○ talk to the child about what you are doing, de- can try these strategies.
scribe and name the objects that you are using ○○ Observe your child carefully to see what their
○○ describe to the child what they may be doing, interests are, what upsets them and what calms
feeling or seeing throughout the day them down. Learn the signals the child gives to
○○ create fun games with words in them, such as ‘I express their feelings.
spy’, which can teach descriptive words ○○ Slow down routines across the day, allowing
○○ read to your child from picture books and de- your child to take their time.
scribe the illustrations in detail ○○ During your routines give your child opportuni-
○○ use the correct language or grammar without ties to express themselves, although this may
pointing out your child’s mistakes only be through their actions (e.g. the child
○○ if your child is watching TV, ask them to tell you may choose to walk away to show you that they
about the programme once it is over don’t want to do something – recognise this
○○ do not force your child to speak and respond to it appropriately).
○○ sing songs with your child and use gestures to ○○ Wait for your child to request your help and
reinforce the meanings of what you are saying. allow them to communicate with you. For
example, if the child wants a drink they should
request it, instead of you anticipating their
needs and giving them a glass of water.
○○ Help your child by decreasing the instructions
you give them. Instead, show them by using
simple steps or give simple one-word instruc-
tions (e.g. ‘dinner time’).
○○ Give your child a simple explanation of what
will happen next in new situations; this will
help them to stay calm in unfamiliar places.

section 11.2 summary box

things to remember for the child with difficulty in communicating
○○ There are varied reasons for a child to have ○○ Early detection is important to help provide the
communication difficulties, including hearing appropriate language-enriched environment
impairment, intellectual disability and autism. for the child.
○○ Communication difficulties should be evalu- ○○ Parents may also need information on where to
ated by a specialist if possible, as the approach access special education to support the specific
to each can be quite distinct. needs of their child.

11.3 The child who has difficulties studies may be caused by a lack of adequate
parental care or neglect (11.5). Being a first-
with studies generation learner means that the child is grow-
Children may have problems with their studies ing up in a family where the adults have not been
for many reasons. For example, they may need to school themselves, and they may
to help their parents by working or helping out be unable to support the child
at home. The school may be in poor condition or with their studies. Problems
the teacher may be badly trained; this may make within the school may include
a child feel that education is of no use. There are poor classroom facilities, large
also important child mental health problems class sizes, poorly trained teach-
that can make it more difficult to study. Helping ers and the language of instruc-
children to stay in school is a fundamental part tion (which may not be the
of health promotion, since educated children language the child speaks at
grow up to be healthier adults. When a child has home). The child may have
difficulties with studies or drops out of school, a one or more of a number of
health worker should try to find out why and offer mental health problems which
appropriate advice and support. may also lead to difficulties with
studies. These could be:
●● intellectual disability, which may
11.3.1 What causes children to
cause a difficulty in learning (11.1);
have difficulties with studies? ●● hyperactivity, which may be accompanied
The common reasons can be found in the family, by a difficulty in concentration and attention
school or child. In the family, difficulties with (11.4);
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●● depression, because of which the child (typi- all of the common childhood mental health prob-
cally an adolescent) feels unhappy and loses lems in the following manner.
interest in studying and other things (11.8); ●● When did you realise that your child has dif-
●● conduct disorder, which results in the child ficulties with studies? ( Ask questions about
‘misbehaving’ and delayed development in childhood. Remember
getting into trou- that mild intellectual disability may go unde-
ble (11.6); tected until the child reaches school. A careful
●● child abuse, history of milestones may suggest that the child
which may result has an intellectual disability 11.1).
in the child being If you are confident that the child does not have
unhappy, scared an intellectual disability, ask these questions.
and distracted
●● Do you think your child’s vision or hearing is a
(11.5);
problem?
●● difficulties with hearing or
●● Can you tell me about your child’s activity lev-
vision;
els throughout the day? (Consider hyperactiv-
●● drug misuse, especially in ity and restlessness 11.4.)
adolescents (9.2);
●● Can you tell me about your child’s ability to lis-
●● intellectual disabilities or dyslexias (11.1, ten to and follow up on instructions that you
Box 11.7). give them? (Enquire about a difficulty in con-
centration and attention 11.4.)
11.3.2 How to deal with this ●● What difficulty does your child have with stud-
problem ies? Does the child make errors mainly with
reading or spelling or writing? Do they have
Questions to ask the parents specific problems with mathematics? Do they
The child is rarely brought to the health worker for have difficulty in understanding instructions?
problems with studies. Most likely, you will need (These may be present on their own or in com-
to be alert to which children in your community bination and are typically reported in children
are not in school and then actively follow up to with dyslexia Box 11.7.)
find out why. You will need to ask questions about ●● Does your child have difficulty in telling right

BOX 11.7 WHAT IS DYSLEXIA?

Learning disabilities, which are commonly called We do not know why some children have learning
dyslexias, are conditions in which a child has diffi- disabilities or dyslexia; it is possible that there is a
culty to understand and process particular aspects problem in the way the brain processes informa-
of their studies. For example, a child may have a tion. We do know, though, that dyslexia is common
specific difficulty with reading, spelling, writing or and that it is not the same as intellectual disability.
mathematics. These children usually have normal With special educational help, many children with
intelligence. Because of low awareness of these dyslexia will do as well as other children. Children
difficulties amongst educators, many children with with dyslexia can have difficulties with:
dyslexia are labelled as intellectually disabled or ○○ copying, spelling and writing
‘lazy’ by their teachers. Behaviours in a classroom ○○ understanding instructions
would include a child who loses concentration and ○○ numbers and mathematics
becomes bored, frustrated and then misbehaves ○○ reading aloud
in the class. This often results in academic failures ○○ understanding what they are reading
and an accompanying loss of confidence. ○○ behaviour, because the child gets frustrated
with struggling with their studies.

from left? Are they clumsy or poorly coordi- difficulty with spelling? Do you have difficul-
nated, for example, in sports? (Many children ty with mathematics? (Ask to see the child’s
with dyslexia have these difficulties Box 11.7.) school notebooks and look for untidy writing or
●● Finally, consider a family problem. Ask the par- repeated patterns in spelling errors.)
ents about problems in the home, including ●● How do your teachers and parents react to
violence and child abuse, which may be upset- your difficulties?
ting the child (11.5). ●● Which aspects of school do you enjoy?

Questions to ask the child Asking to see a school notebook may allow
you to see the difficulties the child is having in
Interviewing children to identify dyslexia requires their schoolwork (next section for the kinds of
experience and skill. Ideally, you should refer the errors to look for).
child to a special education facility or clinic for fur-
ther tests. Explain to the parents why this is being Things to look for during the interview
done; they may become very worried about the
‘testing’. If, however, you do not have such a spe- ●● Examine the child’s hearing and vision, ideally
cialist facility near you, you could ask the follow- in a quiet room. Both tests described below
ing questions to help detect dyslexia in the child. are only crude screeners if you do not have
●● What do you find difficult in your studies? (The access to specialists.
child’s views are important; remember that ●● Vision can be assessed by allowing a child to
the child is probably very worried about their read a normal-sized text or describe a picture
difficulties.) in a book and assessing how close they hold
●● Do you have difficulty with hearing what the the book to their face to explore details or how
teacher is saying? Or seeing what is written on well they can read letters on a graded wall
the blackboard? (This could reflect a hearing or chart.
vision problem.) ●● For hearing assessment, you should stand an
●● Are there some subjects which you find more arm’s length behind the child, ask them to
enjoyable than others? (For example, children cover one ear at a time and whisper a combina-
with specific problems with numbers will not tion of three distinct numbers and letters (e.g.
like mathematics but may enjoy languages.) 4, k, 6), and ask the child to repeat them. If the
child responds incorrectly, the test is repeated
●● Do you have difficulty with reading or follow-
using a different number/letter combination.
ing what the teacher is saying? Do you have
The child is considered to have passed this test

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if they repeat at least three out of a possible six understanding instructions or telling a sim-
numbers or letters correctly. ple story.
●● Specific signs of dyslexia can be of three types:
academic, motor and language. What parents can do
○○ Academic signs. Ask the child to read a sim- ●● Parents are often frustrated and puzzled
ple text (at the child’s class level) and write because their child appears bright and normal
a few lines on any subject (e.g. their family) and yet is doing badly in school. They may be
and copy a few shapes. While reading, look worried that their child has intellectual disa-
for errors such as replacement of words by bility. Explain that the difficulty in studies may
guessing, and understanding the context have a number of causes, of which dyslexia
(e.g. ‘litter’ for ‘letter’ or ‘home’ for ‘house’), could be one. Explain to the parents that the
errors such as dropping letters and omitting child may be suffering from a learning prob-
words (e.g. saying ‘red’ for ‘read’). Look at lem and is not to be blamed for poor perfor-
the writing for crowding of letters, poor let- mance in school. Ideally, you should refer the
ter formation, reversal of letters or words child for further evaluation before making any
which look like a mirror image of each other statement about the problem.
(e.g. ‘b’ and ‘d’ or ‘no’ and ‘on’). For spell-
●● Remedial education is a special type of teach-
ing difficulties look for mistakes such as
ing method which helps children with dyslexia
omitting letters or putting the wrong letter
to learn better. Remedial education usually
in the word. Assess number skills by asking
identifies and then tries to support the spe-
the child to sum up simple two-digit num-
cific learning area which the child is struggling
bers. Observe for a difficulty in recognising
with, whether this is breaking down letter
numbers or explaining number concepts
and word recognition (reading), understand-
such as ‘bigger than’ or ‘less than’. They
ing and working with numbers, or processing
may also have a difficulty in recognition of
information which is placed in front of them
operational signs (plus, minus, times and
in the written format. With this focused help,
division) correctly ( e.g. multiplying when
most children will be able to complete their
the sign is for addition).
schooling and many do quite well. Children
○○ Motor signs. The child may be restless or with dyslexia do not need ‘special’ schools,
overactive. They may appear distracted and which are mainly geared for children with
forgetful. They may be clumsy with an unu- intellectual disability. However, they can be
sual grip on the pencil and with poor hand- helped by a special educator in a resource
writing. You can ask the child to point out room in a mainstream setting.
her right arm or left ear to check for right–
●● If possible, talk to the teacher about the child’s
left orientation. They child may be unable
needs. Explain that the child does not have
to tie their shoelaces or button their shirt.
intellectual disability. Many school boards
○○ Language signs. Speech may be delayed give ‘concessions’ for children with learning
or unclear. The child may have difficulty disabilities, so you can encourage the teacher

Dyslexic handwriting.

section 11.3 summary box

things to remember when dealing with children who have difficulties with
studies
○○ A child who has difficulties with their stud- ○○ Diagnosing dyslexia needs specialist evalua-
ies may also be experiencing a mental health tion.
problem. Intellectual disability, hyperactivity, ○○ Children with dyslexia should continue in a
dyslexia, depression and child abuse can all regular school. Inform their teachers about the
lead to difficulties with studies. dyslexia and advocate for special educational
○○ Dyslexia can cause a child of normal IQ to do help to be provided. (Advice on promoting
badly in school because of a specific difficulty mental health in schools 13.4.)
with reading, writing, spelling or mathematics.
○○ Dyslexia is an important cause of childhood
misbehaviour and depression.

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11.4 The child who cannot sit still These behaviours may be so extreme that they
affect the child’s life in many ways:
When they are younger, many children have a ●● at home, the boy may be difficult to discipline
short attention span and will move from one and may exhaust his parents with the levels of
activity to another in quick succession. However, his activity, his impulsive behaviour and diffi-
as children grow they develop the ability to focus culty concentrating;
on a given task for longer and longer periods.
●● at school, he may do poorly in studies and
Being able to sit in one place reflects the ability
distract his teacher with his inability to sit still
of the mind and body to pay attention to a par-
and listen, as well as constantly interrupting
ticular task, for example, reading a book. If a child
the class;
cannot pay attention, then they will not follow
what is being taught in the classroom. Similarly, ●● at play, he may annoy his peers by not waiting
if the child is not paying attention to what the his turn, interrupting others, getting into fights
parents want them to do, the child is more likely and wanting his own way.
to be considered to be misbehaving. When the
inattention is accompanied by restlessness and 11.4.2 Why is ADHD an important
a lack of thinking through the consequences of
one’s actions (impulsivity), the child may have a
problem?
disorder called attention-deficit hyperactivity Most children with ADHD are labelled as being
disorder (ADHD). naughty and irresponsible instead of being rec-
ognised as having a mental health problem which
11.4.1 Why do some children have can be addressed by specific strategies. By not
detecting and treating this problem, the child may
difficulty being still? fail to do well and drop out of school, and con-
ADHD is a mental health problem which causes tinue to have problems in adjusting to life even
difficulty in being still. ADHD is more common in when they grow up. Some may develop behav-
boys. Children with ADHD will: iour problems (11.6) during their teenage years
and start using drugs or alcohol. Recognising this
●● be restless, for example, being unable to sit in
disorder can help parents and teachers under-
a chair through a full lesson;
stand that the child’s behaviour is a symptom of
●● have difficulty concentrating or paying atten- an underlying problem.
tion, for example, not being able to complete
homework or carrying out an instruction;
11.4.3 How to deal with this
●● be easily distracted and not finish what they
have started; problem
●● be impulsive – doing things before thinking Children with the symptoms of ADHD will rarely
of the consequences, for example, running be brought to a health practitioner since the prob-
across a busy road; lems are considered to be due to bad behaviour,
●● be unable to wait their turn in games or while which is primarily a discipline issue in the school
talking to others; setting.
●● be extremely
demanding of Questions to ask the parents
attention; ●● Can you tell me about your child’s levels of
●● be disorganised, activity throughout the day? Since when have
untidy and prone to you been noticing these behaviours? (Explore
losing things; how long the child’s behaviours have been caus-
●● and as a result often ing problems. Get a detailed description of the
have difficulty in learning. behaviours that the parents find challenging

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●● If even after establishing the advice in Box When to refer
11.9; the child continues to have significant
ADHD can be a difficult problem to treat without
behaviour problems, it is worth suggesting to
support from the family and school. If you have
the parents that their child may benefit from
access to a specialist child or mental health ser-
a medication called methylphenidate (Table
vice, then refer all children with this condition,
14.6). This medication is usually prescribed by
since there are effective medical treatments avail-
a child or mental health specialist.
able which can help transform the child’s learning
●● Do not use sedative medications; these will potential.
only make the child drowsy and worsen their
ability to concentrate.

BOX 11.9 MANAGING THE HYPERACTIVE CHILD: ADVICE FOR PARENTS

Parents should be advised the following. ○○ Create clear predictable routines for your child
○○ Avoid physical punishments and humiliating in the day. Make visual timetables which they
the child for the behaviours that they may can refer to from time to time. Discuss new
not be able to control. Physical punishments activities and outings with your child before-
‘justify’ to the child that it is OK to hit others hand; explain what you expect from your child
and they may do this in school. Instead, focus and negotiate a reward for good behaviour in
on the positive behaviours that they see and advance.
actively praise them, for instance, by saying ○○ Make sure there is regular sport or physical
‘Well done for sitting for 2 min’. An alternative to activity every day so that your child can get rid
physical punishments is the negative conse- of excess energy.
quence of ‘time out’ (Box 11.12). ○○ Avoid sweetened drinks, sodas and junk foods
○○ Use a ‘behaviour contract’ (Box 11.4) and link – they often have additives which overstimulate
it to a system of appropriate and consistent the child.
rewards which can be used once the child has ○○ Create calming routines around periods like
been told how they work. bedtime. For example, a story and a glass of
○○ Give rewards when the child behaves in the milk, instead of activities and games.
right manner. Keep a ‘pride’ file of the child’s ○○ Listen to your child’s feelings and thoughts.
achievements; you can file drawings, cer- Many children with ADHD feel misunderstood
tificates and other mementoes of the child’s and unhappy. Show the child that you know
abilities. why they are having difficulties and that you
○○ Make sure you have the child’s attention when want to help them get more in control of their
speaking to them, and give one instruction at life.
a time. For example, do not say ‘Have a bath
and finish your studies’. Instead, break this up
into two requests; after the child has finished
their bath, praise them and then ask them to
complete the second request.
○○ Be specific in what you expect. For example,
instead of telling a child who is about to eat ‘Be
a good boy now’, you could say ‘Please finish
your food, then you can leave the table’.

Teachers should be advised to do the following. ○○ Make the student keep a homework book in
○○ Seat the student as close to the teacher’s desk which you can check whether the homework
as possible. This will allow the teacher to focus tasks have been written down before the child
on the student as required. They will also be goes home. This will also help improve commu-
less distracted by other students. nication between the teacher and parent.
○○ Place the student away from windows or doors. ○○ Reinforce clear classroom and school rules
○○ When giving instructions, look at the child. Ask calmly. Do not humiliate the child, but give
the student to repeat the instructions to make them pre-agreed consequences (e.g. that they
sure they have understood what was said. Give will stay back in class for 5 min at break time).
the child a personal written instruction if this ○○ A suitably modified ‘behaviour contract’ may
helps them – a ‘post-it’ note on the table can also be used (Box 11.4). Always praise and re-
help. ward the child for every task successfully com-
○○ Make instructions clear and concise. Avoid mul- pleted. Praising the effort is just as important as
tiple instructions. Break up tasks into smaller praising the achievement.
parts and give short rests in between. Monitor Many of these principles can be applied for all chil-
the child frequently during tasks to make sure dren to promote mental health in schools (13.4).
they are on track.
○○ Try to follow a timetable which is predictable;
if changes do occur, inform the child of what to
expect.
○○ Be patient and clarify things for the student if
they come back for help.
○○ Allow the child to get up at regular intervals. For
example, they can help clean the blackboard or
distribute books.
○○ Allow the child more time in tests; for example,
take their answer paper last.

section 11.4 summary box

things to remember when dealing with a restless child
○○ Many children show restless behaviour and ○○ As a child grows, the restlessness will improve,
have poor attention span, especially when they although problems with getting distracted may
are toddlers. However, if this remains as they stay.
grow and becomes severe, affecting the child at ○○ It is advisable to refer the child to a specialist
home, at school and with friends, then this may when possible. There are medications which
be ADHD. can help many children with ADHD, but they
○○ ADHD is best managed initially by giving advice should be given only under specialist supervi-
to parents and teachers on how to create sion.
a structured environment for the child and
strategies to manage the restlessness and poor
attention.

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11.5 The child who has been 11.5.1 Why do children get abused?
abused It is important to remember that both boys and
girls can be abused. Most commonly, the per-
Child abuse can be considered as any action, son involved in child abuse is someone the child
either deliberately or through neglect, which can knows well – they may be part of the family, the
negatively affect a child’s health or development. household or environment the child is in (e.g.
There are a number of ways in which children can neighbourhood, school or religious institution).
be abused. The adult takes advantage of their close relation-
●● Emotional abuse. This is the most common, ship and influence over the child. Families in which
but least reported, type of abuse. The child child abuse is taking place are often also families
can be neglected by not being given suffi- where there are other forms of violence (such as
cient attention, love, care or food. This may the father being violent towards the mother).
include not being brought for vaccinations or Less often, a child may be abused by a stran-
not being given medications when the child is ger. In some situations, children who are already
sick. Sometimes, just one child in the family is vulnerable, such as those living on the streets,
abused while others are treated in a different can be abused and used as sex workers by adults
manner; this may be due to the child’s gender, (13.5). Most abusers tend to be men, but this
nature or abilities. Verbal abuse, by shouting, does not rule out women as abusers or facilitators
mocking or calling the child insulting things, for children being abused. Most abusers look the
is also a form of emotional abuse. Neglect same as anybody else and do not behave in an
may also affect a child with par- unusual manner.
ents who have mental health
problems.
11.5.2 How are children affected by
●● Physical abuse. Many
parents use a slap abuse?
occasionally to discipline This depends on the type and severity of abuse.
their children, although this For example, the occasional corrective slap
is not recommended. When (though not advised) by a parent who is other-
the physical punishment wise loving and supportive is unlikely to have any
is more severe and more harmful effects. On the other hand, repeated or
frequent, it can cause great severe emotional and physical abuse and even
damage to a child’s physical and emotional single episodes of sexual abuse can lead to severe
health. Some children can also be hit or problems:
shaken so badly that they break bones. In ●● physical health:injuries such as bruises, cuts,
the worst case they can die from the fractures or burns, recurrent unexplained uri-
trauma inflicted on them. nary tract infections in girls
●● Sexual abuse. This is when ●● sexual health:injuries to the sexual organs,
an adult uses a child for their pregnancy and sexually transmitted diseases
sexual pleasure. The adult
●● mental health:anxiety, aggression, poor
may show their sexual organs
concentration, depression and antisocial
to the child, touch the child
behaviour
on their sexual organs, and
make the child touch their ●● school performance:a drop in the child’s
sexual organs, or even try to school performance.
have full intercourse with the
child.

