Beruflich Dokumente
Kultur Dokumente
Based on the
WHO Primary Care Guidelines for Mental
Disorders
and
adapted for Sri Lanka
Endorsed by:
List relevant bodies here
Eg Sri Lanka Psychiatric Association
Contents
Foreword……………………………………………………………………………..5
Introduction…………………………………………………………………………. 6
Health is “the complete physical, mental and social well-being and not merely the absence of
disease or infirmity” (World Health Organisation Constitution 1948).
Mental health is an integral part of health and plays an important role in the overall health of
individuals, families, communities and nations. Indeed, there is no health without mental health. It is
therefore important to include mental health in promotive, preventive, curative and rehabilitative
health care services in every stage of development in the human life cycle.
Pregnancy, delivery and Newborn (up to 2 weeks of age)
Early childhood (unto 5 years of age)
Late childhood (6-12 years)
Adolescence and youth (13-24 years)
Adulthood (25-59 years)
Elderly (60 years and above)
Each phase represents various age groups or cohorts, each of which has special needs including
mental health needs.
Sri Lanka has six service delivery levels (community, dispensary, sub district, district, province and
national ), and two parallel dimensions of work, namely public health and curative services:
In the ongoing Health Sector Reforms, emphasis is given to decentralization towards Primary
Health Care facilities and integration of health care services in order to provide quality health care
services, which are acceptable, equitable, accessible and affordable by all Sr Lankans.
In order to realize this goal, it is critical that the primary health care workers are empowered by
appropriate training on mental health to acquire the necessary knowledge, skills, competence and
attitude to recognize and manage mental health problems both in the community and Primary
Health Care facilities.
In Sr Lanka , as elsewhere in the world, at least one in three patients attending primary care has
some form of mental disorder.
Levels of disability are high and often worse than for common physical diseases. Simple effective
treatments are available for mental disorders and can be delivered in primary care.
The WHO Primary Care Guidelines were developed by WHO in 1996, adapted for the UK (1st
edition 1999, and 2nd edition 2004) and are now adapted for Sr Lanka (2010) through a process of
extensive consultation .
The Guidelines have been endorsed by the organizations listed below. They are intended to assist
good quality assessment and management of people with mental disorders attending dispensaries
and health centers. They will also be useful for general district, provincial hospital clinics and
emergency settings.
The guidelines will be regularly updated and all suggestions for improvement should be passed to
Director of Mental Health, Ministry of Health.
Vision:
A comprehensive and community based service is to be established which will optimise the mental
health of Sri Lankan people. This accessible and affordable service will promote the mental well
being of the community at large and ensure the dignity and human rights if all citizens, especially
those in vulnerable or disadvantaged circumstances.
Principles
Provide mental health services at primary , secondary and tertiary levels
Provide services of good quality where and when they are needed
Provide services that will be organised at community level with community, family and
consumer participation
Ensure mental health services will be linked to other sectors
Ensure mental health services will be culturally appropriate and evidence based.
Protect human rights and dignity of people with mental illness
Objectives:
Ensure clarity of vision and purpose in the improvement of mental health and psychological
wellbeing of the citizens of Sri Lanka
To treat mental disorders in an efficient and holistic manner.
Mission:
To improve Sri Lanka’s mental health services and make them locally accessible. The emphasis of
the service is on prevention of mental illness, promotion of mental wellbeing, treatment and
rehabilitation of people with mental illness, and maximising their normal life where illness does
occur.
Where admission to hospital is necessary, this should be as near a person’s home as possible. To
these ends there is a need to modernise existing services, create new and additional services,
recruit and train more skilled staff, and link to both other government and nongovernment sectors.
Based on the assessed needs, current services and principles of mental health care , seven areas
for action have been identified. .
Drugs
Ensure availability of antidepressants, anti-psychotics and anti-epileptics in the primary
care clinic, and hence reduce use of benzodiazepines for mental disorders
Physical nutrition
infection
trauma
endocrine
genetic
Abnormal personality traits which Not known but probably Not known
are handicapping to the individual around1-5%
and /or others
Tropical organic
dementias :
situation specific
Caution: Though fever is sometimes associated with mental illness, there are other instances
where organic factors might be the primary cause of symptoms including hypothyroidism
(depression), thyrotoxicosis (anxiety). In the early stages of HIV infection, many unexplained
symptoms may be the earliest indication of infection.
