The World Health Organization (WHO) has today published the third edition of the Mental Health Gap Action Programme (mhGAP) guideline which includes important new, and updated, recommendations for the treatment and care of mental, neurological and substance use (MNS) disorders.
MNS disorders are major contributors to morbidity and premature mortality in all regions of the world. Yet it is estimated that over 75% of people with MNS disorders are unable to access the treatment or care they need.
The mhGAP guideline supports countries to strengthen capacity to deal with the growing burden of these conditions. It is intended for use by doctors, nurses, other health workers working in non-specialist settings at primary health care level, as well as health planners and managers.
“For 15 years, mhGAP has played a vital role in improving access to evidence-based psychological interventions and medicines for the treatment and care of people with mental, neurological and substance use disorders. Considering the growing relevance of mental health, this evidence-based guide is more important than ever in supporting primary health care workers to treat people with MNS disorders,” said Dévora Kestel, WHO Director for Mental Health and Substance Use.
The 2023 guideline update includes 30 updated and 18 new recommendations related to MNS conditions, alongside 90 pre-existing recommendations.
New recommendations on anxiety disorders
The guideline contains a new module on anxiety reflecting the increased number of people with anxiety disorders, which are among the world’s most common mental disorders. The module includes the following recommendations:
- Psychological interventions based on cognitive behavioural therapy (CBT) should be offered to adults with generalized anxiety disorder and/or panic disorder. These interventions can be offered in a variety of formats including online, in-person, in groups, or self-guided.
- Stress management techniques should be considered for adults with generalised anxiety and/or panic disorder.
- Selective Serotonin Reuptake Inhibitors (SSRIs) should be considered for treating adults with generalized anxiety and/or panic disorder.
Psychological and psychosocial interventions
The guideline sets out the continuing importance of psychological treatments for a range of MNS conditions.
The mhGAP guideline contains new recommendations on psychosocial interventions for carers of persons with psychosis or bipolar disorder as well as new recommendations on psychosocial interventions for psychosis, alcohol dependence, substance use, dementia, and children and adolescents with neurodevelopmental disorders including autism, ADHD and cerebral palsy.
Women and girls who want to become pregnant or may become pregnant should not use valproic acid (sodium valproate)
The guideline contains an updated recommendation which advises against the use of valproic acid (sodium valproate), a medicine for the treatment of epilepsy and bipolar disorder, due to risk of birth defects if taken during pregnancy.
The guideline recommends the following:
- Valproic acid (sodium valproate) should not be prescribed to women and girls who want to become pregnant or may become pregnant because of the high risk of birth defects and developmental disorders in children exposed to valproic acid in the womb.
- For women and girls currently prescribed valproic acid (sodium valproate), advice should be provided on use of effective contraception.
- It is important that women and girls do not stop taking valproic acid (sodium valproate) without first discussing it with their doctor.
- Women should be advised to consult their physician as soon as they are planning pregnancy and the need to urgently consult their physician in case of pregnancy. Every effort should be made to switch to appropriate alternative treatment prior to conception.
- A specialist should periodically review whether valproic acid (sodium valproate) is the most suitable treatment for the person.
The guideline reflects the WHO safety statement issued in May 2023 on the use of valproic acid (sodium valproate) for the treatment of epilepsy and bipolar disorder in women and girls of childbearing potential. This was discussed at the meeting of the WHO Advisory Committee for the Safety of Medicinal products (ACSoMP) [2022 December ACSoMP recommendations]. A safety statement was also added to the Essential Medicines List (EML).
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Other recommendations:
- Digitally-delivered psychological and psychosocial interventions feature across multiple modules - alcohol use disorders, anxiety, conditions related to stress, drug use disorders, and self-harm and suicide
- Recommendations for non-pharmacological interventions to improve outcomes for people with dementia have been updated to include physical exercise, CBT, cognitive stimulation therapy and cognitive training.
- The antipsychotic medicines quetiapine, aripiprazole, olanzapine, paliperidone, and the long-acting antipsychotics haloperidol and zuclopenthixol are included for treatment of psychosis and bipolar disorder. Levetiracetam and lamotrigine are included for treatment of epilepsy.