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●● Do not ask questions about abuse until you sure that you are gentle and do not hurt the
have established a rapport with the child. If child further. Document the findings in detail.
this means spending more time, then do so. These may be needed in a police investiga-
Use toys, drawings or story-telling as a way to tion. Do not force an examination if the child
help the child become comfortable with you. is uncomfortable.
●● Speak to the child calmly, keeping in mind the ●● Do not make accusations or threats against
developmental level of the child so that your anyone. You may frighten the child and make
questions or suggestions are framed in an the adults suspicious of your intentions.
appropriate way. Make it clear that the child
can ask questions about anything and that Things to look for during the interview
you are there to help them. Clarify to them and examination
that what they tell you will only be used to
keep them safe. A thorough examination of the child should
include:
●● Interview the child with the mother or with
another family member who is definitely not ●● an impression of the child’s mental health and
a suspected abuser and whom the child trusts demeanour
(ask the child which adult they would like to ●● injuries on any part of the body
have with them during the assessment). Ask ●● any injuries or inflammation of the sexual
the child to describe what happened in their organs – always examine the anal region as
own words, using open-ended questions. well, especially for boys.
●● A physical examination is likely to be neces- Do not make any judgement of what you see.
sary. However, a child who has been abused Write down instead what you observe in detail.
may be very sensitive to being examined phys-
ically. Respect the child’s privacy and comfort.
What to do immediately
A very young child could be examined on their
mother’s lap. ●● Talk to the family members who are available,
●● Ensure that you are accompanied by an expe- and who can ensure the safety of the child.
rienced colleague. Explain to the child what Explain why you suspect abuse. Many par-
you are doing and why before you start, but ents are not aware that their actions can be
also describe each step as you proceed. Make so damaging to the child’s health. Just telling
them about the dangers of beating a child or
neglecting the child’s emotional needs may
bring about a change in their behaviour. Often,
Sometimes children can a cycle of violence builds up in the home where
get hurt by a grown-up person. Has anyone parents beat their child who, in turn, misbe-
grown-up hurt you recently? haves even more, leading to more beatings.
●● If you suspect sexual abuse, it is unlikely that
the family will accept it easily, particularly if
the abuser is someone close to the family. Do
not accuse anyone. Instead, share your con-
cerns openly with the family and stress that if
the abuse continues, the child’s health will be
even more seriously affected.
●● Your priority is the health and safety of the
child. If you suspect the child’s life is in danger,
refer them immediately to a place of safety.
This could be a family member, a nearby hos-
pital or an organisation working with children.
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I am very concerned about the BOX 11.11 HELPING A CHILD WHO WAS
safety of your child. Can you be sure that the ABUSED
abuse will not happen again at home?
Help the child to trust
○○ Reassure the child that you are an adult they
can trust and that you will be available for
them to talk to in confidence.
○○ Make time when the child can speak to you in
an uninterrupted way.
○○ Be warm and affectionate to the child, but
remember to be careful about physical touch-
ing.
Help the child feel positive about themselves
○○ Reassure the child that they are not responsi-
ble for the abuse.
○○ Help the child identify their strengths and
how they can build on them.
Removing the child to a place of a safety (such ○○ Suggest activities which the child enjoys, such
as a relative’s house) may provide a temporary as playing with friends.
solution.
Help the child to identify and express
●● Teach the child how to ensure their safety. emotions
Explain that the abuse is not their fault and ○○ Talk about what emotions the child is experi-
that they should not feel guilty for having spo- encing and how they can be managed.
ken out about it (also Box 11.11). It is impor- ○○ Use drawings or stories to help the child
tant to make sure this never happens again. explore their emotions.
Suggest the following to the child regarding ○○ Teach the child ways of dealing with anger.
how they may prevent abuse from recurring:
Help the child make a safety plan
○○ try to avoid being alone with the abuser;
○○ Choose a friend or neighbour to whom the
○○ tell the abuser, in a firm loud voice, not to child can go for help. Make sure this adult is
touch you; informed that the child will come to them for
○○ get away from the abuser – go to another help.
adult who can provide protection. ○○ Allow the child to practise with you how to say
●● Put the family in touch with community sup- ‘no’ to the adult who is abusing them.
ports. This could include child support groups, ○○ If there is a local police number, give it to the
family violence groups, legal support, child child.
protection agencies, the police or specialist
Healing messages for children
health care workers (Chapter 15).
○○ ‘I care about you.’
●● Explain to the adults concerned that child ○○ ‘I respect you.’
abuse is a serious criminal offence and that ○○ ‘You are lovable.’
the abuser is liable for police action if a com- ○○ ‘You have strengths.’
plaint is made. Carefully write down what ○○ ‘It is a good thing you have told me; now we
was said during the interview. In some places, can make sure you will not be hurt again.’
health workers are required by law to inform ○○ ‘Most adults would never hurt children.’
the police of cases of child sexual abuse; famil-
○○ ‘You can say no if you don’t like the way some-
iarise yourself with these requirements. In
one touches you.’
such places, you must inform the police and
let the legal process take its course.

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Who do you trust? When to refer
Could that person be someone Refer any serious physical abuse to a specialist
who could help you when you feel you facility and be sure to inform the police.
may be hurt?

What to do later
Keep in close touch with the child and the fam-
ily at regular intervals for at least 6 months. Very
often, the abuse stops once it has been openly
discussed. If it does not, you may need to strongly
intervene with the family to take action to stop
it. Talk to the child each time; many children do
recover from the trauma, but some children may
develop mental health problems. Such children
may need specialist help.

section 11.5 summary box

things to remember when dealing with child abuse
○○ Child abuse is much more common than is ○○ Most abusers will stop the abuse once they are
actually reported. This is because most children found out. It is important for you to inform the
are too scared or embarrassed, or feel they are parents and relevant authorities immediately
to blame. if you suspect abuse. It is essential to follow
○○ The most common type of abuser is someone up on the action taken, especially when the
whom the child knows – often a father, other abuser is in a position of authority, for instance,
male relative, domestic help or family friend. a teacher.
○○ Boys can be abused as well as girls. ○○ Never doubt a child’s claims that they are being
○○ Abuse can be emotional, physical or sexual. All abused. Take it seriously since it will not stop
three types of abuse can damage the physical until someone intervenes and addresses the
and mental health of children. problem.

11.6 The child who behaves worried and may seek help. It is therefore useful
to know when a child’s misbehaviour becomes a
‘badly’ health problem.
Most children will be disobedient or refuse to fol-
low family rules at some time or another. Many 11.6.1 When is misbehaviour
children, especially those under the age of 4, will a health problem?
lose their temper and have tantrums if they do not
get what they want. However, the majority of chil- A child’s misbehaviour is a health problem if it:
dren will outgrow this behaviour as they learn to ●● results in serious and repeated breaking of
handle their emotions and deal with disappoint- family or social rules, such as continuous lying;
ment. Many parents recognise that this behaviour ●● is accompanied by serious aggression against
is part of normal childhood and that a combina- others, such as hitting or abusing;
tion of the right mixture of love, firmness and con-
●● is accompanied by potentially criminal acts,
sistent discipline will bring the behaviour under
such as stealing;
control. Some parents, however, may become
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Children can behave badly in a number of ways:
a. by getting into fights
b. by committing crimes
c. by abusing drugs.

a. b. c.

●● is accompanied by not attending school or by allow the parents to ‘label’ the child as ‘bad’ but
poor school performance; refocus the conversation on the ‘unacceptable’
●● is present for a long time (more than 6 months). behaviour. Get a detailed description of it.
●● Can you describe the behaviour in detail?
When a child’s bad behaviour becomes a health
When did this behaviour start? How has it af-
problem, it is called a behavioural disorder.
fected the family? How has it affected the
child’s studies?
11.6.2 Why do children ●● What happens before the behaviour and what
behave badly? happens after the behaviour?
There are notable situations which lead to behav- ●● Why do you think the child is behaving this
iour problems. way? What do you do when the child behaves
like this? (Find out how the parents discipline
●● When there is violence in the family (e.g.
the child. Ask both parents this question sepa-
between parents, or physical beating of the
rately, since this may reveal a different attitude
child to impart discipline), a child copies these
to, or method of, discipline. Violent discipline or
behaviours to express anger, disappointment
inconsistency in the disciplinary practices of the
and unhappiness.
parents or other adults is likely to make the be-
●● When parents are not consistent in the way haviour problem worse.)
they discipline their child, the child is no
●● How do you expect your child to behave? (Find
longer sure whether the behaviour is right or
out the parents’ expectations; are they unreal-
wrong.
istic for the age of the child?)
●● When a child is neglected, they may learn that
the only way to get attention is to misbehave.
Questions to ask the child
●● When a child is using drugs, they may steal to
get money to buy drugs. ●● Having heard your parents’ thoughts on your
behaviour, do you think they are right? Why
Sometimes, children have behaviour prob-
do you feel they are upset by your behaviour?
lems because of a mental health problem, such as
(The child will have heard their parents’ com-
ADHD (11.4) or dyslexia (11.3, Box 11.7).
plaints about them. Now they have a chance to
respond.)
11.6.3 How to deal ●● What is the reason for your behaviour? What
with this problem does it achieve? Do you feel upset with your
parents? (Finding out about difficulties from the
Questions to ask the parent child’s viewpoint can help identify a solution.)
Find out what is meant by the ‘bad’ behaviour. ●● How do you think the situation could be
Where, when and with whom does the ‘bad’ changed? What are you willing to do? What
behaviour occur? If the child is present, do not would you like your parents to do? (These
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questions will indicate how far the child is pre- they feel about what is being said. The child may
pared to go to address the behaviour problem.) be defiant or sad. Always talk to the child so that
they know that their account is just as important
Special interview suggestions as that of their parents.
Most child behaviour problems are related to
the child’s environment. Interview the child and
What to do immediately
family members together as well as separately. ●● Reassure the family (in the presence of the
Observe how they react to one another. You child) that behaviour problems are common.
may notice anger between the parents and their Make both child and parents understand that
child. When a parent is speaking, the child’s facial it is the behaviour that is ‘bad’ or ‘unaccepta-
expressions may tell you something about how ble’, not the child.

BOX 11.12 DISCIPLINING CHILDREN: WHAT’S USEFUL AND WHAT’S NOT

As a health worker, you should be able to advise ○○ Spend time with the child talking about their
parents on how to discipline their children. Of feelings and hopes and fears, and share your
course, this is also helpful for your own role as a own with the child. Treat your child as a loved
parent! Here are some points regarding positive and trusted friend. The key to discipline is
disciplining practices which should be accept- showing love and respect for your child.
able to most parents, especially if you explain to These general principles can be applied to two spe-
the parent how they may help improve the child’s cific techniques to modify the child’s behaviour.
behaviour. 1. Establish a behaviour contract with the child
○○ Praise good behaviour and efforts at good (Box 11.4 and next page).
behaviour. 2. Use ‘time out’. This means that when a child
○○ Be consistent. Stick to the rules you have made misbehaves, they are told to go away (e.g. to
and make sure that your rules apply each time another room) and come back after a pre-
the child misbehaves. scribed amount of time. Using ‘time out’ like
○○ Be sure that all adults treat the child the same any other method to change behaviour must
way. A big challenge is if the two parents treat be explained to the child in age-appropriate
the child’s behaviour in different ways. The terms. It should not be explained as a punish-
child will learn that if they misbehave with one ment but as a negative consequence of the
parent, the other will come to their rescue. child’s disruptive behaviour. The place chosen
○○ Be clear. Explain why you are upset and why should not be fun or interesting (e.g. a bedroom
you are disciplining the child. Be specific in full of toys) and the time period should, as a
your requests. Make one request at a time. Tell simple rule, not be more than the age of the
the child what to do rather than what not to child in minutes (so a 7-year-old should have a
do. For example, say ‘Be home before 10 p.m.’ 7 min period). It is important to talk to the child
instead of ‘Don’t come home late’. after the ‘time out’ period and discuss why they
○○ Be calm and speak in a normal tone. Do not needed to have ‘time out’, which behaviour led
lose your temper. If parents lose their temper, to them having ‘time out’ and ways in which
this is what the child will copy when they are they could avoid this in the future. ‘Time out’
angry. must be coupled with ‘time in’. This means
○○ Do not use violence under any circumstances. playing with or listening to the child for some
A slap, even in extreme circumstances, will not time every day.
help change the problem in the long term and
only illustrates to the child that it is sometimes
all right to hit.

What do you want He must study

your parents to allow you to do, and for his exams.
what are you prepared to do for They should
them? stop hitting me and allow
me to play with my friends.

We will not hit him or shout

If your son spends at least at him if he studies at least an hour a
one hour a day with his books, can he play with day, but he can only play once a week.
his friends for an hour?

Negotiating a behaviour contract.

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●● See the family every 2 weeks, after asking When to refer
them to keep a diary in which they record their
Refer to a mental health or child specialist if:
child’s behaviour. At each meeting, review the
child’s behaviour. If there is no improvement, ●● the child is at risk of harming others (or them-
find out why not. Often, the reason is because self, such as through drug abuse);
the agreement made by the parents and child ●● the child’s family has severe problems, for
is not being observed. example, severe violence or abuse.

section 11.6 summary box

things to remember when dealing with children who behave ‘badly’
○○ All children will show challenging behaviours at ○○ The most common underlying causes of this
some time or another, especially when they are problem are domestic violence, which may
young. This is normal. be directed at the child and be a cause of
○○ When the disruptive behaviour is present for inconsistent parental discipline. Hyperactivity
many months and is consistently associated (ADHD), intellectual disability and dyslexia are
with breaking family or school rules by lying, other causes.
stealing, bullying, fighting or not attending ○○ Practising simple ways of encouraging posi-
school, then this is a mental health problem. tive behaviour and encouraging parent–child
○○ Encourage families to regularly spend time contracts on acceptable behaviours are the
on activities which both the child and parent key methods of dealing with this problem.
enjoy. Medication has no role.

11.7 The child who wets the bed bed-wetting after having learned how to control
their urine. This may be due to the child becoming
Like other developmental milestones, children upset about something, such as fights in the fam-
vary in the age at which they achieve control for ily or the arrival of a younger sibling. Other, less
when they pass urine. Urinating in clothing in the common, reasons include urinary infections, child
daytime (enuresis) is a problem only when a child abuse, diabetes, physical problems in the uri-
repeatedly does it after the age of 3, and pass- nary tract and some rare neurological problems.
ing urine during sleep (also called bed-wetting Some children wet themselves in the daytime.
or ‘nocturnal enuresis’) should be considered If children wet themselves during the day even
a problem only after the age of 7. Children with after starting primary school, then it can cause
intellectual disability may take longer to achieve problems because of shame and guilt. Common
this milestone, in keeping with their overall delay. reasons for daytime wetting are not wanting to
use the school toilets and urinary tract infections
11.7.1 Why do children wet the (especially in girls).

bed?
11.7.2 How to deal
The most common cause is inherited. So, if there
is a family history of a parent of the child having with this problem
had delays in achieving control then the child is Special interview suggestions
more likely to also have this problem. Many chil-
dren will continue to have occasional accidents Bed-wetting can be a very embarrassing topic
as they grow up, especially at times of exhaus- for a child to talk about. By the time a child with
tion and stress. Some children may start regular bed-wetting is brought to see you, they will

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should be done in a way that doesn’t cause ●● Special ‘buzzer’ alarms are available in some
accidents which would further embarrass the places which can be attached to the bed
child. sheets and make a loud noise the instant the
●● Ask the parent to restrict liquids (water, milk bed is wet. This wakes the child before they
etc.) after 6 p.m. in the evening, but ensure complete urinating and the parent can then
that children under 8 get at least 1.5 litres of take the child to the toilet. If such devices are
fluid in the day, and 2 litres if older. available, the process needs to be explained to
the child prior to its use.
●● Create a routine where the child passes urine
in the toilet just before bedtime. ●● If there are any worries or stresses in the home,
try to correct them.
●● A behaviour chart (e.g. a star chart) can moti-
vate the child to achieve behaviours which ●● If none of the advice above works, then
encourage dry nights (e.g. not drinking any- there are medications that you can try. If
thing after 6 p.m., passing urine before bed- available and affordable, the first choice is
time). These goals are more motivating and desmopressin. This can be used if there is a
less stigmatising than actual dry nights, which need for rapid control of bed-wetting or need
may be harder to achieve for the child. for short-term control. The initial dose is 200 µg
for Desmotabs®. If the child is still not dry after
●● If the child wets their bed, the parent should
1 to 2 weeks, increase the dose to 400 µg. The
not get angry but instead tidy the bed up with-
usual length of treatment is 3 months, after
out a fuss. In an older age group, the child
which the medicine should be withdrawn
can help strip the bed and place the sheets in
slowly to prevent rebound bed-wetting.
the laundry, but this should not be used as a
punishment. ●● If bed-wetting comes back, an alternative
medication is imipramine (Chapter 14)
●● If bed-wetting persists, set the alarm at a fixed
at a dose of 25–50 mg 2 h before bedtime.
time in the night, for example, at midnight,
Imipramine will help many children, but the
wake the child and take them to the toilet to
problem often comes back when it is stopped.
pass urine. Older children, depending on their
Thus, its real advantage is that by helping con-
maturity, may be able to handle the alarm
trol the problem, it will boost the child’s con-
independently.
fidence. The medication must be combined
●● Aim to have 2 weeks of consecutive dry nights. with all the other advice above. It can be used
●● An exercise which can help the child develop for up to 6 months.
control over urine is encouraging the child to
Daytime wetting (advice for parents)
stop urinating before they have finished, then
hold the urine for a few seconds, and start uri- ●● Reward the child with praise or other rewards
nating again until they finish. The more the for each day that passes by without wetting.
child can stop–start urinating in this manner, One way to support children is using a behav-
the more control they will gain. iour contract (Box 11.4). By prior agreement,

Never scold a child who has wet their bed

– children never wet their beds purposely.
Showing them love is an important part of
helping stop the problem.

a. b.

section 11.7 summary box

things to remember when dealing with bed-wetting
○○ Bed-wetting is a concern only if it occurs re- ○○ Bed-wetting is most commonly due to delay in
peatedly after the age of 7. the development of the ability to control the
○○ Children with intellectual disability may take bladder, which is often inherited from one’s
longer to learn how to control their urine. How- parents.
ever, just because a child wets the bed, it does ○○ Simple advice on how to control the bladder
not mean they have intellectual disability. and passing urine at regular intervals can help
most children.

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11.8 The adolescent 11.8.2 Depression in adolescents
who is distressed Depression is a common problem in adoles-
cents. It often presents with physical symptoms,
Adolescence is the period of life which begins frequently related to difficulties in schoolwork.
around puberty and may continue until the early Common features are:
20s. It is a unique period for many reasons.
●● headaches and non-specific aches and pains
●● This is when young people start to see them-
selves as unique individuals different from ●● difficulty with concentration
their parents. ●● poor sleep
●● Their bodies change physically and they ●● loss or increase of appetite
become sexually mature. This means they ●● withdrawing from family and
begin to be attracted, sexually, to others. And, friends
of course, they become more sensitive to the ●● the adolescent feeling that they
attraction other people have towards them! are not as attractive or intelli-
●● This is also the time when important decisions gent as others
about education and their career will be made. ●● becoming moody and irritable,
With all these great changes taking place, it and getting into fights with
is not surprising that some adolescents may find family and friends
themselves feeling under stress. ●● stopping activities that previ-
It is rare for an adolescent to seek help inde- ously brought pleasure
pendently. They will most frequently be accom- ●● seeing life as being pointless
panied by a parent or have been referred by a
●● suicidal feelings.
teacher or school counsellor.
Depression can affect adolescents in many
11.8.1 Why do some adolescents ways by resulting in:
●● poor school performance
feel distressed?
●● poor relationships with friends and family
Adolescents may become distressed for many
●● increased risk of harming themselves (suicide
reasons:
is a leading cause of death in adolescents)
●● their family lives are unhappy
●● high-risk behaviours such as drug or alcohol
– violence, abuse and con-
misuse.
stant fights in the family;
●● they are frustrated with their
school performance – failing in 11.8.3 How to deal
examinations or not doing as with this problem
well as was expected;
Special interview suggestions
●● they cannot be with someone
they love – love affairs which Remember to respect the privacy of the adoles-
are broken either by the par- cent. Ask them if they would like to be in the room
ents or by the loved person; when you are speaking to their parents. Similarly,
●● they have a chronic problem make sure that you give them the opportunity
such as obesity, severe acne or diabetes; to talk to you on their own. Building a therapeu-
tic alliance with an adolescent can be a difficult
●● abuse and violence are directed at them at experience, especially when they may perceive
home, school or in a workplace; that they are being ‘forced’ to come to see you.
●● they are suffering from severe depression or Take time to build trust and always treat the ado-
psychosis. lescent as a young adult.

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It is helpful to talk BOX 11.13 COPING WITH STRESS:
about your problems with someone SUGGESTIONS FOR ADOLESCENTS
you are close to. Do you have a friend or
relative you can share your problems
People react to stress in different ways. Some
with? people cope with the stress in ways which leads
to less harm to their health. Here are hints on
how you can do the same.
○○ Identify those situations or events which
make you feel stressed.
○○ List as many ways you can think of to make
these situations less stressful.
○○ Imagine yourself doing one of these things.
○○ Rehearse a situation before you face it.
○○ Share your stress with others, such as friends,
family or teachers.
○○ Imagine how your friends would respond to
these situations, especially friends who you
feel are able to cope with stress better than
you.
●● The adolescent may be worried about an ○○ Do some exercise to release tension.
intimate relationship they are in. Give them ○○ Do not be embarrassed to see a counsellor.
practical advice on safe sexual practices with- Part 4 for mental health promotion in adolescents.
out being judgemental, but also explain the
potential risks.
●● Advise them to avoid using alcohol, tobacco or
drugs, explaining the risks. When to refer
●● Ask the adolescent to come back and see
you regularly until they are feeling better. ●● If there is no improvement despite your efforts.
Improvement can be judged by the adolescent ●● If the adolescent has severe problems such as
feeling more positive about their future, shar- drug abuse, violence or psychosis.
ing their feelings with others, and better per-
formance in school.

section 11.8 summary box

things to remember when dealing with an adolescent who is sad
○○ Vague physical complaints are most commonly ○○ Working with families and teachers is an impor-
related to stress and depression. tant way of helping adolescents, since stress
○○ Depression is common in adolescents and in the family or in school is a major cause of
suicide is a leading cause of death. depression.
○○ Most adolescents with depression will get bet-
ter with counselling.

Previous parts of this manual have described the different types of mental health problems and their
treatments. In Part 4, we discuss how to integrate the care of people with mental health problems in
settings (which we call ‘platforms’ in this manual) where health workers might work and where mental
health problems are an important health concern.
We have classified platforms into two broad categories: those which are associated with health care
(such as primary health care) and those in the community (such as schools).

care workers and, where available, a mental

health worker. Your role is central in this team:
you act as the link or the glue between all the
together. If one is affected for any reason, often other people.
the other suffers too. Thus, mental health is an ●● Coordinated: this means that the care of
integral part of all health care work. Paying atten- the person across care platforms should be
tion to mental health will make your work more smoothly connected. The most important
rewarding and the person who you are working platforms are: the community (e.g. in schools),
with more satisfied. Caring for a person’s mental the primary care facility, and specialist care.
health should be as natural a part of your daily For coordinated care, there should be clearly
responsibilities as looking after their physical defined care pathways, for example, defining
health. Equally important, remember to take as when, how and to whom people should be re-
good care of the physical health of people with ferred when moving from one platform to an-
mental health problems as you do with your other other. To achieve this, you should identify the
patients. relevant contact person in each platform, es-
tablish a relationship with them, and agree on
12.1.1 The 5C model of integration the procedures for communicating with them.
In some places, coordination may also involve
Let us start by thinking of the principles underly-
working closely with traditional healers and
ing all types of integrated care for mental health
faith healers in the community.
problems. These are the same principles as those
you might use for other health conditions which ●● Continuing:this means recognising that many
affect people for long periods of time. Common people with mental health problems will need
examples of such chronic conditions are diabe- support and care for long periods of time, from
tes, heart disease and HIV/AIDS. Many common months to years, to achieve the goals of recov-
mental disorders last up to a year or more if not ery. This will require you to actively monitor
treated, and many relapse over time. Severe men- the person’s health through regular reviews,
tal disorders and disabilities can last a lifetime. even just through a brief chat on the phone or
Therefore, we can consider mental disorder as an sending them a mobile phone text message
example of a ‘chronic condition’. to find out how they are; contacting the per-
There are five principles guiding the effective son if they miss an appointment to suggest a
integration of care of mental health problems new time to meet; encouraging people to take
in routine care platforms, which we call the ‘5C’ their medications or complete the counselling
model. treatments as required; engaging family mem-
bers to support the person where needed; and
●● Collaborative: this word simply means a
referring people who do not show expected
partnership. The care of people with mental
improvements to a specialist.
health problems always involves a partner-
ship between you and the person and all other ●● Person-Centred: this means placing the per-
people involved in the person’s mental health son at the heart of the care plan in all respects,
care, including family members, other health from deciding which issues to focus on in

12.1.2 The barriers to integration

There are many barriers which can get in the way ●● The lack of time or skills to detect mental
of integrating mental health in general health health problems or deliver psychosocial treat-
care. The most important ones are as follows. ments; this could be addressed by asking all
●● Health workers feeling stressed by mental people a few quick and simple questions re-
health work: most community and general garding their mental health (3.9), reorgan-
health workers are already very busy and add- ising your schedule so that you deliver these
ing mental health care can lead to them feel- treatments during ‘quieter’ periods in the day
ing overwhelmed. In addition, mental health (e.g. many clinics are less busy in the after-
care can be stressful. Be aware of the negative noons) and finding courses (including those
effects of stress and how to maintain positive which are available on the internet 15.9) to
mental health (2.2.3). get training and peer support.
●● The lack of support from other health work- ●● The lack of engagement of the person or their
ers: this could be addressed by demonstrat- family with the treatment: this could be ad-
ing the additional value of addressing mental dressed by always taking time to explain to
health, for example, by increasing the person’s the person (and family) about the nature of
satisfaction with care and improving recovery the problem; avoiding the use of labels which
rates. can cause fear or shame; discussing the per-
son’s thoughts about their health condition
●● The non-availability of essential medications
without judging them negatively; and explor-
for mental health problems: this could be ad-
ing barriers to care such as the person having
dressed by demonstrating to the authorities
small children to look after and finding ways
the numbers of people with mental health
to get around this, for example, by visiting the
problems who could benefit from medica-
person at home.
tions, and mobilising people to demand medi-
cations from their political representatives or ●● Resistance from specialists: some mental
health care managers. health specialists do not like to ‘share’ their re-
sponsibility of care with those who do not have
a specialist degree in mental health. Some
may actively obstruct efforts to improve com-
munity mental health care. Remember, these
specialists are a minority and you should try to
find a different person who is willing to work in
a team with you. If there is no alternative, be
patient and hope that the good work you are
doing will ultimately change the specialist’s
mindset.

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12.1.3 Using appropriate ●● Internet-based counselling, support and
learning: a larger number of psychological
technology treatments are now available for people to use
A variety of technologies may be available which themselves for the management of a range
can make mental health care easier to deliver. of mental health problems, in particular, the
The main examples of such technologies are the common mental disorders and substance use
following. problems. The internet is also becoming a me-
●● The mobile phone:the mobile phone is now dium for people with mental health problems,
used by most people in the world. The sim- or their family members, to form support net-
plest technology is to use the phone to make works and groups. A third way the internet is
calls to follow up people receiving mental making mental health care easier to deliver
health care and provide psychosocial support. is by enabling health workers to learn how to
You can also use mobile phone text messages deliver counselling through online learning
to: remind people about appointments or tak- platforms.
ing medication; find out how they are (‘How ●● Telemedicine: this technology enables a per-
have you been’?); send encouraging messages son to be assessed remotely by using video-
(‘Hope your sleep has improved’); and deliver conferencing, either through a telemedicine
psychosocial interventions (‘Just a reminder network (which requires an appropriate tel-
to try meeting up with your friends’). ephone connection) or the internet (e.g. using
●● The electronic medical record: in Chapter communication programs such as Skype). This
2 (p. 25) we discussed the importance of keep- is similar to using the mobile phone to call a
ing good case notes. In some places, you can person, with the main additional value that
now keep case notes in the form of electronic you and the person can see each other, so that
records by entering the person’s information you can have a better understanding of how
into a computer (either a desktop or a tablet). they are doing.
These data, if backed up on to a server, can be While these technologies offer a lot of prom-
accessed from any location and can be updat- ise, remember that there are some potential risks
ed by any health care provider. They are very which you need to be aware of. You can address
useful for coordinated and continuing care. them in the following ways.
These records can also be used to automati- ●● Using a separate phone for work and personal
cally send reminders for appointments and use so that people do not call your personal
help health workers track people who do not phone at times when you are not available.
follow up on time.
●● Checking with the person if it is OK to call or
●● Tablet-based decision support systems: send a mobile phone text message, as the
these are computerised guidelines which phone may be used by more than one person
guide the health worker in asking and re- and there is a risk of breaking confidentiality.
cording relevant health information (e.g.
standardised questions about ●● Checking about the quality of mobile cover-
depression or drinking be- age in the person’s area before relying on the
haviour) and, based on the phone as a way of communicating with them.
responses, give recommen- ●● Keeping your computing devices secure (e.g.
dations to the health worker password-protected), safe from theft and dam-
on what medications to age by dust or extreme weather conditions.
prescribe and what type
of counselling to pro-
vide. These systems
can be linked to the
electronic medical
records.
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12.2 Primary health care Have you been feeling
under stress recently? How is this
Primary health care is the point in the health care affecting your health?
system to which a person first goes with a health
complaint. It is the backbone of a health care sys-
tem. In some places, a government primary health
centre is the main primary care provider. In other
places, private physicians and nursing homes pro-
vide primary care. In most places, primary health
care is provided by a combination of private and
public health care providers.
If we use a parallel from how we manage phys-
ical health problems, we can say that most mental
health problems are like simple fractures or res-
piratory tract infections – they are best treated by
the primary health care workers. However, some
severe types of fracture (such as compound frac- ●● ensuring regular supervision and mentoring of
tures) and respiratory infections (such as pneu- primary health care workers by mental health
monia) need specialist care. In the same way, just professionals, and clear referral pathways;
a minority of mental health problems need to be ●● ensuring the supply of at least one antide-
referred to the specialist. The added advantage of pressant, one antipsychotic, one antiepilepsy
receiving care in primary health care is that it is medication and a benzodiazepine in the pri-
less expensive, more accessible and is more ac- mary health care facility (Boxes 5.2 to 5.8);
ceptable to most people. The detection, diagno- ●● providing afternoon sessions for counselling
sis and management of mental health problems when the regular out-patient clinic is less busy;
described in Part 2 are consistent with primary
●● establishing a system to detect when people
health care. But always remember your limits:
with severe mental disorder drop out of care
4.10 for advice on when you would need to refer
and plan outreach to them in their homes;
someone with a mental health problem for spe-
cialist care. ●● increasing the number of social workers and
psychologists in the health service, as these
professionals are less expensive than a doctor
12.2.1 Improving the system and bring different skills which are important
Some health workers may be in a position to play in mental health care;
an important part in improving the overall pri- ●● establishing an information system where dif-
mary health care system. For example, if a health ferent mental health problems are counted
worker is a member of a district health commit- and recorded;
tee, their views may be sought on various policy
●● advocating for mental health during planning
issues. There are some specific steps which can
meetings and countering stigmatising atti-
improve primary mental health care:
tudes among planners and managers.
●● providing training in the detection, diagnosis
and treatment of common mental disorders to
community and primary health care workers 12.3 Reproductive and maternal
using this manual;
health care
●● using screening instruments to detect com-
mon mental disorders or alcohol-related Reproductive health concerns physical, men-
problems; tal and social well-being in all matters relating
to the reproductive system. In practice, a num-
ber of different subjects are included, such as

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gynaecological health, domestic violence, adoles- cancer) may experience mental health prob-
cent health, maternal health and HIV/AIDS. There lems. Gynaecological surgery poses a unique
are important mental health issues relevant to stress for women because of the identification
each of these. Many are considered elsewhere in of the reproductive organs both with sexuality
this manual (e.g. 10.2, 12.5). The broader is- and with a woman’s sense of femininity.
sue of gender and mental health is discussed in
As with patients in primary health care, you
13.12. Here, the focus is on the mental health
should always ask women with gynaecological
issues in relation to gynaecological morbidity and
complaints about depression and anxiety.
maternal health.

12.3.1 Gynaecological health and 12.3.2 Integrating mental health

mental health with maternal health care
Motherhood can be one of the most enjoyable and
Three specific types of gynaecological problem
rewarding periods in the life of a woman. Yet it is
are important from a mental health perspective.
also a period of enormous change in the woman’s
1. Gynaecological complaints. Gynaecological body, relationships and work. For example, rela-
complaints are common, particularly vaginal tionships with her partner and other children may
discharge and pain in the lower abdomen. be affected. The workload may increase consider-
Many women with such problems also suffer ably with a new baby. These changes can affect
from tiredness and weakness, and depression emotions. Mental health problems are important
and anxiety. in a number of maternal health situations (7.7).
Health workers in maternal health settings,
such as midwives and antenatal clinic staff, can
play an important part in preventing depression
associated with pregnancy loss (7.7.2) or child-
birth (7.7) and providing additional support and
care for mothers who have existing mental disor-
ders or substance use problems. Counselling may
be given, for example, to those mothers who are
drinking heavily, mothers whose babies have died
or who have miscarried, mothers whose marriag-
es are unhappy and who have little support from
other family members. Counselling should focus
2. Menstrual complaints. Some women com- on the following.
plain of feeling unwell just before the monthly ●● To empower the mother to cope with her diffi-
period. This is sometimes called the ‘premen- culties and with caring for her newborn baby,
strual syndrome’. Women with this syndrome by giving advice on baby care, of the need for
may complain of feeling irritable, depressed,
having poor concentration and feeling tired.
During the menopause, when menstrual peri-
ods stop in later life, some women complain
of headaches, crying, irritability, anxiety, sleep
problems, fatigue and lack of sexual feelings.
3. Following surgery on the gynaecological or-
gans. Women who have surgery, such as family
planning operations (e.g. tying of the Fallopian
tubes) and operations on the womb (e.g. re-
moval of the uterus) or breast (e.g. for breast

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problems, such as loneliness. Finally, some physi-
cal diseases, such as cancer, lead to a slow and
painful death. Remember to take care of the men-
tal health needs associated with palliative care
(Box 12.1).

vulnerable to health problems, in particular,

chronic diseases. People retire from regular work
and earn less than they used to. Their daily rou-
tine changes. Their children become adults and
may leave the home and start their own families.
Social lives change and there may be less contact 12.4.2 Why mental health care
with friends and family. and chronic disease care must be
While most elderly people enjoy good mental
health, some develop mental health problems. integrated
There are many reasons for these problems. Not surprisingly, mental health problems and
●● Loneliness. In many places, joint family sys- chronic diseases often occur together. The rea-
tems are giving way to smaller families. More sons for this are complex and can be grouped into
and more elderly people are living alone with three pathways: (1) factors associated with living
little support from their children. Loneliness is with a mental disorder lead to the chronic disease
marked when an elderly person loses a spouse (e.g. the side-effects of antipsychotic medications,
(10.4). The risk of a person dying is especially smoking); (2) factors associated with the chronic
high in the period after they lose their spouse. disease lead to mental disorders (e.g. disability
●● Chronic diseases. Some elderly people de- and pain); and (3) some factors cause both (e.g.
velop chronic diseases which cause pain and drinking alcohol and stressful environments).
disability. Beyond the simple fact that these two groups
of conditions often occur together, there are many
●● Brain diseases. Some types of brain disease,
other good reasons for the health worker to have
especially dementia (7.8) and stroke, are
the skills and motivation to help manage mental
more common in elderly people. By affecting
disorder and chronic illness.
the brain, they can also lead to mental health
problems. ●● When they occur together, they make the im-
pact of each condition worse; for example,
●● Financial difficulties. Elderly people gener-
levels of disability in people with diabetes are
ally do not work. They are therefore reliant on
much greater if the person also has depres-
pensions and savings which, in a world of ris-
sion, and depression increases the risk of dy-
ing costs, may be inadequate.
ing in people with heart disease.
Keeping regular contact with elderly people ●● The care of chronic diseases in people with se-
provides an excellent opportunity to support vere mental disorders is often neglected, be-
them and to detect mental health problems early cause they do not receive the same quality of
on. Update the resources section of the manual medical care as people without severe mental
(Chapter 15) to record nursing homes and other disorders. This is one reason people with se-
services geared for the elderly. These can be valu- vere mental disorders die much younger than
able when you need to provide an elderly person those without.
with shelter or help address other practical
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BOX 12.1 CARE IN TERMINAL ILLNESS problems and alcohol problems. These impacts
of caring (also 12.6), can lead to several mem-
People who are suffering from a terminal illness bers of the same household suffering one or more
such as cancer or AIDS can suffer mental health chronic disease or mental health problems, and
problems for many reasons, such as pain, fear of require the health worker to shift their attention
dying and sadness at leaving behind loved ones. from the sick person to the entire household.
You can help promote mental health by integrat-
ing mental health with terminal care (also called
palliative care) by:
12.4.3 Integrating mental health
○○ establishing a good relationship with the care and care for chronic diseases
person by visiting regularly; The 5C model of integration is very relevant to in-
○○ talking about what dying means to the person tegrate mental health and chronic disease care. In
(What are the person’s worries and how can particular, the health worker should:
they be best tackled now?);
1. always be alert for common mental disor-
○○ involving the family, especially close relatives, ders and alcohol and tobacco use in persons
in sharing concerns (family disputes which with chronic diseases; asking a few questions
may have not been resolved for a long time about these conditions every 6 to 12 months is
could be tackled); good practice;
○○ advising the person to close unfinished busi-
2. always carry out a general examination (or ar-
ness, such as financial or legal matters;
range for one in a primary health care centre)
○○ ensuring the person understands the nature
and relevant laboratory tests in people with
of the illness and is getting the best possible
severe mental disorders and disabilities, es-
treatment available, especially for pain relief;
pecially those receiving antipsychotic medica-
○○ giving counselling, antidepressants or other tion, to check for chronic diseases;
medications if there is depression or another
3. always encourage people with either chronic
mental health problem;
diseases or mental health problems to engage
○○ with children, trying to get the family to meet
in healthy lifestyles, for example, avoiding
a wish that the child has;
sugary foods or too much salt, abstaining from
○○ caring for the carer (12.6).
tobacco, drinking alcohol in moderation and
exercising regularly;
●● Mental health problems may interfere with
4. put a special focus on encouraging people to
the person’s ability to stick to the treatment
take their medications regularly and, where
programme for chronic diseases, for example,
indicated, monitor their health condition (e.g.
being more likely to forget to take medications
taking medications and checking blood sugar
or less motivated to exercise.
in people with diabetes);
In short, the occurrence of both a chronic dis- 5. adapt the care for chronic diseases to be suited
ease and a mental health problem leads to poorer to people with severe mental disorders; some
quality of care, higher health care costs, and poor- may need more flexible care arrangements
er outcomes for both conditions. and information presented in a way which is
It is also important to note that the impact of easier to understand.
mental health problems and chronic diseases ex-
tends beyond the people who are directly affect-
ed: there are also adverse effects on the health of 12.5 HIV/AIDS care
their family members. Caring for a person with
a chronic, disabling disease or mental disorder, AIDS is a disease which is caused by HIV, the hu-
such as cancer or dementia, is stressful and asso- man immunodeficiency virus, which destroys
ciated with an increased risk of chronic diseases, those cells in the blood which are responsible for
including depression, hypertension, sleeping protecting the body from infections and cancers.

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Owing to advances in the treatment of HIV and the ●● Resentment of others in the family. People
efforts of the global community and advocacy by who cannot contribute to the family and, in-
community groups, today AIDS is no longer such a stead, need constant help and support, may
deadly disease. With adequate medication, most be seen as a burden. The spouse may be angry
people with AIDS can expect to live a long life, and that the person has been sexually unfaithful
thus we can now think of AIDS as a chronic dis- and brought the disease on themselves and
ease like diabetes. exposed them to the disease too.
However, many people continue to die of this ●● Stigma and discrimination. There is much
disease. This may be because treatment began too misunderstanding of HIV and discrimination
late, because they cannot access the treatments against those infected. This is especially true
easily or because the disease does not respond of those groups in the population who are at
to the medications. Thus, even today, in many higher risk, such as sex workers, men who have
countries, especially in southern Africa, AIDS is a sex with men, and intravenous drug injectors,
leading cause of death. HIV can only be transmit- all of whom are also shunned by society.
ted through direct contact with the bodily fluids
●● Direct involvement of the brain. The brain
of a person who is infected, for example, through
can be affected by HIV or other diseases such
sexual intercourse, blood transfusion, sharing
as dementia. This can lead to seizures and se-
needles (as some drug users do) or from an in-
vere mental disorders.
fected mother to her newborn child. Needle-stick
injuries, when a health worker accidentally jabs a Mental health problems can complicate the
needle used to inject an HIV-positive person (e.g. treatment of HIV/AIDS in
while collecting blood) is a rare cause of trans- many ways, but most im-
mission. Treatments are now available which can portantly by increasing the
minimise the risk of transmission in these situa- chances that the person
tions, and to stop mother-to-child transmission. may not adhere to their
treatment plan. Being
12.5.1 HIV/AIDS and mental health irregular with medica-
tions for HIV/AIDS can
problems greatly increase the
HIV/AIDS can affect mental health in many ways. risk of resistance to
these treatments.
●● Pain. Many diseases associated with AIDS
cause severe pain. Pain, in turn, can make a
person miserable. 12.5.2 Integrating mental health
●● Disability. People who feel so weak and tired with HIV care
that they are unable to function at work or at
Mental health can be affected at two different
home can feel helpless and angry.
times: when people are first faced with the news
●● Fear of dying. The person may be scared of that they have HIV/AIDS; and later, when the re-
death. They may be worried for the future of ality and implications of taking life long treat-
their family, particularly their spouse and chil- ment or the risk of dying begin to sink in. In the
dren, who may also be infected. first instance, many people will react with shock
●● Expense. The medications for HIV infection and disbelief. Thoughts such as ‘It can’t be true’
may be expensive. Even if the medications are may come to mind. People may feel sad and an-
free, there may be costs related to having to gry. They may develop depression some weeks
go regularly to clinics to get the medications. after the diagnosis. This early reaction to find-
Some families cannot afford them, and those ing out about the sickness can be reduced by a
that can must bear considerable financial sensitive way of sharing the information. Mental
hardship. health problems can occur at any stage after this
initial discovery, but are especially likely when

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●● Loss of other activities. The person providing
I think it would be very
care may have to push aside their own inter- helpful for you to find ways to share the
ests and perhaps give up work. work of looking after your sick mother.
●● Loss of social contact. When someone is sick,
the home environment changes so that peo-
ple may stop coming for social visits.
●● Grief. This will follow when the person who
has been sick dies.

12.6.2 The mental health of carers

Carers can experience all types of distressing
emotions:
●● anger at the sick person for having made life
difficult When the person providing care is elderly, isolat-
●● sadness at seeing a loved one suffer ed and/or suffering from physical health problems
●● guilt because of negative thoughts about the themselves, they are more likely to suffer from
sick person the stresses of caring. You must act to promote
mental health before the person providing care
●● fear of catching the disease from the sick becomes depressed. Whenever you visit the sick
person person, take a few minutes to talk to them about
●● hopelessness about the future for the sick per- their own health. Do this in private, away from the
son and themselves sick person. Most carers would not be frank about
●● frustration at finding that, no matter what they their negative feelings in front of the person they
do, the sickness remains are caring for. Keeping in regular touch with the
●● shame because of what neighbours and other sick person and the person providing care is the
community members may think or say about best way of promoting their mental health.
the sickness.
These emotions are common in all carers, es-
12.6.4 Helping a person providing
pecially during the earlier days of caring. However, care who is distressed
most people cope admirably well in the long term.
Helping a person who is providing care who is
Love for the sick person, receiving practical help
distressed requires patience and empathy, that
from others, talking about feelings with friends
is, the ability to put yourself in their situation and
and family, and finding time to enjoy personal
imagine what it must feel like.
pleasures are some of the ways in which people
cope with caring for someone. Some, however, do ●● Listen to the person’s experiences. Many car-
not cope as well. Their negative feelings can get ers will display an outward picture of strength,
worse with time, and the person who is caring for even when they are feeling sad. Always ask
someone may themselves begin to feel depressed about feelings of sadness and, where appro-
and anxious (7.4). priate, suicidal thoughts.
●● Counsel for grief. Often, the person providing
care is faced with the imminent death of the
12.6.3 Promoting the mental sick person. Preparing them for death and
health of carers counselling them for grief (10.4) is an impor-
The first step is to recognise a person providing tant task.
care who is at risk of experiencing mental health ●● Treat depression using both antidepressants
problems and may benefit from your support. and counselling (Box 4.1).

chapter 12 summary box

things to remember about integrating mental health into health care platforms
○○ Mental health care needs to be integrated into ○○ The 5Cs (Collaborative, Coordinated, Continu-
all aspects of health care, including primary ing, person-Centred and Compassionate) are
care, maternal and child health care, chronic the key principles for the integration of mental
disease care, reproductive health care, elderly health care.
care, and care for people with HIV/AIDS. ○○ Take care to address the mental health needs of
people caring for those who are sick.

notes

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13 health in community platforms are similar to
Integrating mental health
into community platforms

Many of the principles of integration of mental

those for health care platforms, for example, the

of humanitarian crises and are associated with
grave mental health consequences. Thousands
of people are displaced from their homes as they
need to work in partnership with other people attempt to flee conflict, persecution or natural
and organisations, as well as the barriers related disasters each year. We call them displaced per-
to stigma. However, there are some important sons or refugees. The crimes committed in war-
differences. fare include the rape of women, the torture and
1. The people involved: The types of people and murder of civilians, the kidnapping of children to
organisations concerned with working in com- convert them into soldiers and the genocide of
munity platforms can include a much wider specific ethnic communities. Recent times have
range of people, from political leaders to also seen an increase in random attacks in popu-
grass-roots advocacy groups. lations not affected by war, such as bombings and
massacres perpetrated by terrorist groups around
2. The scope of work: The scope typically goes
the world. Disasters, on the other hand, are
well beyond the care of those with mental
unpredictable events, most often due to natural
health problems, and includes promotion of
calamities such as hurricanes, earthquakes and
mental health and prevention of mental dis-
landslides.
orders and disability. Even the care of people
The impact of humanitarian crises is greatest
with mental health problems takes on a very
on communities in low- and middle-income coun-
different form: for example, the focus is often
tries, because they generally have few reserves
on enabling the person to integrate with rou-
and resources to begin with and no planned strat-
tine activities in society and to advocate for
egies for dealing with disasters. As a rule, the most
their rights to a life with dignity and free of
vulnerable populations suffer the most as a con-
discrimination.
sequence of these humanitarian crises: women
Here we consider some of the key activities for and children (13.1.2), elderly people, people
integration of mental health in community plat- with disabilities, and those who are disadvan-
forms. However, it is important to remember that taged for other reasons (e.g. poverty).
mental health is integral to virtually all commu-
nity development activities.

13.1 Humanitarian settings

Humanitarian settings refer to situations where
there is an emergency affecting large popula-
tions, forcing them to leave their homes or dev-
astating their livelihoods. Armed conflicts and
natural disasters are the most common types

13.1.3 Integrating mental health in

humanitarian settings
The guiding principle is integrating mental health
with all other activities associated with humani-
tarian relief, rather than setting up a separate,
stand-alone mental health programme.
The key elements of an integrated approach
are summarised in a figure (pyramid) on the next
page. Moving from the base to the tip of the pyra-
mid, the interventions become more specialised
and needed by a smaller proportion of people.
●● Ensure basic services and security. The most
important basic needs are those of safety,
water and food, shelter, and treatment of life-
threatening injuries.

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to prepare food and caring for sick people.
Specialised services
Support groups can help identify and solve
shared problems (5.26). Children should
be given an opportunity to restore some sem-
Focused, blance of normal life by going to classes and
non-specialised being provided with opportunities and safe
supports spaces to play.
●● Address the needs of all sections of the com
Community and family munity. Not all sections of the community
supports are equally affected by the crisis or equally
benefited by humanitarian relief; for exam-
ple, women and men, or members of certain
Basic services and security ethnic groups, may be disadvantaged for one
reason or another. Violence and discrimina-
tion can occur at any time, and you should
Integrated approach to mental health care in take steps to build trust (e.g. when empower-
humanitarian relief. Source: IASC (2007). ing the community, ensuring participation of
all its sections) and fairness in the distribu-
●● Empower the community and mobilise tion of resources and care to all sections of the
family supports. One of the most disturbing community.
experiences of being a refugee is the loss of
●● Coordinate with other agencies. Many differ-
control over one’s life. From being responsi-
ent agencies may be working in areas affected
ble people and able to make decisions, refu-
by crises. It is important for you to be aware of
gees find themselves entirely dependent on
the different services being offered by them to
relief workers. It is important to hand back
avoid duplication. You may find that there are
responsibilities. This requires involving com-
specific services being organised for mental
munity members in making decisions on what
health care. If this is the case, then you should
actions need to be taken to address problems,
discuss coordinating the care of persons with
and assigning specific tasks to individuals
mental disorders with this agency.
based on their strengths. Be sensitive to, and
incorporate, culturally appropriate beliefs ●● Counsel the individual. Some refugees may
and practices, in particular those which could need specific help, for example, a woman who
promote mental health. Refugees can work in has lost her children or was raped. Counselling
a variety of group activities, such as helping individuals should include:
○○ finding out about where other members
of the family are – often, families are sepa-
rated and putting families together can be a
Do you know where
very important task;
the rest of your family are?
○○ asking about what the person needs – prac-
tical help, for example, information on how
to rebuild a home, may be the most impor-
tant thing;
○○ providing psychological first aid and prob-
lem-solving counselling strategies – the
person may feel overwhelmed by the scale
of problems he or she is facing (5.11);
○○ do not insist on the person retelling their ex-
periences of trauma; however, if they want
to share their experiences, listen patiently
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and do not offer false promises or reassur- some individual practitioners may abuse the
ances (e.g. that their lost family member trust placed in them.
will be found). ●● Try to find a ‘broker’ – a healer who also sees
●● Provide medications. Sometimes, a person the value of medical care and can help you to
may be very depressed or anxious. Using anti- find areas of collaboration.
depressant medications may be helpful in ●● Try to engage with healers as part of com-
these situations. People with existing severe munity awareness-raising about what mental
mental disorders or epilepsy need the medi- health care can (and cannot) provide.
cation they were taking before the crisis to be
●● Assume that many people will continue to go
restarted as soon as possible.
to healers, even while they attend for medical
●● Look after yourself. Working in humanitarian care. Try to understand the potential benefits
settings can itself be stressful; look after your (e.g. providing family support) and pitfalls (e.g.
own mental health as well (2.2.3). contradictory advice) of such combined care.
●● Understand that traditional and faith healers
may feel threatened by medical treatments
13.2 Traditional and faith healing being introduced into their community: find
Traditional and faith healers provide a significant ways for healers to develop new skills (e.g. in
amount of care for people with mental health counselling) in addition to their existing areas
problems in some low- and middle-income coun- of expertise.
tries. We know little about the effectiveness of ●● Consider collaboration in specific areas such
traditional and religious approaches. In the same as early case detection, tackling abuses of
way that human rights abuses have been docu- human rights, providing holistic care which
mented in psychiatric asylums, abusive practices attends to spiritual needs, and promoting
have been identified in some traditional and faith social inclusion and recovery.
healing sites. But we can also assume that a cul-
turally relevant approach to the challenges posed
by the effects of mental health problems will be 13.3 Early child development
of value to the community and affected individu-
als and families. Traditional and faith healers are We increasingly know that the first thousand days
well-placed to be ‘in tune’ with community values of life after conception are crucial to the overall
and belief systems. When attempting to expand health and development of a child. It is also a
access to evidence-based medical care, tradi- critical period when care around pregnancy and
tional and faith healers need to be recognised delivery can potentially prevent some forms of
as important partners. The following actions can developmental disabilities. The most important
help to establish a respectful alliance. promotive and preventive actions include pro-
viding comprehensive care through pregnancy,
●● Develop local knowledge about the types of
traditional and faith healers active in the area
where you work: there is immense diversity
both between and within countries, so it is dif-
ficult to generalise across healers.
●● Find out which healers are involved in mental
health care and what they do.
●● Don’t just consider healers as a block to timely
treatment. Be open to the idea that they can
do things that health practitioners can’t do.
●● On the other hand, do not assume that healers
are harmless. Some practices are abusive and

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childbirth and the early years of life. This includes avoid contact with people with measles,
empowering mothers and families with informa- mumps or chicken pox while pregnant.
tion and support on positive behaviours they ●● Advising pregnant women to plan to give birth
should adopt around these periods. in a health facility with a skilled attendant.
●● Supporting the mother to carry her pregnancy
13.3.1 Before the child is born to term, which may include giving up heavy
The key message when the woman is pregnant is labour, taking adequate bed rest and being
to ‘support the mother and know when to refer’. alert to bleeding.
Supporting the mother includes the following. ●● Motivating the mother that she should breast-
●● Equipping the woman to delay pregnancy until feed her baby in the ‘golden hour’ after
she is at least 18 years old, and being aware of delivery. Information should be around the
increased risks if a woman is younger. importance of giving the first milk or colos-
trum, which acts as the baby’s first vaccination
●● Ensuring family or community support for
against infections. The mother should also
a pregnant woman so that she is able to get
be encouraged to continue to nurse her child
enough to eat and adequate rest, especially
exclusively for 6 months.
around daily work which may mean carrying
heavy loads and working long hours. ●● Enquiring about who will support the mother
during the delivery and making sure that they
●● Prescribing iron and folate to all women in the
too will help support the baby being immedi-
first trimester of pregnancy.
ately put to the breast.
●● Monitoring the progress of the pregnancy
regularly; if there is evidence of poor growth
of the baby (by less-than-expected increase in
13.3.2 At the time of childbirth
weight or abdominal size in the mother), refer Childbirth is a crucial time to promote a healthy
her to the gynaecologist. entry into the world and minimise the risks of
●● If the woman is over 40 years of age or if par- brain damage. These are some of the strategies
ents are related to each other, refering to a which can ensure a safe childbirth.
gynaecologist who can conduct further tests ●● Only skilled persons should conduct deliver-
to rule out detectable causes of intellectual ies, ideally in a setting which can support
disabilities and other inherited conditions. problems if they occur.
●● If the mother is drinking alcohol, educating her
about the potential harm of any alcohol drink-
ing in pregnancy, and advising that while any
reduction is worthwhile, stopping altogether
is the preferred goal.
●● Treating high blood pressure or seizures in
pregnant women urgently. Refer any pregnant
woman who is semi-conscious, confused or
has vaginal bleeding for specialist care.
●● Avoiding prescription medications and unnec-
essary investigations involving X-rays unless
absolutely necessary.
●● Try to create a positive enabling environment
●● Encouraging the pregnant woman that she for the birth; give clear and simple instructions
should not work with toxic substances (e.g. to the mother without shouting at her.
pesticides).
●● As a health worker, familiarise yourself with
●● Immunising pregnant women against measles all the emergency measures of childbirth. For
and tetanus. Inform them that they should example, what to do if the baby is born blue
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and limp and does not breathe right away. If ●● Ensure early control of any high fever by
the birth cry is delayed, give oxygen and seek unclothing the baby or using a light cover,
help. administering the correct dose of paracetamol
●● In case of abnormal position of the baby (e.g. and increasing the frequency of breastfeeding.
breech presentation), refer to a specialist. ●● In case of an unwell child, look for signs of
jaundice, seizures, difficulty in breathing
13.3.3 After childbirth and irritability. Consider appropriate treat-
ments for the specific conditions and refer to
specialists.
●● General advice on parenting (Box 13.1). Many
parents are unaware that the healthy develop-
ment of the brain requires more than just food
and good physical health: spending quality
time with the baby, for example, at least an
hour a day playing with children in a manner
which is age appropriate is critically important.

●● Urge family members to support the mother to

breastfeed her baby in the ‘golden hour’ after
13.3.4 Stimulating the child: a
delivery. Mothers are often exhausted and parenting practice to promote
need nourishment, gentle encouragement brain development
and support.
The first 5 years of life are critical to the way the
●● ‘Kangaroo care’ allows a child to make skin-
child develops and whether they will reach their
to-skin contact with their mother. This is
full potential. There are three key strategies to
facilitated by putting the unclothed newborn
achieve this: protecting the child from infections;
immediately between her mother’s breasts
healthy feeding practices, such as exclusive
and covering both the mother and child. The
breastfeeding for the first 6 months and respon-
warmth of the mother helps keep the child
sive feeding; and child stimulation. The brain
warm naturally (particularly if the infant is
needs stimulation to develop properly. Child stim-
small for age), stimulates the breastfeeding
ulation involves encouraging the parents to make
reflexes and promotes emotional attachment
time every day to talk and play with their child.
of the baby to the mother.
These games should start from the child’s first day
●● Encourage all women to exclusively breast- of life when the mother can talk, sing and stroke
feed their babies for the first 6 months of life;
this includes avoiding water, sugar water and
all unnecessary medications. Exclusive breast-
feeding provides the right nutrition for a child
and prevents infections.
●● Encourage the mother to be responsive to her
child’s needs. This means feeding on demand,
which will again require family support.
●● Ensure timely and complete immunisations
for diphtheria, polio, tetanus, tuberculosis,
measles and whooping cough.
●● Inform the mother and family that young the baby’s head while nursing. As the child grows,
babies get sick very quickly. If they suspect the the parents can use simple rattles, bunches of
child is irritable, not feeding as usual or has keys or coloured cloth to attract the child’s atten-
fever, they should seek help immediately. tion and make them watch and follow objects in

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their environment. As the child grows, introduce are at risk for delayed development, for example,
language for the world around the child, encour- babies born with very low birth weight, convul-
age them to explore this world and provide oppor- sions, jaundice and meningitis, lack of oxygen at
tunities for the child to be exposed to the world birth and genetic disorders such as Down syn-
outside the home. drome 11.1. The aims of stimulation are to
Child stimulation is particularly valuable for promote the healthy development of the child,
promoting the development of babies who are to help the child to function as independently as
also experiencing delays in their development or possible, and to improve family functioning.

BOX 13.1 GENERAL PARENTING ADVICE

Although parenting may seem to be a ‘natural’ skill, ○○ Be consistent in your responses to your child’s
many families would benefit from simple advice on behaviour, whether good or challenging. Make
what to expect and the best ways to respond. Here sure that all adults understand and follow the
is some guidance on positive parenting techniques. same rules.
○○ Use language which is positive and encourag-
For very young children
ing. Praise behaviour that you want to see.
○○ Respond to the child’s needs quickly and
○○ Make time to have fun with your child and enjoy
appropriately – children at this age need to
the new skills and knowledge that they learn in
understand that their adults are dependable,
these years.
whether they need food or comfort.
○○ Integrate simple play and songs into everyday For adolescents
activities such as feeding and bath time. This ○○ Be a good role model for your adolescent – use
enriches the learning environment for the child. the language you want to hear and drop the
○○ Make the play more challenging as the child habits you don’t want them to adopt.
grows; for example, once they are able to find ○○ Negotiate rules and follow up with agreed
one hidden object, increase it to two. consequences.
○○ Start reading to your child as early as possible. ○○ Prioritise the rules, so that you are not saying
‘no’ to everything your adolescent wants to do.
For children in school
○○ Be approachable, so that your adolescent
○○ Make rules which are simple enough for your
can talk to you about difficulties they may be
child to follow.
having.

13.4 Schools help those children who are having difficulties

coping with school life, whether this is with stud-
Schools provide unique opportunities to promote ies or other social activities in school. The well-
the mental health of children and adolescents. described model for integrating mental health in
Being in school is often itself a major factor influ- schools is the health-promoting school.
encing good health. In addition to education,
there are opportunities to make friends, play
13.4.1 The health-promoting
sports, participate in group activities, and learn
how to regulate emotions in response to happy or school
sad events. The principles of a health-promoting school cover
A school mental health programme aims all aspects of health and well-being of children
to promote the mental health of all people in a and adolescents and include the following.
school (including teachers) and to identify and
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●● The active participation of all school com-
munity members, including teachers, man-
agement, parents and, of course, students, in
efforts to make the school a healthy place.
●● Enabling a healthy environment in the school
(13.4.2).
●● Providing access to knowledge and skills
related to health promotion, including repro-
ductive and sexual health, nutrition and men-
tal health. This is sometimes called ‘life skills ●● Creating an inclusive learning environment
training’ and is typically provided through a which takes into account individual learn-
classroom-delivered curriculum (13.4.5). ing differences; for example, using multiple
●● Conducting health-promotion programmes teaching strategies within a classroom or
for all school community members, for exam- establishing resource rooms for youth with
ple, screening camps (e.g. dental checks, developmental disabilities.
vision and hearing checks), meditation classes ●● Implementing healthy school policies, in par-
and physical exercise. ticular regarding bullying 13.4.3.
●● Providing first aid for physical and mental ●● Implementing ‘circle time’ activities in the
health problems, including counselling. class 13.4.4.
●● Connecting the school with the community ●● Creating a ‘buddy’ or a peer-pairing system for
through activities in which school members students who are having problems. For exam-
contribute to the health of the community, ple, a ‘buddy’ could help a peer with academic
for example, by participation in cleanliness problems, partner with a younger student to
programmes. encourage social skills, help a student with
disability manage physical obstacles on cam-
13.4.2 Improving the school pus, or help a youth who is being isolated by
peers (e.g. someone who is bullied).
environment
●● Creating awareness about what triggers
Changes to the school environment can be very mental health problems (e.g. bullying and
important to promote mental health. Key activi- substance abuse) through the use of poster
ties to enhance the school environment include competitions, plays, assemblies, lectures or
the following. debates. In addition, information about issues
●● Establishing a group which takes responsibil- such as reproductive and sexual health, self-
ity for ensuring a healthy school environment, harm and drug/alcohol use brings taboo sub-
with participation of school management, jects out into the open so that students can
teachers, students and parents. seek additional information and help from the
counsellor.
●● Encouraging the school to celebrate interna-
tionally recognised days which promote men-
tal health issues (e.g. World Autism Awareness
Day on 2 April, World Mental Health Day on 10
October, International Day for Persons with
Disabilities on 3 December).

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13.4.3 Bullying
Bullying is very common and can range from teas-
ing to physical violence. Often, older students are
the main culprits and younger students are the
victims. Those who are shy and less likely to fight
back are often targeted by bullies. Children who
are perceived as being ‘different’ or have some
type of disability, for example, stammering, are
also picked on. Children who are bullied may
become quiet, lack confidence and have few
explore issues which are of concern to a group of
friends. Some children may even try to end their
young people. It provides a structured approach
lives or drop out of school. A school where bully-
to problem-solving in a group regarding issues
ing is a problem often has other problems too.
that concern the majority of students (e.g. disci-
Tackling bullying will help both individual chil-
pline in the classroom, bullying in school). The
dren and the entire school system.
students and facilitator sit together, ideally in a
circle, with a view to creating a safe and equal
environment for the participants to share their
thoughts and feelings. With young children, the
facilitator may wish to sit in a smaller chair or on
the ground to symbolise the equal nature of the
engagement.
Circle time should be conducted with a small
group, ideally not more than 25 students. However,
if these circumstances cannot be arranged, it is
possible for circle time to be conducted in a class-
room with students at their desks. Rules of behav-
The key in tackling bullying is to encourage
iour for this activity are: respecting each person’s
the school to have a policy on the issue. Students
opinion, allowing each person the opportunity to
should be encouraged to share experiences of
speak, allowing individuals the freedom not to
being bullied, and firm and consistent action
share (that is, not forcing anyone to share some-
must be taken against those who continue to bully
thing they do not want to) and respecting each
despite warnings. Any child who is complaining of
other’s right to confidentiality (that is, not sharing
being bullied must be taken seriously; dismiss-
outside the circle what has been communicated
ing them as ‘weak’ is wrong. Supporting the child
during circle time).
who is the bully is also important since they them-
The facilitator and students set the agenda
selves may be the target of bullying in a different
for each session with a clear focus on the issue
setting (e.g. at home by an elder sibling) or may
to be discussed (initially, agenda may be set by
have a mental health problem (Chapter 11).
the facilitator, and the students may contribute
once they become familiar with the process). For
13.4.4 Circle time in the school younger children, circle time can deal with issues
setting† of managing emotions and building self-esteem
(e.g. exploring what makes a child angry, how to
Circle time (sometimes called ‘group thinking know when one is feeling angry, how to deal with
time’) is an active strategy which allows the facili- anger); for older youth, circle time can include top-
tator (either the teacher or the counsellor) to ics such as substance use, bullying and decision-
making. The facilitator’s role is to actively listen
†
Adapted from A School Counsellor Casebook in a non-judgemental way and allow the group
to come up with their own solutions. Often, circle
(Chapter 18).
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time discussions do not arrive at a conclusion, but ●● Self-awareness and empathy:self-aware-
pave the way for further classroom discussions ness is the skill of recognising one’s tempera-
and debates. ment and character in order to anticipate and
modify one’s reactions to fit a situation. The
13.4.5 Elements of a life skills skill of empathy (or the ability to appreciate
another person’s point of view) increases a
education programme young person’s ability to form and maintain
Life skills help young people deal effectively with relationships.
the demands and challenges of everyday life and
translate knowledge and values into positive 13.4.6 Mental health
actions. Although acquiring life skills is a lifelong
process, a school-based life skills education pro-
problems in schools
gramme allows young people to acquire knowl- Most children and adolescents cope with school
edge and positive values in an age-appropriate life very well. However, some children struggle
manner in a safe setting and through a participa- from the start, while others who seemed to be
tory approach. doing well start failing in later years. Young people
There are five pairs of related skills which are who are experiencing serious difficulties in stud-
generally included in a comprehensive life skills ies or settling down in school should be assessed
education programme. for a mental health problem. There are several
●● Critical and creative thinking:critical think- important mental health issues which are associ-
ing skills allow a young person to objectively ated with school-age children (Chapter 11 for
analyse information and experiences. Creative clinical management):
●● Becoming anxious or depressed. Common
thinking skills, on the other hand, help young
people think ‘outside the box’ so that they can reasons for anxiety or depression include
flexibly and creatively meet challenges. fights within the family, difficulties in cop-
●● Decision-making and problem-solving: ing with studies, being bullied or isolated in
decision-making skills allow a young person school, and problems in relationships with
to review all the information pertinent to a friends (11.8).
problem and to evaluate the various outcomes ●● Being unable to cope with learning or social
that accompany possible decisions. Problem- expectations. Certain developmental disabili-
solving skills involve acting on these deci- ties, such as autism or intellectual disabilities,
sions and anticipating and managing possible may create considerable difficulties in coping
obstacles that may be encountered. with academic demands or making friends.
●● Relationships and effective communica ●● Being disruptive in the classroom. Some
tion: these two skills help the young person mental disorders, such as attention-deficit
build and consolidate hyperactivity disorder (ADHD) or conduct dis-
important relationships orders, can lead to the youth causing disrup-
in their daily life by tions in the classroom or getting into fights
employing non-aggres-
sive and effective ways
of expressing opinions,
desires and anxieties.
●● Coping with emotions and with stress:these
skills are closely linked and enable a young
person to handle positive and negative emo-
tions in a socially acceptable way, and to rec-
ognise sources of stress and respond to them
in a healthy way.

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mental disorder, often begins in adolescence,
especially in boys. If teachers tell you that a
student has gradually become more with-
drawn from his friends and family, behaves in
an odd manner and says odd things, think of
psychosis (7.3).

13.4.7 Providing counselling for

young people in schools
a. b. c. As a health worker, you may have access to a
few neighbourhood schools, from which you get
Some mental health problems faced by adolescents:
referrals. Ideally, the school should have its own
a. depression, b. drug abuse, c. schizophrenia.
counsellor who is based in the school or who visits
the school on a regular basis, at a minimum once
with other students or breaking school disci- a month on a particular day. The teachers can
plinary rules. then refer children they are concerned about to
Adolescence is a period when children begin the counsellor for an assessment. The most com-
to feel grown up, and when they begin to see mon problems noticed by teachers are disruptive
themselves as unique and special individuals. behaviours in the classroom and poor perfor-
Their major influences are their friends, rather mance in studies. Emotional problems, such as
than families. Social networks on the internet also feeling depressed or withdrawing from peers, are
become important. They face academic pressures less often noticed by teachers. As a health worker,
as a result of the major examinations which will it is important that you create a partnership with
lead them into college or university. Most impor- the school counsellor or directly engage with the
tant, adolescence is that exciting period when student community in case the schools do not
people first begin to feel sexually attracted to oth- have such a service. The key goals of building this
ers. Some adolescents may find all these changes relationship are to:
difficult to cope with and develop mental health ●● establish how you or a counsellor can help
problems. In addition to the problems discussed the young people who may be experiencing
above, some others can occur in adolescence. concerns
●● Harming oneself. Self-harm and suicide are ●● clarify the kinds of problems and concerns you
leading causes of death in adolescents. This will be able to address
problem is most common in those young peo- ●● emphasise the confidential nature of the
ple who have faced violence or academic fail- counselling relationship
ure and who do not have a supportive family ●● inform the students how to make contact
or peer group. with you, either directly or through the school
●● Problems with use of drugs and alcohol. systems
Many young people try smoking, drinking ●● inform parents that you may be able to sup-
alcohol and taking drugs such as cannabis port their needs with respect to their child
(hashish, marijuana). The danger is that what (Box 13.1).
may have begun as an experiment can turn
into a habit or lead to more dangerous types Counselling young people should follow the
of drugs (9.2). same principles as any other type of counselling
session (5.9).
●● Developing a severe mental disorder (psy
chosis). This is much less common than the
other problems. However, it is important to
keep in mind because psychosis, a severe

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●● long hours, with not enough breaks ●● Give talks on promoting mental health with
●● an unhealthy workplace culture (e.g. bullying, the goal of enabling a culture of openness
harassment) where people feel comfortable to talk about
mental health.
●● lack of a sense of belonging or ownership for
the work done (e.g. due to lack of acknowledg- ●● Develop a workplace mental health policy
ment for one’s efforts) – having a concrete policy reassures employ-
ees that their company cares about their
●● lack of mentoring and opportunities for career
well-being.
growth
●● Involve all employees, both senior and junior,
●● lack of support for employees who face prob-
to collectively make suggestions on how to
lems or have family needs (e.g. mothers of
improve workplace mental health, and to be
young children)
part of the process of change.
●● exposure to trauma and violence as a result of
●● Encourage social interactions among staff, for
the work (e.g. as a police officer or soldier).
example, by organising sports matches or staff
Some jobs may put greater strain on a per- picnics.
son’s mental health than others (2.2.3 on how ●● Recognise and appreciate good work
a health worker can look after their own mental performance.
health). Workers who are exposed to threats to
●● Put in place workplace policies on health and
their own safety or are exposed to the suffering
safety, and on zero tolerance for bullying or
of others are also vulnerable (e.g. fire fighters,
harassment.
police officers, ambulance workers and soldiers).
Farmers have to cope with unpredictable agricul- ●● Provide workplace crèches to enable parents
tural outputs, for example, due to weather condi- of young children to return to work when they
tions and pests. People who work in boring and wish, without worry about the welfare of their
unfulfilling jobs may become demoralised. Those child (which, in turn, improves the mental
working in the informal sector live with uncertain health of their children).
income and a high level of environmental hazards, ●● Allow flexibility for staff to work from home
and may be treated as slaves with few protections where possible.
for their well-being. ●● Introduce stress management sessions, for
The most common mental health problems in example, on relaxation training.
the workplace are depression, anxiety and alco-
●● Encourage staff to take regular breaks away
hol and drug problems. In some jobs (such as law
from their desks and to get out of the office to
enforcement or the army), trauma-related men-
reduce stress.
tal health problems can also develop (e.g. post-
traumatic stress disorder). ●● Create a peer-to-peer support system so
Improving mental health in the workplace people can talk with colleagues about their
requires two major steps: promoting mental concerns.
health awareness and supporting workers with ●● Provide clear information on how and where
mental health problems. to seek help for mental health problems, and
make it clear that this would not have an
13.5.2 Promoting mental health adverse effect on the person’s occupational
records.
The key is to change the environment of the work-
place to promote everyone’s mental health (and,
ultimately, the productivity of the work). These
13.5.3 Supporting workers with
are some steps you could take (and remember to mental health problems
start with your own workplace!). Stigma and discrimination can both be potent
barriers to people seeking help in the workplace.

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specialist care, for example, people with chronic labourers, servants and sex workers. They may
diseases or severe mental disorders. become members of criminal gangs and end up
in prison. Street children suffer from a variety of
13.6.2 Street children physical health problems caused by poor hygiene
and malnutrition (e.g. skin infections, diarrhoea).
Children live on the streets of cities mainly because These often go untreated because there is no one
of the poverty in their own homes. Violence and to take the child to a health centre. Children living
abuse also lead children to run away from home. on the streets miss out on the two most important
However, street life can be cruel. Street children parts of childhood: growing up in a safe and lov-
have to work, often in dangerous conditions, as ing family environment, and being able to go to
school and get an education.
BOX 13.2 WORKING WITH STREET CHILDREN Street children are more vulnerable to expe-
When working with street children, you must be riencing mental health problems because of the
aware of certain issues. stresses they faced that led them to leave their
○○ Some children may resent attention and re- own homes, and because of the stresses they
ject offers of help. They may be suspicious of face living on the streets. Street children often
adults because of their unpleasant experienc- come from homes where they may not have had
es with adults in the past. Provide whatever adequate food or attention to their emotional
practical help the child needs and concentrate development. Parents or other adult guardians
on building a trusting relationship. may have a mental disorder, or may have abused
○○ The opposite may also occur: some street
the children, or been in conflict with each other.
Some children may become loners and isolated,
children become so attached to you that
engaging in antisocial activities such as crime and
they relate to you as if you were a parent. You
drug use, particularly inhaling solvents such as
should not encourage an unhealthy depend-
glue. Others become unhappy and miserable, and
ency.
sometimes suicidal.
○○ Be on guard for any relationship with a child
The most important way to help street chil-
which begins to acquire a sexual character.
dren is to give them what all children need for
The best way of dealing with this is to be
healthy emotional development: love and atten-
sensitive to any feelings of sexual attraction to
tion (Box 13.2). This is best done by providing an
the child, or to any evidence of sexual educational opportunity. Informal schools can
approaches in the child’s behaviour. You provide children with an hour or two a day of
should explain to the child that there is a need rediscovering their lost childhood. As with home-
to reduce the close relationship because the less adults, a good opportunity to integrate men-
nature of the relationship has become too tal health care is in shelters and informal schools
intimate. You could entrust the care of the for homeless children. Visit these as part of your
child to another colleague but must try to do regular work routine and get to know the resi-
so in a way that does not make the child feel dents individually. People who run the shelter will
betrayed. Remember that the child may often guide you to those children who they think
already have been abused and neglected in may have a mental health problem.
the past.

13.7 Prisons
The mental health of prisoners is important for
two reasons.
1. Some people with mental health problems
break the law and end up in prison.
2. Being in prison can be a stressful experience.

them feel they had to carry out an unlawful act.

This, of course, does not justify the crime, but it
can help you understand the prisoner as a vulner-
able human being.

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You can help improve the mental health of prisoners and the prison staff can help reduce sus-
prisoners in the following ways. picions. Regular group meetings and the involve-
●● Advocating for zero tolerance for bully ment of organisations which are concerned about
ing and violence in the prison. Violence is a mental health issues or the rights of prisoners
common experience in prisons and, as with can be beneficial. Efforts to help both prisoners
violence in any setting, leads to poorer mental and staff to deal with stress through meditation
health. Advocate with prison authorities and or relaxation training (5.12) and to be involved
prisoner groups (13.7.2) to put into place a in recreational activities (such as sport competi-
zero-tolerance policy for violence. tions) can also help create an environment which
promotes mental health.
●● Individual counselling. The key elements are:
○○ listen: allow the prisoner to share feelings
and use this discussion to assess the nature 13.8 Preventing alcohol, drug and
of the mental health problem;
○○ discuss practical needs: for example, a pris-
tobacco abuse
oner may be desperate to meet his family Alcohol and tobacco abuse together account for
and this may be making him very unhappy a large proportion of deaths and disability in the
– simply arranging a family visit may do world. It is important to distinguish between alco-
wonders for his mental health; hol on the one hand, and drugs and tobacco on
○○ problem-solving strategies (5.11). the other. If consumed within limits and with com-
●● Peer support. Prison health workers often get mon sense, alcohol does no damage to health; on
to know which prisoners are compassionate the other hand, tobacco and drug use are dan-
and have the skills needed to help others. You gerous irrespective of the amount which is used
can use such people to act as counsellors or (although, of course, the more one uses these
friends to support other prisoners in need of substances, the greater the risk of harm). Thus,
help. prevention of alcohol use problems may focus on
strategies to educate people on ‘sensible’ drink-
●● Groups. Suggest to the prison authorities the
ing behaviour. On the other hand, strategies for
need for group meetings of prisoners where
combating tobacco or drug abuse should focus on
common concerns can be discussed (5.26).
complete abstinence. ‘Just Say No’ is the slogan of
●● Treatment for specific mental disorders. choice for these substances.
Specific symptoms are likely to include:
○○ withdrawal reactions from alcohol or drugs 13.8.1 Prevention in the clinic
(Chapter 9)
The simplest strategy is to ask every person
○○ violent, agitated or confused behaviour
attending the clinic two simple questions.
(7.1, 7.2 and 7.8)
●● Do you drink alcohol? If yes, have you been
○○ suicidal thoughts or behaviour (7.6).
concerned about the amount you drink?
●● Do you smoke/chew tobacco?
13.7.2 Improving the system
In young adults you could also ask a similar
It is often difficult to work with prisoners because
question about specific drugs (e.g. opium) based
the prison system can be unsympathetic towards
on your knowledge of how common this is in the
their mental health needs. Working in prisons
community you serve.
can also be stressful, leading to mental health
If use of any of these substances is reported,
problems in prison staff. Improving the quality
educate the person about the dangers of use, and
of life within prisons will ultimately benefit the
the benefits of reducing drinking and completely
mental health of all those who live or work there.
giving up tobacco. There is no better prevention
Activities which enable frank discussion of con-
technique than this (9.4).
cerns, without fear of punitive actions, between
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13.8.2 Prevention in the community BOX 13.3 MESSAGES THAT CAN BE USED IN
SCHOOLS AND COLLEGES

○○ It is not ‘cool’ to drink alcohol or smoke ciga-

rettes. Do you think smelling of stale smoke
and having a blotchy face is ‘sexy’?
○○ Advertisements which show beautiful and
athletic people smoking and drinking are
selling a lie. In fact, those who smoke or drink
are much sicker than others and look much
worse.
○○ You can have fun and party without drugs or
alcohol. Having a good time means enjoying
It is important that health workers are familiar friendships and activities without the need for
with the law in their country regarding alcohol any substances.
and tobacco. For example, in most countries, ○○ If you know someone who is smoking or
bars and shops selling alcohol are not allowed
drinking, be a friend and suggest to them they
to stay open beyond a certain time, children are
should stop.
not allowed to purchase tobacco or alcohol, and
○○ You will use up all your money on alcohol or
smoking is banned in schools or enclosed spaces.
tobacco; imagine what you could do with that
If the health worker knows of potential offenders,
money if you stopped.
they can approach either the community lead-
○○ Why do you need a drug to ‘be yourself’? Stop,
ers or police to ensure the law is enforced. Health
and you will really be yourself.
workers can try to educate bar owners to insist
that customers do not drink and drive home, or
teach them ways of politely, but firmly, refusing Yuck! Who
to serve alcohol to someone who is clearly drunk. would ever want to
Encouraging the formation of self-help groups kiss those guys?
such as Alcoholics Anonymous in the community
can help those who have drinking problems, as
can campaigning against heavy drinking.

13.8.3 Prevention in schools and

colleges
Adolescence is the time when many people first
refers to the attitudes which people have about
try smoking, drinking or using drugs. This is the
mental health problems; discrimination refers to
most important time to provide education on how
their behaviour in response to these attitudes.
to avoid substance abuse (Box 13.3).
For example, believing that people with mental
health problems are dangerous is stigma; banning
them from getting married is discrimination.
13.9 Promoting the rights of Stigma and discrimination are commonly
people with mental health experienced by people with mental health prob-
problems lems, and those associated with such people
(such as carers and even health workers), in all
Stigma literally means a physical mark on the societies. Some mental health problems, such
body. This is what was done to people with as the psychoses and intellectual disability, are
mental health problems in some societies, as a more often associated with stigma, and these are
way of marking them as being different. Stigma the conditions which most people associate with

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●● not employing people with mental health
Do you know, he’s
a mental case. problems
●● not providing time off from work when ill, or
dismissing people from their work
●● not providing health insurance for treatment
of mental health problems
●● not providing adequate resources for mental
health care.
It is useful to remember that society has stig-
matised many types of illnesses, from leprosy to
HIV/AIDS. Just as health workers have sought to
‘madness’. This is also a reason that people with challenge stigma associated with these illnesses,
other types of mental health problems do not like so too must they strive to challenge discrimina-
to be labelled as having a mental disorder. tion against people with mental health problems.
Today, people with mental health problems The key to challenging discrimination is under-
are discriminated against and excluded from soci- standing why it occurs. Of course, sometimes
ety in a number of other ways. These include: people with mental health problems do behave
●● not allowing people with mental health prob- differently; a depressed person may appear with-
lems to live in the community drawn, while a psychotic person may be aggres-
●● not allowing them to vote in elections or to get sive. However, the main reason for discrimination
married is ignorance. Some common questions about
mental disorders are presented in Box 13.4.
●● not providing assistance in schools so that Challenging stigma requires that the health
children with problems have no choice but to worker is clear in their mind about the facts.
leave

BOX 13.4 MENTAL HEALTH PROBLEMS: FACTS AND MYTHS

Are mental health problems hereditary? Can a person with a mental

Some mental disorders can run in families. However, health problem hold a job or marry?
this is rare. Most children of a parent who has a mental Absolutely yes. If treated, most people with
disorder will not have a mental health problem. Most mental health problems can work and have family
mental disorders are the result of a combination responsibilities. Of course, just as with physical
of social, lifestyle and biological factors. illnesses, the kind of job may need to be adapted
to suit the person’s needs.

Isn’t mental disorder the

result of curses, black magic or evil spirits?
Not at all. Mental disorders are the result of changes in
the way the brain works interacting with stressors Do people with
such as family problems. mental health problems have to take
medications for the rest of their lives?
Many people with mental health problems do not
need medications at all. Those who do may need it for a
year or more depending on the kind of illness.

There are many ways a health worker can help

address stigma of people with mental disorder in
the community.
○○ Putting up posters and other information ma-
terials in public spaces (e.g. clinics, schools)
with positive messages about mental health
problems, e.g. that they are treatable and that
people can contribute actively to society.
○○ Sensitising key persons in the community, Many people with mental disorders are denied
such as village heads, other health workers, their basic rights to freedom and appropriate
police officers, potential employers, com- health care. Many people continue to be locked
munity leaders and traditional and religious up, in prisons, traditional healing sites, mental
leaders. hospitals or in the community. They are often
○○ Supporting people with mental health prob- denied access to medical care, which is what is
lems to share their stories of recovery with the most needed during the acute phases of their
community. illness. Many spend years in mental hospitals
○○ Encouraging employers to give opportuni- because their families have abandoned them.
ties to people recovering from mental health Mental hospitals are often run as prisons where
problems. the aim is not to treat and rehabilitate the sick,
○○ Encouraging police to take into account men- but to keep them locked away from society. Cruel
tal health problems by referring someone who practices, such as beating, tying up the person or
is behaving inappropriately for medical care giving shock therapy without anaesthetics con-
rather than putting them in prison. tinue to be in use. The human rights of people
○○ Encouraging the family to permit the person with mental health problems can also be violated
with mental health problems to participate in their own homes, for example, if they are locked
in family activities like any other member of or tied up, or in places of traditional or religious
the family and to ensure they get adequate healing (e.g. from beating to chase out spirits).
medical care. Addressing human rights violations is an
○○ Encouraging doctors to take the health com- important task of the health worker. The aim is to
plaints of people with mental health prob- identify individuals whose rights are being abused
lems as seriously as they would those of any (e.g. they are locked up at home or are chained in
other person. a traditional healing shrine) and to intervene as
early as possible to reverse these abuses. This

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avoid diarrhoeal diseases, then, in the same way,
helping resolve relationship difficulties can help
prevent mental health problems in those affected.

13.10.1 The reasons relationships

break down
There are many common reasons why relation-
ships run into difficulties.
requires building trust with the relevant people ●● Major life events. Both happy and unpleasant
involved (e.g. family member or traditional events can cause relationship difficulties. For
healer), education that such practices are very example, when a baby is born, the child can
damaging, and proposing a humane alternative bring pleasure and joy to parents and families.
(which should include appropriate health care). However, babies can also lead to a mother
The goal is to stop the human rights abuses. If and father becoming less affectionate towards
efforts to change the behaviour through educa- one another. Babies mean hard work too, and
tion fail, the health worker may need to take resentment may build up if the mother feels
stronger action by informing the police or lawyers she is not getting enough support. On the
about the human rights abuse. Making links with other hand, the husband may feel he is not
non-governmental organisations (NGOs) con- getting enough time with his wife. Unpleasant
cerned with human rights is an important aspect events such as losing one’s job can place great
of community mental health care (Chapter 15). stress on the person, which then causes dis-
tress to their relationships with others. The
unemployed person’s self-esteem is affected,
13.10 Relationships in distress which makes them feel sad and irritable. The
partner may resent the fact that they are hav-
ing to support the entire family.
●● Money problems. This is a common cause of
relationship difficulties. Shortage of money
means that many of the things families would
like to do may not be possible. Resentment
about who spends money and who earns the
money can lead to conflicts and arguments
between family members.
Humans are social by nature. Those who have
●● Violence. Violence is a very difficult situation
relationships which are affectionate and support-
to deal with. The most common victims of vio-
ive enjoy better mental health. The most impor-
lence in relationships are wives. Children can
tant relationships in our lives are the ones we
also be abused by their parents, and elders
have with our spouses or partners, with our par-
by their children. Emotional violence, such as
ents and our children, and with our close friends.
threats and verbal abuses, can hurt a relation-
For most of us, these close relationships provide
ship just as much as physical violence. Sexual
us with joy and pleasure. When we feel worried,
violence, such as forcing your wife to have sex,
these relationships provide us with support and
can do terrible damage to the relationship
hope. However, relationships can also become
(10.2).
unhappy. When they run into trouble, we can
become sad and angry. This is why helping to ●● Falling in love with someone else. When we
resolve relationship difficulties is an important marry, we believe our relationship is for life.
way of promoting mental health. If the health Unfortunately, this is not always the case.
worker can advise people to boil drinking water to Having a love affair with someone outside the

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person could suggest some other rules they ●● when, despite help, the relationship remains
wish their partner to follow. By discussion deeply unhappy.
with the health worker, both partners agree on
The health worker should not tell a couple
a set of rules which will govern the way their
what to do, but if the couple decide to separate
relationship is to be rebuilt. For example, the
then they can help by supporting both individuals
wife may suggest that her husband should
in making the right decisions about how to part
reduce his drinking so that he only drinks once
(e.g. sharing parenting responsibilities for chil-
a week. In return, the husband may say that
dren) and the need to avoid costly and stressful
his wife should not get angry with him when
legal fights. After separating, the health worker
he spends time with his friends. These rules
could play a part in counselling the person in
are then monitored regularly to see how the
coming to terms with their new lives and instilling
couple is progressing. If things are going well,
hope for a happier future. Mental health problems
the rules may gradually become part of their
are always a risk during and after the process of
daily lives.
separation.
●● Step III: Improving communication. This is
the key to sustaining healthy relationships.
Communication can be improved by asking 13.11 Advocating for social
partners to spend some time, say half an hour,
each day talking to each other about their day. change to promote mental health
Here are some simple ways to improve com- Many social problems which affect entire com-
munication between partners: munities, nations and the world are linked to
○○ talking about what made them happy and poor mental health. The major ones are poverty
what made them sad that day and gender inequality. Several other issues are
○○ sharing in each other’s activities; for exam- also important, such as environmental degrada-
ple, sharing household chores and looking tion, climate change and hatred against sections
after children can build emotional bonds of the community. It is beyond the reach of a sin-
○○ finding common and trusted people to talk gle health worker, or any one person, to make a
to, such as another family member or friend change in these ‘big’ issues which are influenced
by policies and ideologies of the government and
○○ setting aside time to enjoy activities, such
of the global community. However, it is important
as going to see a movie, which the partners
for the health worker to support actions which
shared during happier times
address these social problems. Here, we will con-
○○ exploring, when you have built trust, wheth- sider examples of such actions at the local level in
er there are any sexual problems 8.5. response to poverty and gender inequality.

13.10.3 Knowing when to separate 13.11.1 Poverty and mental health

Sometimes, a relationship is so unhappy that Let us consider some of the factors which may
separating may be the best solution. An unhappy increase the risk of mental health problems in a
relationship can be much worse for the entire person living in poverty.
family than a separated one. The kinds of situa-
●● Urban migration and disintegration of rural
tions where separating is probably best include:
communities. People who have migrated to
●● when violence in the relationship is not reduc- urban areas often live in slums, in squalid liv-
ing or is getting worse ing conditions, with few social networks and
●● when one partner is having another relation- exposure to crime and violence. For those
ship or affair and has no intention of changing left behind, usually women, children and the
this behaviour elderly, the loss of a productive member of the
●● when both partners want to separate household may lead to loneliness and fear due
to vulnerability.
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●● Material stressors. Poor people have fewer ●● Family members may need to take time off
material resources and are more likely to suf- work in order to care for the person or take
fer the physical hardships associated with them to the clinic, thus losing earnings.
poverty. Thus, access to basic utilities, food ●● Increased expenditure on sustaining a habit
and banking credit are more restricted. such as alcohol or drug dependence can
●● Crowded and unhygienic living conditions. impoverish the addicted person and their
Living in such environments leads to stress family.
and unhappiness, which predisposes the indi- ●● The stigma associated with mental disorder
vidual to experience mental disorder. limits opportunities for employment.
●● Lack of education/employment opportuni ●● Some mental disorders, such as substance
ties. Poor people have less access to afford- abuse, developmental disabilities and psy-
able quality education and, subsequently, to chosis, affect the ability of the person to com-
employment. The lack of education limits the plete their education, and therefore limit the
ability of the person to find ways out of pov- economic opportunities available to them in
erty, leading to a loss of hope and despair for the future.
the future.
Thus, people living in poverty are more likely
●● Higher burden of physical ill health. Poor
to suffer from mental health problems, and men-
people experience a greater burden of physi-
tal health problems worsen poverty. Across the
cal disease and disability. Mental health prob-
world, especially in poor countries, globalisation
lems occur more often in those who have a
and economic developments are leading to enor-
physical disease or disability.
mous changes in day-to-day life. These policies
●● Inadequate access to good health care. Poor are influencing the health prospects of every citi-
people have less access to appropriate health zen in a number of different ways. In some coun-
care. Thus, people with mental or physical tries, the cost of health care is getting higher, as
health problems are less likely to receive the government subsidies are withdrawn. User fees
right treatment. mean that public health care is no longer free
Mental health problems, in turn, can worsen and private health care is getting more expensive
economic circumstances in a number of ways. all the time. Medications can be very expensive.
But perhaps the greatest risk to health posed by
●● Mental disorders may be associated with
current economic policies is that it is worsening
severe disability. This affects the ability of the
inequalities in most countries. The richest few in
person to function at work and at home, and
every society are getting much richer, while the
leads to a greater number of sick days.
poor majority get poorer. This inequality poses
●● Owing to the inappropriate treatment of men- a grave challenge for the future harmony of our
tal disorders, many patients seek multiple societies and the health of entire populations.
sources of health care and, consequently,
spend more money on their health.
13.11.2 Promoting mental health in
poor communities
When faced with the problems of poverty, we
think of mental health problems as being irrel-
evant. Sometimes, we assume that depression
and other mental health problems are the result
of ‘materialism’ and ‘excess’ and that mental ill
health is a ‘luxury’ for poor individuals. On the
other hand, some people think that mental health
problems are the natural consequence of pov-
erty. Both these kinds of beliefs are wrong. Mental

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health problems are not only more common in to cope with work and caring for the children.
poor people, but they also have a greater impact The health worker could suggest to these dif-
on their health and ability to work. ferent people the possibility of supporting
In much the same way as health workers would each other. For example, the elderly person
give antibiotics for the treatment of tuberculosis, may mind the children in the day, and the sin-
a disease associated with poverty, we should be gle mother may provide friendship and shared
able to provide treatment for depression and meals.
other mental disorders associated with poverty. ●● Reducing levels of violence. Crime and vio-
Promoting mental health in poor people can lence are more common when there is greater
focus on the following actions, many of which can inequality or when a community is divided
also address the factors which contribute to envi- along religious or ethnic lines. The health
ronmental degradation and hatred against sec- worker must collaborate closely with other
tions of the community. community leaders and opinion-makers on
●● The provision of basic services in the com the need to build social cohesion. This may
munity. Individuals who live in a community involve:
which is clean and has safe drinking water are ○○ boycotting all forms of political action
more likely to be in better health. If, for exam- which seek to divide people into groups;
ple, a health worker is playing an active part in
○○ advocating for equal treatment of all mem-
improving sanitation in the community to
bers of the community to the police, health
reduce diarrhoeal diseases, this action will
and legal systems;
also help promote mental health.
○○ identifying those politicians who are com-
mitted to reduction in violence as the fa-
voured candidates in local elections;
○○ sensitising police on dealing with com-
plaints of violence in the community or in
specific families.
●● Improving economic opportunities in the
community. A health worker may not have
much scope to directly influence the provi-
sion of new jobs or economic opportunities.
●● Promoting community networks and har However, keeping yourself well informed on
mony. Health workers may be especially well employment or livelihood schemes or oppor-
placed to support social networks at an indi- tunities is one way of providing information
vidual level. For example, you may know of an to those who might need it. For example, debt
elderly person who is living alone and is very may be tackled by providing greater access
unhappy. Nearby is a family of a single mother to small loans through micro-credit schemes.
and two young children; she is finding it hard You could encourage local councillors or wom-
en’s groups to set up similar schemes.
●● Providing effective care in the health cen
tre. Be competent in detecting and treating
common mental health problems. Never dis-
miss these as inevitable consequence of pov-
erty. Instead, treating mental health problems
will not only make the person feel better, but
will also provide them with the necessary
strengths in thinking and feeling to come up
with solutions for their problems.

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●● If you have obtained the woman’s permission, as an area of concern for women. Facilitate the
speak to the husband or other family mem- formation of self-help or support groups for
bers about the difficulties the woman is facing women with mental health problems.
and how they are affecting her health. You can
provide specific suggestions to improve rela- 13.12.3 Gender and men’s mental
tionships (13.10).
●● Sensitise your colleagues in the clinic about
health
gender inequality in the way health care is pro- Although most discussions about gender and
vided. Be sure that you, and your colleagues, health focus on women because women are dis-
treat health complaints in men and women advantaged in so many ways, it is also true that
with equal concern. gendered attitudes can affect men in ways which
●● When you know that a particular woman has a are relevant to mental health. Three important
severe mental disorder, pay special attention examples are:
to her personal needs by ensuring she sees ●● because people associate masculinity with
you regularly and is able to access all health getting intoxicated, this increases the risk of
services, including cervical cancer screening young men drinking and taking drugs;
and family planning. If she is not brought to ●● because men are supposed to take care of their
the health centre, arrange to see her at her family’s needs, unemployment and financial
home. Counsel her family members to remove difficulties can greatly damage a man’s self-
doubts they might have about the illness, for esteem. In extreme cases, this can lead to sui-
example, that the illness is a sign of bad luck cide (indeed, men are much more likely to die
for the family. by suicide than women);
●● When you know that a woman is living in a ●● because men are supposed to be ‘strong’, they
home where she is suffering a great deal of are less likely to consult health workers for
stress or being exposed to violence, make mental disorder, in particular, common men-
an effort to ask her how this is affecting her tal disorders in response to life stressors such
health. If you find she is suffering from a men- as marital conflict or problems at work.
tal health problem, counsel her appropriately
to help her address her problems. Many of the actions described above on how
to address gendered attitudes in promoting the
●● If women’s groups are active in your commu-
mental health of women would apply equally to
nity, take the initiative to participate in their
men.
meetings and discuss mental health problems

notes

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Part 5
Localising this manual for your area

The earlier sections of the manual have described the clinical approach to mental health problems
from a general health worker’s perspective. Part 5 allows readers to record information that is specific
to their area of work. Four chapters are included.
Chapter 14 provides a quick reference guide to different medications for mental health problems
and space for you to write the local brand names and costs of these medications.
Chapter 15 suggests how you might record information on resources in your local area that may be
useful in helping people with mental health problems.
A glossary of technical terms is provided in Chapter 16, and Chapter 17 has space in which you can
note the word for particular items in the local language.

medication, and there are no differences in

side-effects. Recommend the older, cheaper
medication. A good example from medica-
Throughout the world, the cost of health care is tions for mental health problems is the choice
rising. Particularly in low- and middle-income between amitriptyline and nortriptyline,
countries, this means making hard choices about two tricyclic antidepressants. Whereas the
which medications to prescribe. Many newer former is cheaper than the latter, both are
medications are protected by international pat- equally effective and have similar side-effects.
ent laws. This means that only one company is Therefore, you should choose amitriptyline.
allowed to produce that medication for a certain Many of the newest psychiatric medications
period of time. These medications are almost are no different from the ones produced a few
always much more expensive than older medica- years earlier in terms of both side-effects and
tions. When making a decision on whether to use efficacy. Do not recommend them.
an older, cheaper medication or a newer, more ●● The older, cheaper medication is more effec-
expensive medication, you must consider these tive or just as good as the newer, expensive
issues: medication, but there is a greater risk of side-
●● the cost of the medication effects with the older medication. A good
example of such a choice is that between older
●● the efficacy of the medication (how good it is)
antidepressants, such as amitriptyline, and
●● the side-effects newer antidepressants, such as fluoxetine.
●● the income bracket of the family. The former is just as good as the latter but has
more side-effects. More people using amitrip-
Thus, a newer medication, which may be no
tyline will drop out of treatment because of the
better than an older medication in reducing the
side-effects. Another example of such a choice
symptoms of mental health problems, may have
is that between older antipsychotic medica-
lesser side-effects. This could be very important
tions, such as haloperidol, and newer antipsy-
for some people. For example, older antipsychotic
chotic medications, such as risperidone. Two
medications produce more stiffness and restless-
options are available to you. For those people
ness than newer ones. A person taking an older
who can afford the newer medication, you can
medication many feel so restless that they cannot
offer both options and explain the pros and
work and, therefore, cannot earn any money. On
cons of each. Let the person make the choice.
the other hand, a person taking a newer antip-
If, on the other hand, the person cannot afford
sychotic medication may spend more money on
the more expensive medication, recommend
the medications, but because they can work, they
the older medication. Monitor the person’s
can more readily afford the treatment than would
progress; if severe side-effects appear, switch
have been the case with the older medication.
to the newer medication.
In choosing medications, the following situa-
tions may arise. ●● The newer, more expensive medication is
more effective than the older medication. In
●● The older, cheaper medication is more effec-
this situation, you should ideally recommend
tive or just as good as the newer, expensive
the newer medication. However, if the person
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cannot afford the new medication, the older BOX 14.1. THE ESSENTIAL MEDICATION LIST
medication may be given a trial. If it works FOR MENTAL HEALTH PROBLEMS
well, there is no need for a change. If it does
not work well, then the newer medication may ○○ Fluoxetine* or sertraline (if neither is
be the only choice left. An example of such a available, amitriptyline* or imipramine)
choice is between using carbamazepine to ○○ Chlorpromazine* or haloperidol* (in tablet
prevent relapse in bipolar disorder compared form or short-acting injection)
with using valproate. Thus, lithium or val- ○○ Biperiden* or procyclidine or benzhexol or
proate may produce better results in people benztropine
with bipolar disorder than carbamazepine. ○○ Risperidone* or olanzapine
○○ A long-acting antipsychotic (depot), for
example, fluphenazine decanoate*
14.2 A quick reference guide to ○○ Sodium valproate* or lithium*
medications for mental health ○○ Phenobarbitone* or phenytoin* or
carbamazepine*
problems ○○ Diazepam*
Tables 14.1 to 14.6 contain summaries of medi- ○○ Thiamine*
cations in common use for treatment of mental
health problems. You should enter the local trade
*Listed in WHO (2015)
names and costs of the medications where there
(Chapter 18).
is space under the generic names in the tables.
The list of medications is not exhaustive – only the
most commonly used or well-recognised medica-
control weight gain. Drowsiness is often tem-
tions are included. However, space is provided at
porary and goes away as the person continues
the end of each table for you to enter any other
taking the medication, but warn people to
medications available in your region. Box 14.1 lists
take care when driving or operating machin-
the medications that are essential to have avail-
ery until they get used to the medication.
able for the treatment of mental health problems.
Sexual problems may be tackled as described
in Chapter 8 (8.5).
14.3 Cautions when using ●● Avoid the following medications during preg-
nancy: lithium, carbamazepine, valproate,
medications for mental health benzodiazepines, and medications for side-
problems effects of antipsychotics (e.g. benzhexol).
●● Medications recommended in the World
●● Many medications interact with alcohol. In Health Organization’s Mental Health Gap
particular, medications that cause sedation Action Programme (mhGAP) Intervention Guide
will worsen the drowsiness felt after drinking are presented in shaded boxes with bold font.
alcohol. ●● Medications recommended in mhGAP and
●● The doses given in the tables are for healthy requiring specialist oversight are in bold
adults unless specific child doses are given italics.
(e.g. for epilepsy). Where only adult doses are ●● There are some medications (or doses of med-
given, use a third to a half for people over the ications) for mental health problems included
age of 60, for children aged under 16 years and in the tables that should not be initiated by a
for people with chronic medical illness. general health worker. These medications are
●● Many medications for mental health problems in italic font. They are included here so that
produce drowsiness, weight gain and sexual you are aware of the monitoring requirements
side-effects. Be aware of that. Advise people and side-effects if the person comes to see you
taking them to diet and exercise regularly to while they are being treated by a specialist.
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Table 14.1 Antidepressant medications

Tricyclic antidepressants (TCAs)
General cautions
○○ Can easily be fatal in overdose, so take care if person is suicidal
○○ Do not use to treat depression in children under 18 years of age
○○ In elderly people and people with other medical conditions, side-effects may not be tolerated
○○ Try to avoid in ischaemic heart disease, prostate enlargement, seizure disorder, hyperthyroidism, glaucoma or bipolar disorder
○○ Advise the person to avoid alcohol, take care when driving or operating machinery owing to sedative effects, not to take more than the prescribed dose,
and to keep the medication stored safely so that children cannot access it

Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Amitriptyline Common mental Starting dose: 25 mg at night Common: dry mouth, sedation, postural hypotension (blood
disorders time pressure falls when standing up suddenly), constipation,
................................................................. difficulty passing urine, dizziness, blurred vision, nausea,
Minimum dose: 75 mg
weight gain
Increase by 25–50 mg/week to
usual dose of 75–150 mg Rare: cardiac arrhythmia, increased risk of seizure
Maximum dose (only with In overdose can lead to seizures, cardiac arrhythmias, low
specialist support): 300 mg blood pressure, coma or death
Night-time bed-
wetting in children Dose for bed-wetting 25 mg Drug–drug interactions: levels can be increased by
antimalarials (e.g. quinine)
Dosulepin (or dothiepin) Common mental As for amitriptyline As for amitriptyline
disorders
................................................................
Doxepin Common mental As for amitriptyline but As for amitriptyline
disorders maximum 100 mg in one dose
................................................................
Clomipramine Common mental As for amitriptyline As for amitriptyline
disorders, but also
................................................................ useful for obsessive–
compulsive disorder
Cont.

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Imipramine Common mental As for amitriptyline, but As for amitriptyline but less sedating
disorders maximum 100 mg in one dose
................................................................
Bed-wetting in
children
Lofepramine Common mental Starting dose: 70 mg/day As for amitriptyline but less sedating, fewer cardiac effects,
disorders Minimum dose: 140 mg/day less dry mouth, blurred vision or problems passing urine,
................................................................ more problems with constipation
Relatively safer in Maximum dose: 210 mg/day
overdose so useful
for people who are
suicidal
Nortriptyline Common mental As for amitriptyline, but As for amitriptyline, but less sedating, less dizziness, less dry
disorders maximum 100 mg in one dose mouth, blurred vision or passing urine, more problems with
................................................................ constipation and postural hypotension when starting
Trimipramine Common mental As for amitriptyline As for amitriptyline, but more sedating
disorders
................................................................
SSRI antidepressants
General cautions
○○ Do not use in children under 12 years of age
○○ Start with low dose in adolescents, elderly people and people with medical conditions
○○ If the person is agitated or has high levels of anxiety, also prescribe a benzodiazepine (e.g. diazepam) for the first 5 days
○○ Advise the person to take in the morning and after food

Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Fluoxetine Common mental Starting dose: 10 mg in the Common: restlessness, nervousness, sleep problems, nausea,
disorders morning, with or after food (if headache, sexual dysfunction, rash
................................................................ only 20 mg capsule available Rare: bleeding abnormalities in people taking long-term
then can be taken every other aspirin or non-steroidal anti-inflammatory medications (e.g.
day) ibuprofen) and restlessness (akathisia)
Minimum dose: 20 mg Drug–drug interactions: avoid combination with warfarin
Maximum dose: 60 mg
Cont.
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Citalopram As for fluoxetine Starting dose and minimum As for fluoxetine, but less insomnia and agitation
dose: 20 mg/day
................................................................
Maximum dose: 40 mg/day
Escitalopram As for fluoxetine Starting dose and minimum As for fluoxetine, but less insomnia and agitation
dose 10 mg/day
................................................................
Maximum dose: 20 mg/day
Fluvoxamine As for fluoxetine Starting dose: 100 mg/day As for fluoxetine, but increased risk of nausea and many
Up to 300 mg/day (divided interactions with other medications
................................................................
doses)
Paroxetine As for fluoxetine Starting dose: 20 mg/day As for fluoxetine, but more sedating, more weight gain and
Up to 50 mg/day for depression sexual problems, can cause movement side-effects
................................................................
and 60 mg/day for panic or Discontinuation symptoms common
obsessive–compulsive disorder
Sertraline As for fluoxetine, Starting dose and minimum As for fluoxetine
but short half-life dose: 50 mg
................................................................ means useful in Maximum dose: 200 mg
breastfeeding
women and people
with medical illness
Monoamine oxidase inhibitors (MAOIs)
MAOIs can only be prescribed by mental health specialists
The MAOIs are: phenelzine, moclobemide, isocarboxazid and tranylcypromine
If a person being prescribed these medications is under your care, be aware of the following.
○○ You should avoid prescribing opioids, other antidepressants, levodopa or adrenaline-like medications
○○ The dietary advice for people prescribed MAOIs is to avoid foods containing tyramine (e.g. cheese, fermented, smoked or pickled foods, aged meats,
meat extracts, alcohol, ripe avocados and fava beans)
○○ Common side-effects are: high blood pressure, low blood pressure on standing, dizziness, sleep problems, headache, nervousness
○○ MAOIs can affect the liver and white cells
Cont.

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Other antidepressants
These newer antidepressants have no increased benefit in terms of effectiveness but may have more tolerable side-effects than TCAs and SSRI
antidepressants. However, availability and affordability may limit use. Specialist oversight is preferred.

Medication, trade name and cost Special note Dosage Side-effects, interactions and monitoring
Duloxetine Take care with 60–120 mg/day Common: nausea, sleeping problems, headache, dizziness,
alcohol Minimum dose: 60 mg/day dry mouth, sleepiness, constipation, reduced appetite, small
................................................................ increase in pulse rate and blood pressure
Rare: hypertensive crisis (very high blood pressure)
Mirtazapine Uncommon to get 15–45 mg/day Common: increased appetite, weight gain, sleepiness,
nausea or problems Minimum dose: 30 mg/day swelling, dizziness, headache
................................................................ with sexual Rare: blood cell abnormalities
dysfunction
Reboxetine Uncommon to get 8–12 mg/day (split doses) Common: sleeping problems, sweating, dizziness, dry mouth,
sexual dysfunction Minimum dose: 8 mg/day constipation, nausea, fast heart rate, difficulty passing urine,
................................................................ headache
Do not prescribe
with erythromycin or Rare: problems with erections
ketoconazole
Trazodone Not anticholinergic 150–300 mg/day Common: sedation, dizziness, headache, nausea, vomiting,
Not as much cardiac Minimum dose: 150 mg/day postural hypotension, fast heart rate
................................................................
toxicity as for TCAs Rare: erection that won’t stop
Take care when
prescribing with
sedative medications
Take care when
prescribing with
digoxin or phenytoin
Cont.

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Venlafaxine Avoid in people at 75–225 mg/day Common: nausea, sleep problems, dry mouth, sleepiness,
risk of a cardiac Minimum therapeutic dose: dizziness, sweating, nervousness, headache, sexual problems,
................................................................ arrhythmia constipation
75 mg/day
Stop gradually to Increased blood pressure at higher doses
avoid symptoms
Take care when
prescribing
with cimetidine,
clozapine or warfarin
Other locally available antidepressants:

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Table 14.2 Antipsychotic medications

First-generation (‘typical’) oral antipsychotics
General cautions
○○ Ideally prescribe in consultation with a mental health specialist, or arrange review at the earliest opportunity
○○ Take care when prescribing to people with cardiac disease, kidney disease or liver disease

* indicates the maximum allowable dose.

Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Haloperidol Psychosis Starting dose: 1.5–3 mg Common: stiffness, tremor, restlessness (akathisia), problems
Mania Minimum dose: 2 mg passing urine, ECG changes, long-term involuntary muscle
................................................................ movements (dyskinesia)
Second-line Maximum dose: 20 mg oral
prevention of (12 mg i.m.) Rare: sudden contraction of muscles (dystonia), rare
relapse in bipolar complication of fever, muscle rigidity and high blood pressure
disorder (neuroleptic malignant syndrome)
Drug–drug interactions: levels may be increased by
antimalarials including quinine
Chlorpromazine As for haloperidol Starting dose: 25–50 mg Common: sedation, weight gain, light-headed on standing,
Minimum dose: 75 mg increased risk of sunburn (advise wearing a hat), blurred
................................................................ vision, dry mouth, constipation, difficulty passing urine, fast
Maximum dose: 1000 mg/day*
pulse rate, sexual dysfunction, effects of raised prolactin
but 300 mg maximum without
(breast enlargement in men, milk production and reduced
specialist support
menstruation in women)
Rare: as for haloperidol, and jaundice
Flupentixol As for haloperidol Minimum dose: 3 mg twice daily As for haloperidol
Maximum dose: 18 mg/day*
................................................................
Perphenazine As for haloperidol Minimum dose: 12 mg/day As for haloperidol
(in three divided doses)
................................................................
Maximum dose: 24 mg/day*
Sulpiride As for haloperidol Minimum dose: 200–400 mg As for haloperidol
twice daily
................................................................
Maximum dose: 2400 mg/day
Cont.
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Trifluoperazine As for haloperidol Starting dose 5 mg As for haloperidol

Minimum dose: 10 mg
................................................................
Maximum dose: 20 mg*
Zuclopenthixol As for haloperidol Minimum dose: 20–30 mg in As for haloperidol
divided doses
................................................................
Maximum dose: 150 mg/day*
Second-generation (‘atypical’) oral antipsychotics
General cautions
○○ Ideally prescribe in consultation with a mental health specialist, or arrange review at the earliest opportunity
○○ If risk of weight gain, monitor weight. If possible, also monitor blood levels of cholesterol and lipids, as well as fasting blood glucose
○○ Caution in people with cardiac disease

Medication trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Risperidone Psychosis Starting and minimum dose: Common: headache, lightheaded on standing, restlessness,
Bipolar disorder 2 mg/day drowsiness, effects of raised prolactin (breast enlargement in
................................................................ men, milk production and reduced menstruation in women)
(manic phase and to Maximum dose: 6 mg/day
prevent relapse)
Olanzapine As for risperidone Starting and minimum dose: Common: weight gain, raised cholesterol and lipids, increased
5 mg/day (average dose: 10 mg) fasting blood glucose, sedation
................................................................
Maximum dose: 20 mg/day
Amisulpride Psychosis Minimum dose: 400 mg/day Common: effects of raised prolactin (see risperidone)
(estimate) Rare: weight gain, restlessness (akathisia) and movement
................................................................
Maximum dose: 1200 mg/day* side-effects
Aripiprazole Psychosis Minimum dose: 10 mg/day Rare: restlessness (akathisia)
Maximum dose: 30 mg/day*
................................................................
Paliperidone Psychosis Minimum dose: 3 mg/day Common: effects of raised prolactin (see risperidone), low
Maximum dose: 12 mg/day blood pressure and weight gain
................................................................
Rare: sedation, restlessness, movement side-effects and
anticholinergic side-effects (dry mouth, blurred vision,
constipation, difficulty passing urine)
Cont.
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Quetiapine As for risperidone. Minimum dose: 150 mg/day Common: weight gain, sedation and low blood pressure
Can be used as Maximum dose: 750 mg/day Rare: anticholinergic side-effects (see paliperidone)
................................................................ monotherapy for (schizophrenia), 800 mg/day
bipolar depression (bipolar disorder)

Clozapine Potent medication Start with 12.5 mg at night, Common: drowsiness, weight gain, drooling saliva,
useful for people increase by 25 mg every 2 to 3 constipation (can be severe)
................................................................ who do not days up to 250 mg for women Rare: drop in white blood cell count can cause fatal infections,
respond to other or 350 mg for men (higher in myocarditis (fever, palpitations, chest pain), blood clots
antipsychotics tobacco smokers)
Monitor blood count weekly
Use only in consultation with a specialist
Long-acting injectable antipsychotic medications
General cautions
○○ Always give a test dose (the lowest dose of the range) and wait 5 to 7 days before starting regular treatment
○○ Administer by deep intramuscular (i.m.) injection in the gluteal (buttock) region ( Box 5.9, p. 61)
○○ Avoid in people with cardiac disease, kidney disease or liver disease
○○ Avoid in women who are pregnant or breastfeeding
○○ Do not use in children or adolescents

Medication trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Fluphenazine depot Long-term treatment Test dose 12.5 mg i.m. As for haloperidol
of psychosis or Therapeutic dose: 12.5–75 mg
................................................................ bipolar disorder in i.m. every 4 weeks
people with non-
adherence to oral
medication
Flupentixol depot As for fluphenazine 12.5 to 200 mg i.m. every As for haloperidol
decanoate 4 weeks
................................................................
Cont.

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Haloperidol depot As for fluphenazine 12.5 to 100 mg i.m. every 4 As for haloperidol
decanoate weeks
................................................................
Zuclopenthixol depot As for fluphenazine Test dose 100 mg i.m. As for haloperidol
decanoate 200–500 mg every 1 to 4 weeks
................................................................
Pipotiazine depot As for fluphenazine 50–200 mg i.m. every 4 weeks As for haloperidol, although may have lower chance of
decanoate movement side-effects
................................................................
Aripiprazole depot As for fluphenazine 300–400 mg i.m. monthly As for oral preparation
decanoate
................................................................
Olanzapine pamoate As for fluphenazine 150 mg i.m. every 4 weeks to As for oral preparation
decanoate 300 mg every 2 weeks Rarely associated with post-injection syndrome: delirium or
................................................................
sedation
Paliperidone depot As for fluphenazine 50–150 mg i.m. monthly As for oral preparation
decanoate
................................................................
Risperidone long-acting injection As for fluphenazine 25–50 mg i.m. every 2 weeks As for oral preparation
decanoate Medication release is delayed for 2 to 3 weeks, so oral
................................................................
medication needs to be continued
Other locally available antipsychotics:

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Table 14.3 Mood stabiliser medications

General cautions
○○ Caution is required in pregnant women (and all women of reproductive potential); avoid valproate
○○ Mood stabiliser medications have many interactions with other medications (and also with one another)

Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring and cautions
Lithium Bipolar disorder Starting dose: 300 mg Common: sedation, tremor, weight gain, coordination
(treatment of mania Typical effective dose: 600– problems, passing lots of urine, drinking more liquids, heart
................................................................ and prevention of rhythm abnormality and ECG changes, thyroid problems, hair
1200 mg
relapse) loss, nausea, diarrhoea, rash
Target blood level: 0.6–
As an add-on 1.0 mEq/l (0.8–1.0 mEq/l in Rare: lithium toxicity can cause seizures, delirium, coma and
treatment for mania; 0.6–0.8 mEq/l for death
depression that does maintenance) Contraindicated in people with severe cardiac or kidney
not improve with disease. Can only be prescribed when laboratory monitoring
antidepressants is available
alone
Advice for people taking lithium:
○○ avoid getting dehydrated
○○ seek medical advice if you get diarrhoea and vomiting
○○ watch out for signs of toxicity: bad tremor, nausea/
vomiting, unsteady, confused or sedated – get urgent
medical advice
○○ be careful with over-the-counter medications, especially
painkillers, and other prescribed medications
○○ take special care to keep lithium away from children
Drug–drug interactions: NSAIDs, ACE inhibitors, thiazide
diuretics, metronidazole and tetracycline can increase lithium
levels
Check blood level after 1 week, increase the dose and re-
check the blood level after another week. Continue until the
level is therapeutic, and then every 3 months
At baseline, measure thyroid function, renal function and full
blood count; repeat once per year as routine
Do an ECG if possible
Cont.

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Valproate Bipolar disorder Usually split the dose to give Common: nausea, drowsiness, diarrhoea, tremor, temporary
(treatment of mania 2 or 3 times/day hair loss (can last 6 months), weight gain, headache,
................................................................ and prevention of coordination problems
Starting dose 500 mg (total)/
relapse) day in divided doses Rare: liver problems, low platelets, low white cell count
Preferred choice Typical effective dose: 1000– Caution in people with liver disease
in people living 2000 mg Monitor liver function tests and platelets if possible
with HIV/AIDS
owing to drug–drug
interactions
Carbamazepine Bipolar disorder Starting dose: 200 mg (at Common: skin rash (can be severe), blurred vision, double
(treatment of mania bedtime), increase by 100– vision, difficulty walking, nausea, sedation, tremor, weight
................................................................ and prevention of 200 mg every 2 weeks gain, liver problems
relapse) Typical effective dose: 400– Rare: bone marrow suppression (low platelets, low white cell
600 mg count)
After 2 weeks, a further dose
increase may be needed
because carbamazepine
induces enzymes which make
the plasma level drop
Risperidone As for lithium Table 14.2 Table 14.2
Preferred for
................................................................
pregnant women
Olanzapine As for lithium Table 14.2 Table 14.2
Preferred for
................................................................
pregnant women
Cont.

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Quetiapine As for lithium Table 14.2 Table 14.2

Preferred for
................................................................
pregnant women
Lamotrigine Depression in Starting dose: 25 mg/day for 14 Common: blurred vision, double vision, joint and back pain,
bipolar disorder days. Then increase to 50 mg/ nausea, diarrhoea, sleep problems, headache, rash, tremor,
................................................................ day for another 14 days. After difficulty walking, drowsiness, aggression or restlessness
that, increase in steps of up to Rare: severe rash, blood disorders, confusion, liver failure,
100 mg every 7–14 days hallucinations
Usual maintenance dose 100–
200 mg/day (can split the dose)
Other locally available mood stabilisers:

ACE, angiotensin-converting enzyme; ECG, electrocardiogram; NSAIDs, nonsteroidal anti-inflammatory drugs.

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Table 14.4 Antiepileptic medications

General cautions
○○ Caution is required in pregnant women (and all women of reproductive potential); avoid valproate
○○ Caution in people with liver or kidney disease: lower doses required
○○ Antiepileptic medications have many interactions with other medications (and also with one another), for instance, reducing the effect of the oral
contraceptive pill and some forms of antiretroviral treatments

Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Phenobarbitone All types of epilepsy Starting dose 60 mg/day in one Common: drowsiness, restlessness, confusion, problems with
in adults and or two divided doses coordination, depression, sexual problems
................................................................ children If poor response after 2 weeks, Rare: skin rash, bone marrow depression, liver failure
increase to 120 mg/day
If poor response after 2 months,
increase to 180 mg/day
In children: start 2–3 mg/kg
daily in two divided doses,
increase weekly by 1–2 mg/kg
daily depending on tolerance
(maximum 6 mg/kg daily)
Carbamazepine All types of epilepsy Split the dose to twice per day Table 14.3
in adults and Starting dose: 100–200 mg
................................................................ children (total)/day, increase by
maximum 200 mg/week
Maintenance dose: 400–
1400 mg (total)/day
In children: start 5 mg/kg daily
in two–three divided doses,
increase by 5 mg/kg daily each
week (maximum 40 mg/kg daily
or 1400 mg daily
Cont.

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Phenytoin All types of epilepsy Starting dose: 150–200 mg/day Common: drowsiness, difficulty walking, confusion, twitching
in adults and in two divided doses muscles, tremor, headache, nausea or loss of appetite,
................................................................ children features of face become coarser, gums increase in size
If poor response, increase with
small doses (25–30 mg) – can Rare: anaemia or other blood abnormalities, rash, liver
lead to big changes in blood abnormalities, hair growing on face and body, increase in
concentration suicidal ideation
Maintenance dose: 200–
400 mg/day
In children: start 3–4 mg/kg
daily in two divided doses,
increase by 5 mg/kg daily every
3–4 weeks (maximum 300 mg
per day)
Sodium valproate All types of epilepsy Starting dose: 400 mg (total)/ Table 14.3
in adults and day in divided doses (usually
................................................................ children 2 or 3 times/day), increase by
Preferred for people 500 mg/day each week
living with HIV/AIDS Maintenance dose: 600–
2000 mg (total)/day
In children: start 15–20 mg/kg
daily in 2–3 divided doses,
increase each week by
15 mg/kg daily (maximum
15–40 mg/kg daily)
Primidone All types of epilepsy Starting dose: 125 mg at night Common: drowsiness, restlessness, confusion
in adults Increase in steps up to 500 mg
................................................................
twice daily
Cont.

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Lamotrigine All types of epilepsy Table 14.3 Table 14.3

in adults
................................................................
Can be used as
add-on treatment
for epilepsy that
is resistant to one
medication alone
Antiepileptic medications for people with HIV on protease inhibitors or non-nucleoside reverse transcriptase inhibitors
Levetiracetam Can be used as Starting dose: 250 mg/day. After Common: abdominal pain, aggression, reduced appetite,
add-on treatment 1–2 weeks increase to 250 mg anxiety or depression, unsteady walking, cough, diarrhoea,
................................................................ for epilepsy that twice daily, then increase in dizziness, headache, sleep problems, irritability, nausea, rash,
is resistant to one steps of 250 mg twice daily tremor
medication alone (maximum dose: 1.5 g twice Rare: suicidal ideation, psychosis, rash, low blood count, liver
daily) every 2 weeks as needed failure
Lacosamide Add-on treatment of Starting dose: 50 mg twice daily Common: difficulty walking, blurred vision, difficulty thinking
focal seizures by infusion administered over clearly, constipation, depression, dizziness, drowsiness,
................................................................ 15–60 min for up to 5 days. fatigue, headache, nausea, itching and tremor
After that, increase every week Rare: allergic reactions, suicidal ideation, psychosis, cardiac
in steps of 50 mg twice daily, problems, low blood count
adjusted according to response
Maintenance dose: 100 mg
twice daily
Topiramate Second-line Starting dose: 25 mg/day (at Common: gastrointestinal disturbance, weight loss, mental
treatment for tonic– night) for 1 week, increase in health problems (irritability, anxiety, depression), confusion,
................................................................ clonic seizures steps of 25–50 mg every 1– 2 hair loss, low blood count, drowsiness, dizziness, renal stones,
weeks (split into two doses) tremor
Usual maintenance dose: Rare: rash (severe), liver failure, acute angle closure glaucoma
100–200 mg daily (split into two
doses)
Cont.

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Gabapentin Starting dose: 300 mg/day (day Common: gastrointestinal disturbance, mental health
1), then 300 mg twice daily for symptoms (anxiety, abnormal thoughts, depression, hostility),
................................................................ day 2, then 300 mg 3 times a forgetfulness, confusion, headache, difficulty walking,
day for day 3 drowsiness, dizziness, joint pains, acne, fever, sleep problems,
Usual maintenance dose: low blood count, rash, tremor, visual problems, weight gain
900–3600 mg daily in 3 divided Rare: severe rash, liver failure, change in blood glucose,
doses hallucinations
Pregabalin Initially 25 mg twice daily, Common: gastrointestinal disturbance, visual problems,
increased in steps of 50 mg confusion, memory problems, sleep problems, sexual
................................................................ daily at 7-day intervals, to problems, drowsiness, weight gain, irritability
300 mg daily in 2–3 divided Rare: cardiac problems, blood pressure changes, renal failure,
doses for 7 days and, if low blood count
necessary, up to 600 mg daily in
2–3 divided doses
Other locally available antiepileptic medications:

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Table 14.5 Benzodiazepines

General cautions
○○ Advise to avoid use of heavy machinery and to take care driving until the person is used to the medication
○○ Advise the person not to drink alcohol while taking benzodiazepines

Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Diazepam For severe distress Start with 5mg at night; Drowsiness, dizziness, dependence (if used longer than 3 to 4
states and acute increase up to 10mg twice daily weeks), suppresses breathing
................................................................ sleep problems
Alcohol withdrawal Chapter 9 for regimen
Acute seizures 10 mg i.v. (preferred) or p.r.
Lorazepam For severe distress Start with 1 mg at night, Same as diazepam
states and acute increase up to 4 mg (split in two
................................................................ sleep problems doses)
Acute seizures 4 mg i.v. or i.m. can be used
Midazolam Acute seizures Buccal, intranasal or p.r. Same as diazepam
preparations can be used
................................................................
Chlordiazepoxide Same as diazepam, Chapter 9 for regimen Same as diazepam
but preferred for
................................................................ alcohol withdrawal
Clonazepam Same as diazepam, Start with 0.5 mg at night; Same as diazepam
but also useful in increase up to 2 mg twice daily
................................................................ epilepsy
Alprazolam Same as diazepam Start with 0.25 mg; increase Same as diazepam
up to 1 mg twice a day
................................................................
Oxazepam Same as diazepam, Start with 7.5 mg at night; Same as diazepam
but preferred for increase up to 40 mg twice
................................................................ alcohol withdrawal a day
when liver problems
Cont.

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Triazolam Same as diazepam Start with 0.125 mg at night; Same as diazepam

increase up to 0.25 mg at night
................................................................
Other locally available benzodiazepines:

i.v., intravenous; p.r., per rectum (in an emergency when i.v. access not possible).

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Table 14.6 Other medications for mental health problems

Medications for alcohol and drug problems
Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring and cautions
Thiamine For drinking 100 mg/day Rarely reported
problems and In delirium in context of
................................................................ alcohol withdrawal withdrawal, give 100–500 mg
i.v. or i.m. 3 times daily for 5
days
Naloxone To treat opioid 0.4-2 mg i.v., i.m., intranasal Side effects: can cause opioid withdrawal symptoms
overdose or subcutaneous. Repeat as
................................................................ needed
Acamprosate To maintain 2 tablets of 333 mg three times/ Common: diarrhoea, flatulence, nausea, vomiting, abdominal
abstinence from day (if weight <60 kg should be pain, itching, depression, anxiety
................................................................ alcohol by reducing 666 mg twice/day) Rare: serious skin rash, suicidality
the urge to drink Continue for 12 months
Commence
immediately after
detoxification
Naltrexone As for acamprosate Starting dose: 50 mg/day Common: nausea, vomiting, abdominal pain, anxiety, sleeping
Maintenance dose: 50–100 mg/ difficulties, headache, reduced energy, joint and muscle pain
................................................................
day for 6–12 months Rare: liver toxicity
Must not be taken within 8 days Caution: naltrexone blocks the action of opioid analgesia
of an opioid medication
If possible, check liver function
before starting
Bupropion Smoking cessation 150 mg once daily for 6 days, Common: headache, dry mouth, nausea, insomnia, dizziness,
aid then increase to 150 mg twice constipation
................................................................ daily Caution: do not prescribe if person has history of seizures or
bipolar disorder
Varenicline Smoking cessation Days 1 to 3: 0.5 mg once/day, Common: nausea, headaches, dizziness, fatigue, sleep
aid days 4 to 7: 0.5 mg twice/day, disturbances
................................................................ days 8 to end of treatment: Caution: do not prescribe <18 years, monitor closely for
1 mg twice/day p.o. depression and suicidality
Cont.
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Disulfiram To maintain 200 mg/day Common: drowsiness, fatigue, nausea, vomiting, reduced

abstinence from interested in sexual activity
................................................................ alcohol owing to Rare: psychosis, allergic rash, liver damage, inflammation of
fear of unpleasant peripheral nerves
interaction
Cautions:
Commence
○○ avoid if history of cardiac disease, stroke, high blood
immediately after
pressure, psychosis or suicide risk
detoxification
○○ the person must be motivated to remain abstinent and
well informed about the risk (1 in 15 000 people will die
because of an interaction between alcohol and disulfiram,
although this is lower than the risk of death from
untreated alcohol dependence)
○○ do not use in women who are pregnant or breastfeeding
○○ tricyclic antidepressants, monoamine oxidase inhibitors,
antipsychotics and some antihypertensive medications
make the disulfiram–alcohol reaction more serious
○○ sensitisation to alcohol continues 6–14 days after taking
disulfiram, even if in small amounts
Methadone For opioid Starting dose: 15 to 20 mg, Common: sedation
withdrawal or as increasing up to 30 mg/day if Caution: methadone should only be prescribed in
................................................................ a safer alternative needed. Then taper off over 3 consultation with specialists
to injecting/ to 10 days
There is a potential for misuse and diversion; therefore,
illegal opioid use
prescribing programmes must have measures in place to
(‘substitution’)
minimise this (e.g. supervised daily dosing)
There is a risk of opioid overdose if a person uses illicit opioids
in addition to methadone. Take care if prescribing with other
sedative medications
Cont.

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Buprenorphine As for methadone Starting dose: 4–16 mg/day Caution: the person should not be given buprenorphine
administered under the tongue. within 8 h of using an opioid or within 24 to 48 h of methadone
................................................................ Continue for 3 to 14 days as it will precipitate withdrawal
When using as substitution treatment, the same safeguards
need to be in place as described for methadone
Clonidine For opioid 0.1–0.15 mg three times daily Common: lightheadedness and sedation
withdrawal Monitor blood pressure closely
................................................................
Lofexidine For opioid As for clonidine As for clonidine
withdrawal
................................................................
Medications for child mental health problems
Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Methylphenidate For ADHD in children Starting dose: 5 mg once or Common: sleeping problems, decreased appetite, mood
twice daily changes
................................................................
Over 4 to 6 weeks, gradually Rarer: abdominal pain, headache, nausea, temporary growth
increase up to a maximum of retardation and low weight (consider a break in treatment
60 mg total/day (divided into 2 over school holidays to allow catch-up growth), changes in
to 3 doses/day), depending on heart rate and blood pressure, vomiting (give with food), tics
when symptoms are controlled Monitor and record height, weight, blood pressure, reported
side-effects, and changes in behaviour. Consult specialist if
failure to make expected gains in weight and height, increased
blood pressure, agitation, anxiety or severe insomnia
Medications to reduce cognitive decline in dementia
Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Donepezil Mild to moderate Starting dose: 5 mg daily Common: diarrhoea, nausea, headache, common cold,
Alzheimer’s disease Usual treatment dose: 10 mg hallucinations, reduced appetite, aggressive behaviour,
................................................................ abnormal dreams, dizziness and fainting, sleep problems,
daily (wait 4 weeks between
dose increases) rash, itching, urinary incontinence, fatigue, muscle cramps,
pain
Cont.

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Rivastigmine As for donepezil Starting dose: 1.5 mg twice/day Common: reduced appetite, dizziness, nausea, vomiting,
Usual treatment dose: 6 mg diarrhoea, agitation, confusion, anxiety, headache,
................................................................ drowsiness, tremor, sweating, fatigue and weight loss
twice/day (wait 2 weeks before
increasing by up to 1.5 mg
twice/day)

Galantamine As for donepezil Starting dose: 4 mg twice/day Common: nausea, vomiting, decreased appetite,
Usual treatment dose: 12 mg hallucinations, depression, dizziness and fainting, tremor,
................................................................ headache, drowsiness, high blood pressure, slow heart rate,
twice/day (wait for 4 weeks
before increasing dose by up to abdominal disturbance, sweating, muscle spasms, weight
4 mg twice/day) loss, falls

Memantine Moderate to severe Starting dose: 5 mg daily Common: medication hypersensitivity, drowsiness, dizziness,
Alzheimer’s disease Usual treatment dose: 20 mg balance problems, high blood pressure, breathlessness,
................................................................ and vascular constipation, headache, abnormal liver tests
daily (can be in divided doses)
dementia

Medications for antipsychotic side-effects

Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Biperiden For stiffness and 1 mg twice daily, increasing up Common: dry mouth, constipation, blurred vision, urinary
sudden muscle to 3 to 12 mg/day p.o. or i.m. retention, confusion, sedation
................................................................ spasm caused Rare: glaucoma, gastrointestinal obstruction, myasthenia
by antipsychotic gravis
medications
Potential for dependence
Benzhexol As for biperiden 1 mg once daily; increase up to As for biperiden
4–12 mg daily in three to four
................................................................ divided doses
Benztropine As for biperiden 0.5 mg at night; increase up to As for biperiden
2 mg at night
................................................................
Cont.

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Procyclidine As for biperiden 2.5 mg twice daily; increase up As for biperiden

to 5 mg three times daily
................................................................
Other medications for mental health problems
Medication, trade name and cost Special uses Dosage Side-effects, interactions and monitoring
Promethazine Night sedation Start with 25 mg/night. Can Common: morning hangover, blurred vision, drowsiness,
without risk of increase up to 50 mg/night dry mouth, gastrointestinal disturbance, restlessness,
................................................................ dependence coordination problems, urinary retention
Advise to take 1 to 2 h before
bedtime
Other locally available medications:

ADHD, attention-deficit hyperactivity disorder; i.m., intramuscular; i.v., intravenous; p.o., orally.

Chapter 14 | 339
15 Resources in your area

Enter information on the availability of resources to support mental health care in your area.

notes

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15.1 Resources for children
These may include: children’s homes, juvenile homes, child telephone helplines, organisations work-
ing with street children, child protection agencies, agencies specifically working on children’s issues
(such as Save the Children, UNICEF), training and vocational support, and special schools for children
with developmental disorders.

Name and contact person Services offered Address, telephone, email

15.2 Resources for elderly people

These may include: residential homes for elderly people; government agencies providing welfare and
financial assistance to older people; local chapters of Alzheimer’s Disease International, HelpAge Inter-
national and other agencies specifically working on issues that affect elderly people.

Name and contact person Services offered Address, telephone, email

15.3 Resources for people with alcohol and drug problems

These may include: local chapters of Alcoholics Anonymous, Narcotics Anonymous and other agencies
working with people with alcohol or drug problems and agencies working with their families; health
facilities specialising in alcohol and drug dependence.

Name and contact person Services offered Address, telephone, email

15.5 Resources for livelihood support

These may include: non-governmental or governmental organisations working in micro-finance, credit
transfer or social safety net schemes; agencies engaged in vocational and skills training; supportive
local employers.

Name and contact person Services offered Address, telephone, email

15.6 Resources for support and advocacy for people with mental
health problems
These may include support or advocacy groups linked to specific mental health problems (e.g. autism),
or for people with mental health problems in general.

Name and contact person Services offered Address, telephone, email

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15.7 Resources for families of people with mental health problems
These may include support groups and organisations working with families of those who have any type
of mental health problem; or, more specifically, intellectual disability, dementias in older people, alco-
hol and drug problems (e.g. Al-Anon) and psychoses.

Name and contact person Services offered Address, telephone, email

15.8 Mental health care workers

These may include psychiatrists, psychologists and other mental health care workers. Make sure you
have information on both private and public health care. In particular, record information on the near-
est in-patient facility for mental health care.

Name and contact person Services offered Address, telephone, email

15.9 Telephone helplines or websites

Record the telephone numbers for different services, such as suicide prevention, women in distress,
and so on. Record websites providing self-help resources.

Contact person or website Services offered Address, telephone, email

Mental health specialists use a wide range of specific psychiatric diagnoses which are not usually need-
ed by general health workers. However, you might come across these psychiatric terms if a person you
are caring for has been seen by a specialist, or when receiving a back-referral from specialist care, or
from people with mental health problems who have been reading about their condition. These terms
are shown below, with differences depending on the diagnostic classification system used, and the sec-
tions where these disorders are considered in this manual.

Diagnostic classification system Where to find in this manual

ICD-10 (International DSM-5 (Diagnostic and
Classification of Diseases from Statistical Manuals from
the World Health Organization, the American Psychiatric
10th edition) Association, 5th edition)
Depressive episode, recurrent Major depressive disorder, 1.4.1 introduction
depressive disorder, dysthymia persistent depressive disorder 3.9 checklist for diagnosis
7.4 management
Generalised anxiety disorder, Generalized anxiety disorder, 1.4.1 introduction
mixed anxiety and depressive panic disorder, specific 3.9 checklist for diagnosis
disorder, panic disorder, phobia, social anxiety disorder,
8.1 and 8.2 description and
specific phobia, social phobia, agoraphobia
management
agoraphobia
Obsessive–compulsive disorder Obsessive–compulsive disorder 7.9 description and
(OCD) (OCD) management
Post-traumatic stress disorder Post-traumatic stress disorder 10.1 description and
(PTSD) (PTSD) management
Somatisation disorder, Somatic symptom disorder, 8.1, 8.4 and 8.6 description
hypochondriacal disorder, illness anxiety disorder, and management
undifferentiated somatoform conversion disorder
disorder, persistent somatoform
pain disorder
Schizophrenia, schizoaffective Schizophrenia, schizoaffective 1.4.3 introduction
disorder, delusional disorder, disorder, delusional disorder, 3.9 checklist for diagnosis
acute and transient psychotic brief psychotic disorder,
7.3 description and
disorder, mania with psychotic schizophreniform disorder,
management
symptoms, severe depressive bipolar disorder with psychotic
episode with psychotic features features, major depressive
disorder with psychotic features

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Bipolar affective disorder Bipolar disorder 1.4.3 introduction
3.9 checklist for diagnosis
7.5 description and
management
Harmful use (of alcohol), Alcohol/substance use disorder 1.4.2 introduction
dependence (mild, moderate or severe) 3.9 checklist for diagnosis
Chapter 9 description and
management
Mental retardation, pervasive Intellectual disability, autism 1.4.5 introduction
developmental disorder, specific spectrum disorder 11.1 and 11.2 description and
developmental disorder management
Hyperkinetic disorder Attention deficit/hyperactivity 11.4 description and
disorder (ADHD) management
Conduct disorder Conduct disorder 11.6 description and
Oppositional defiant disorder Oppositional defiant disorder management
Dementia due to Alzheimer Neurocognitive disorder due to 1.4.4 introduction
disease, vascular dementia Alzheimer’s disease, vascular 7.8 description and
neurocognitive disorder management

notes

Glossary of terms for mental health problems and their symptoms

Its meaning Equivalent in your language
A
Addiction Dependence
Alzheimer’s disease The commonest type of dementia
Anorexia A mental health problem characterised
by a desire to lose weight or change body
shape by refusing to eat
Anxiety A state of feeling tense, worried or fearful
Attention deficit Hyperactivity
hyperactivity disorder
Autism A developmental disorder in which the
child has difficulties in interacting and
communicating with others across many
settings. The child typically also shows
narrow areas of behaviours or interests
B
Bed-wetting A condition in which a child is wetting
the bed well past the age when it is not
expected (by 7 years)
Bereavement The experience of losing a loved one
through death
Bipolar disorder A severe mental disorder where a person
experiences episodes of high and low
mood with periods of normal mood in
between
Bulimia When a person eats a large amount
of food and then makes themselves
vomit or takes laxatives because of
unhappiness with body shape or weight
C
Child behavioural Includes conduct disorder and
disorder hyperactivity
Common mental Depression and anxiety
disorders

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Compulsion A behaviour that is repeated again and
again even though the person tries to
resist doing it
Conduct disorder A condition in which a child (usually a
teenager) consistently behaves badly
and is undisciplined
Confusion A condition when a person does not
know where they are, what time it is or
who they are
Conversion disorder A condition in which a person develops
physical symptoms caused entirely by
mental stress
Convulsion Seizure
D
Delirium A state, often due to a physical disease, in
which a person is confused (confusion)
Delusion A belief that is irrational and untrue but
is held with firm conviction
Dementia A condition in which the person shows
progressively worsening memory and
behaviour problems
Dependence A state when a person must take a drug
regularly in order to avoid a withdrawal
syndrome
Depression A state of sadness, despair or loss of
interest in daily life
Developmental A group of conditions present from
disorders early childhood in which there are
delays or persistent abnormalities in
the intellectual, emotional or physical
development of the child
Disorientation A state in which a person does not know
what day or time it is or where they are
(typically associated with delirium or
dementia)
Drug abuse The use of a drug in a manner that may
cause social, legal, economic or health
damage to the person
Dyslexia A group of developmental disorders
in which a child of normal intelligence
has specific problems with school tasks
such as reading, spelling or writing (also
referred to as specific learning disorders)

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Mental distress Symptoms of mental health problems
which are often of short duration and
occur in response to difficulties in life
Mental health problem An overall term for any disturbance of
mental health, including mental distress,
disorder or disability
Mental retardation Intellectual disability
O
Obsession A thought that comes repeatedly into a
person’s mind even though she does not
want it
Obsessive–compulsive A condition in which obsessions and
disorder compulsions occur together
P
Panic A state of severe anxiety during which
the person feels as if he is going to die or
collapse
Perinatal depression A condition in which depression occurs
during pregnancy or in the months after
childbirth
Phobia A state in which a person develops an
irrational fear of an everyday situation
such as crowds or markets
Post-traumatic stress A condition of mental distress occurring
disorder in a person who has witnessed
or experienced a life-threatening
experience
Premature ejaculation A condition in which a man has an
ejaculation (semen being discharged
from the penis) too soon during sexual
intercourse
Psychosis A severe mental disorder associated with
delusions and hallucinations
Psychosomatic A term used to describe complaints
or a condition in which there are
physical health complaints caused by a
psychological illness
S
Schizophrenia A type of psychosis which often lasts
many years
Seizure A condition when a person is not fully
aware of their surroundings and may
show jerky or unusual movements

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Please send us your comments

This manual is based on the clinical, personal and practical its style and contents are for each reader.
research experiences of the authors in Zimbabwe, We would be grateful if you would write to us with
India and Ethiopia. These experiences have been your comments on any aspect of the book. These
supplemented by reviewing other books and will be invaluable in revising its contents with the
papers and by consulting an international panel hope that it will serve the needs of the general
of reviewers. However, there is no better judge of health worker where there is no psychiatrist.
the book than the reader. Most importantly, the Comments may be sent to:
value of this manual depends entirely on how [email protected]

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Index

Compiled by Linda English. Page numbers for the main references in the book are shown in bold type.

A
abortion 145, 224 effects on person and family 193, anticholinergic medication 52
acamprosate 59 199 antidepressant medication 52,
active listening 22 harmful drinking 191 134, 135
activity schedule 92 hazardous/risky drinking 191 cost and efficacy 315
addiction see dependence health workers 28 medically unexplained symptoms
adolescents 6, 229–230, 233, homeless people 296 168, 169, 175
242–243 how to deal with problem primary health care 274
depression 16, 242–243, 263 194–198 SSRIs 141, 147, 148, 153, 156, 163,
distress 263–265 insomnia 176 165, 175
eating disorders 164 medications 59, 198 traumatic events 216
school 289–294, 300 physical health problem 34, 167 antiepileptic medication 52, 160,
suicide 139, 263, 264, 293 in pregnancy 145, 193–194, 287 162–163, 274
aggressive behaviour 126–129 prevention 299–300 antihistamines, sedating 52
causes 126 referral for out-patient antipsychotic medication 34, 45,
children 255 assessment 45 52, 131–132, 137
elderly people 149, 151 relationship problems 304 cost and efficacy 315
how to deal with problem skills to stay sober or control depot medication 62
126–129 drinking 196–198 medication for side-effects of 52,
AIDS see HIV/AIDS suicide 139, 140 316
alcohol, medications interacting three stages to overcome problem postnatal psychosis 148
with 316 195–196 primary health care 274
alcohol abuse or dependence tolerance 192 anxiety disorders 8–9, 168
9–10, 17, 19, 191–199 what is problem drinking breathing 167
abstinence 196 191–192 insomnia 176
adolescents 293 when to suspect a drinking medication 174–175
aggressive behaviour 126, 127, problem 193 prisoners 298
128 why people drink too much 193 schools 292
binge drinking 191 withdrawal syndrome 10, 123, worrying 79–83, 168, 169,
CAGE questions 194 191–192, 193, 196, 298 170–175
controlled drinking 195, 196–198 women 193–194 worrying about physical health
counselling 63, 86 Alcoholics Anonymous (AA) 196 168, 169
dependence 191–192 amitriptyline 315 assessment 25, 29–36
drinking urges or ‘craving’ 198 anger control 86–88 diagnosis 32–33, 35
with drug abuse 201, 207 anorexia nervosa (anorexia) interview 31–32
163–165 person refusing to talk 33

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cocaine 11, 200, 201, 202 giving reassurance 63 on drugs see drug abuse and
cognitive symptoms (‘thinking’ group 66 dependence
symptoms) 6, 8–9 homeless people 296 on prescription medications see
common mental disorders 6, 7–9, how much is needed 66–67 prescription medications,
17, 51, 274 identify and address problems 65 dependence on
see also anxiety; depression individual 66 depot medications 62
communication difficulties in internet-based 273 depression 8, 19, 133–135, 277
children 238–242 mothers 275–276 adolescents 16, 242–243, 263
causes 238–239 motivating for change 88–90, 165, bereavement 228
how to deal with problem 195 bipolar disorder 13, 133, 134
239–242 prisoners 299 bulimia 164
communication skills problem-solving 70–74, 81, causes 133
in family 100 83–84, 99 counselling 63, 77, 134, 135
health worker 21–25 providing an explanation 63–65 elderly people 149, 152, 153
relationship problems 84, 305 psychological first aid 69–70 homeless people 296
community platforms, refugees 285–286 how to deal with problem
integration of mental health relationship problems 83–86 133–135
into 283–310 relaxation exercises 74–76 insomnia 176
conduct disorder 16, 243, 292, 298 review, encourage and support postnatal depression 7, 63, 145,
confidentiality 23 65 146–147, 148
confusion (delirium) 6, 14–15, schools 293 prisoners 298
123–125 self-help 66 refugees 284
aggressive behaviour 126, 128 specific symptoms and problems schools 292
causes 34, 123 67–69 sexual problems 181, 182
elderly people 149, 150, 152 thinking healthy 79–83 suicide risk 133, 134, 135, 139,
how to deal with problem traumatic events 216 140
124–125 cultural factors 17–18, 146 tiredness 167
odd beliefs and hearing voices words used to describe it 17
130, 132 see also antidepressant
physical examination 124 D medication
conversion disorder (sudden loss date rape drugs 201 desmopressin 261
of body function) 187–190 deafness 238–239, 240, 243, developmental disabilities 4, 15,
causes 187–188 244–250 16, 45, 242, 294, 306
epidemic occurs 188 death 4 see also intellectual disability
how to deal with problem of loved one see bereavement developmental milestones 230,
188–190 see also suicide 232
when to suspect mental health decision support systems, tablet- dhat syndrome 181
problem 188 based 273 diagnosis 5, 60
core skills for mental health care delirium see confusion assessment 32–33
21–28 delusions (odd beliefs) 129–132 classification system 344
communication skills 21–25 dementia 14–15, 16, 19, 150–155 dementia 151, 152
for health worker 25–27 abnormal memory problems 150 symptom checklists 35, 266
seek professional help 27–28 affects family 150–151 disabilities 3, 4, 229
counselling 37, 38, 42, 62–90 how to deal with problem disasters 214, 215–216, 283
anger control 86–88 151–155 disorders 4
approach and culture 18 importance of diagnosis 151 children 15–16, 229
bereavement 228 odd beliefs and hearing voices definition 3
challenges 67, 70, 74, 79, 82–83, 130 distress
85–86, 88, 90 referral for out-patient adolescents 263–265
face-to-face 66 assessment 45 children 15, 34, 229
general principles 63–69 when to suspect 150 conversion seizures 159
getting active 77–79 dependence definition 3
giving hope 65 on alcohol see alcohol abuse and emergencies 111
dependence who people turn to 18

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humanitarian settings 283–286 L rape and sexual assault 222–225
human rights 302–303 learning disabilities, specific 15, sexual problems 181–182,
hyperactivity in childhood 16, 45, 243 184–185
242, 247–250 lithium 148, 316 menstrual complaints 275
lofexidine 59 mental health
loneliness 85, 135, 143, 277, 307 actions for 41
I loss of loved one see definition 3–4
ICD-10 classification (World bereavement of health worker 26–28
Health Organization) 6 LSD (acid) 200–201 integration of 271–310
‘imagining’ symptoms mental health problems
(perceptual symptoms) see causes 16–17
chronic diseases and 271,
hallucinations M
imipramine 261 276–278
mania (‘high’ mood) 13, 19,
impotence 181, 184–185, 193 cultural factors 17–18
135–138
information for person and experiences of people with 18–19
after childbirth 145, 147
family 41, 99, 100 features 5–6
aggression 126
injecting drug abuse 202, 206, 207 human rights 302–303
rate of talking 32
injections 62 introduction to 3–20
risk of antidepressants 134
insomnia 176–178 prevention 299–300
sexual problems 187
causes 176 promoting rights of people with
sleep 176
effects 176 300–303
masturbation 183, 184
how to deal with problem psychiatric terms for 344–345
maternal health care 274–276
176–178 in schools 292–293
medical illness see physical
when to use sleeping pills 177 severity 4
illness
intellectual disability 15, 218, types of 6–16
medications 38, 51–62, 315–339
230–238, 262 why health workers need to be
alcohol dependence 59, 198
causes 193–194, 232 concerned 4–5
anxiety disorders 174–175
communication difficulties mental health promotion
as cause 17, 123, 133, 176, 182
238–239 advocating social change
cautions 316
definition 230 305–307
children 316
developmental milestones 230, schools 289–290
cost 62, 315–316
232 for women 308–309
efficacy 315–316
how is child affected 232 workplace 295
if person does not improve 60
how to deal with problem mental health services 5, 45
injections 62
233–238 mental hospitals 45, 302
non-availability 272
learning difficulties 242, 243, 246 methadone 58
quick reference guide 316
medication not indicated 235 methamphetamine (crystal
refugees 286
mild 230, 235, 239, 243, 246 meth) 200, 201
refusal of 59–60
moderate 233, 235 methylphenidate 57, 249
sedative 25, 52, 249, 316
neglect and abuse 234 miscarriage 145
side-effects 40, 60–62, 123, 168,
severe 233, 235 mobile phone, use of 273
315, 316
sexual problems 183, 187 mood stabilisers 52, 134, 137, 148
when to use them 51
what parents can do 235–236 mood swings see bipolar disorder
which ones to use 52
when to suspect 232–233 motivating for change 88–90, 165,
see also specific medications and
internet 273 195
types of medication
internet addiction 213 muscle relaxation 75
memory problems
mutism, selective 238–239, 241
conversion disorder 188
see also dementia
K men
khat 200 domestic violence 216–222 N
gender and mental health 309 naltrexone 59
male rape 223, 224 negative thoughts 79–83
parenting 276

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S problem sexual behaviour 183, life events 16
safety issues 25, 31, 126 233 strategies to deal with 41–42
same-sex relationships 186, 217 relationship break down 303–304 sudden loss of body function 187,
schizophrenia 12, 104 in same-sex relationships 186 189
schools 289–294 in women 182, 184, 185 substance use see drug abuse or
‘buddy’ system 290 side-effects of medication 40, dependence
bullying 290–291 60–62, 123, 168, 315, 316 suicide 4, 16, 139–143
circle time 291 sleeping pills 11, 52, 176, 177, 201, adolescents 139, 263, 264, 293
counselling 293 205–208, 228 bereavement through 227
drop-outs 293–294 sleep problems 176–178, 193, depression 133, 134, 135, 139,
health-promoting school 289–290 214, 216 140
for homeless children 297 smoking feelings in health worker 27
improving school environment of other drugs 201 how to deal with problem
290 of tobacco 11, 182, 201, 208–211 139–142
life skills programme 290, 292, social factors 5, 17, 39, 60 loneliness 143
308 social interventions 38, 91–105 men 309
mental health problems 292–293 befriending 102–103, 135 odd beliefs and hearing voices
prevention 300 in bipolar disorder 137 131, 132
school studies, problems with challenges 93, 96, 102, 105 prisoners 298
242–246 family support 97–102 questions about 22
causes 242–243 general principles 91 reasons for 144
how to deal with problem improving functioning and skills repeated attempts 140, 142–143
243–246 91–93 support groups 27, 103–105
seizures 159–163, 232 improving skills for social alcohol dependence 196, 199
childhood 159 situations 94–96 definition and when to use them
conversion 159, 160, 188 poverty 93–94 103
emergencies 111 response to stigma and how they work 103–104
or faint 160 discrimination 96–97, 103 internet-based 273
generalised 159, 160, 162 support groups 103–105 refugees 285
how to deal with problem social isolation 85, 135, 143 setting one up 104–105
159–163 soiling clothes 262 symptoms
partial 159, 160 solvents, inhalation of 201, 202 checklists for diagnosis 35, 266
types of 159 somatic symptoms see physical counselling 63, 67–69
selective mutism 238–239, 241 symptoms medically unexplained 9,
self-care 32, 41–42 specialists 272, 316, 344 167–190
self-harming behaviours 16, referral to 43–47 physical 4, 5, 8–9, 167–190
139–143, 293, 298 specific learning disabilities 15, types 5–6
sertraline 147, 148 243
severe mental disorders see speech 32, 127
psychoses ‘speed’ (amphetamine) 11, 200 T
sexual abuse of children 182, 251, spirits, belief in 17–18, 130 tele-medicine 273
252, 253 squeeze technique 185 telephone assessments 34
sexual assault 222–225 SSRI antidepressants 141, 147, thinking healthy 79–83
sexual intercourse, pain during 148, 153, 156, 163, 165, 175 ‘thinking’ symptoms (cognitive
182, 185 stammering or stuttering symptoms) 6, 8–9
sexually transmitted infections 238–239, 240–241 thinking too much 17, 79–83,
193, 217, 224, 225, 251 stigma and discrimination 5, 133–135
see also HIV/AIDS 96–97, 279, 295–296, 300 tiredness 9, 167, 178–181
sexual problems 181–187 stimulant drugs 200 causes 178
how to deal with problem street children 296–297 how to deal with problem
183–186 stress 179–180
intellectual disability 183, 186 carers 280–281 not same as laziness 179
loss of interest 181, 182, 185 causes depression 133 sexual problems 181, 182
in men 181–182, 184–185 in health worker 27, 272 tonics or vitamins 180

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