Strengthen health systems health systems are not yet geared up to address childhood
mental disorders and learning disabilities
Good mental health and use of treated bed nets for self, spouse and children
avoidance of malaria control of and avoidance of mosquitoes
boosted immunity and cytokine levels
Diagnostic confusion depressed people often present with headache, aches and
between malaria and pains, and general feeling of being unwell; they are often
depression diagnosed as having malaria despite normal blood film and no
fever
recent research
- Wellcome/Kenya study: only 10% of suspected malaria
cases referred to district hospitals actually have malaria
- studies in health centres in Kenya showed no one at PHC
level was diagnosed with depression despite prevalence of
depression in PHC being around 30-40% of attenders; they
are mostly erroneously diagnosed with malaria instead
Summary of various most adults with depression do not have malaria, although
diagnostic overlaps they are erroneously treated for it
but some adults with depression will also have malaria
and some adults with malaria will also be depressed
some adults with psychotic symptoms are in fact delirious from
malaria -cerebral malaria
some adults with actual psychosis also have malaria
Possible associations
No malaria Malaria Cerebral
malaria
No depression or psychosis
Depression
Psychosis
Solution-accurate bio- If person presents with malaria type symptoms but no fever or
psycho-social assessment parasites, always assess for depression
Mental health is highly relevant to human behaviour, including sexual behaviour. 29.5 million
people in Sub-Saharan Africa live with the HIV/AIDS virus. The impact of this is:
Plan mental health develop self esteem, “how to say no”, anti-bullying/ coping
promotion in schools to: strategies; these help reduce subsequent substance misuse and
HIV infection
reduce risk of contracting HIV with unprotected sex or drug use
ensure girls are supported to be assertive and confident in ensuring
their sexuality and safety
address particular difficulties where use of condoms is not widely
culturally accepted by men
encourage abstention from drugs and harm reduction in those who
use drugs
Mental health influences our emotions, beliefs, relationships with others and behaviour habits
immunity can influence our immune system
long-term stress suppresses immune system to fight viral as well as
bacterial and parasitic infections and thus creating fertile
environment for pathogens
mental health influences prognosis of HIV
- beliefs: believing that you must die from being HIV-infected can
trigger fear, decreases in immunity, avoidance of health
promoting behaviour leading to shorter life span
- grief: if held and not expressed it can trigger a decrease in
immunity and speed up the progression of disease
HIV causes mental HIV enters the brain shortly after first infection, leading to
disorders malignancy, opportunistic infections, vascular lesions and
encephalitis; in advanced HIV, there is chronic loss of general
cognitive function, leading to apathy, withdrawal and deterioration of
personality
as in other major life threatening illness, from the impact of having a
fatal disease, e.g. adjustment disorder, persistent depression,
affective psychosis and suicidal risk
Medical Management
Antiretroviral regime Triple therapy to suppress virus growth and prevent mutants
Niverapine
AZT
Lamivudine
Around 90% of diabetics have type II diabetes. Type II diabetes is characterised by peripheral
resistance to action of insulin and decreased insulin secretion, in spite of elevated glucose levels.
Patients with type II diabetes can often avoid or postpone the need for insulin treatment by a well
regulated diet or exercise programmes.
People with diabetes are more likely to have anxiety and depression than the general population.
(33-45% of people with diabetes have depression or anxiety). Such anxiety and depression, and
their associated social difficulties, makes the person with diabetes less likely to comply with their
dietary and exercise regimes as well as medication, and hence more prone to relapse and diabetic
crises. It is therefore crucial to address psychosocial issues for each person with diabetes, monitor
for the presence of depression and anxiety, and treat promptly.
People with hypertension are more likely to have anxiety and depression, and its presence makes
the person less likely to comply with dietary and exercise regimes, as well as medication, and
hence more likely to relapse.
People with depression are 1.5-2 times more likely to develop heart disease than people without
depression. Therefore effective treatment of depression is important for prevention of heart
disease.
Definition
action to enhance the mental well-being and resilience of individuals, families, organizations
and communities
action to empower/enable individuals, families, organizations and community to take control
of their own destiny/life
Strengthening Individuals
increase emotional resilience through interventions designed to promote self-esteem
the health worker can
o support parents, carers, individuals
o mobilise social support
o develop life skills e.g. effective communication, problem solving, parenting,
decision-making
o liaise with teacher
o encourage nutrition, vaccinations, hygiene, exercise
Strengthening communities
increase social support, social inclusion and participation
health worker can
o mobilise community
o set up self help groups
o initiate youth clubs
o improve community safety and safe environments
o give mental health education within maternal and child health clinics, schools,
youth groups, churches and mosques, workplace, police, prisons
o give talks to community leaders and others
o utilise media and events
o organise celebrations of World Mental Health Day to educate public
Strengthening Society
develop enhancing structures to mental health e.g. policy development, policy guidelines
reduce structural barriers to mental health e.g. unemployment, discrimination, access to
training, education and services
World Mental Health Day
Primary Prevention
support vulnerable people to stop them from getting ill
health workers and CHWs can consider who is vulnerable and give/mobilise support e.g. to
carers
Secondary Prevention
treat ill people quickly to reduce length of illness
health workers and CHWs can be alert to symptoms of illness
Tertiary Prevention
rehabilitate back to normal functioning
health workers and CHWs can organise opportunities for rehabilitation
Vulnerable groups
Street children
vulnerable to hunger, cold, economic and sexual exploitation, drug addiction, sexual
promiscuity, sexually transmitted diseases, criminalisation, imprisonment, sexual and physical
abuse
health workers may be able to provide food, clothing, bedding and use contact to establish
relationship and help them rejoin family or bring them into homes, hostels schools, training
workshops and self financing projects e.g. running café
Therefore care workers in children's homes need information, support and guidance in the
management of such problems.
Prisons
Mental illness and suicide are much more common in the prison population than in general
population. Therefore need systems to
divert psychosis to hospital
treat less severe illness in prison
prison health care staff need to be familiar with assessment and management of mental
disorders
prison staff need to be familiar with depression and management of suicidal risk
Intellectual handicap
Children and adults with intellectual handicap should be able, encouraged and supported to lead as
normal a life as possible. They have
special educational needs
social, physical and psychological needs
specific neurological problems e.g. cerebral palsy, epilepsy. Essential medicines are needed
to ensure that intellectual deficit is not aggravated by these associated conditions
Older people
risk of dementia increases exponentially with age over 65
people with dementia are at risk of neglect (starvation, abuse, hypothermia, neglect of
physical illness).
.
Sensory impairment
deafness is particularly associated with psychological symptoms
profound early deafness interferes with speech and language development, emotional
development and educational attainment
blindness causes difficulty and physical hazard
Ii previously sighted people, blindness causes considerable distress and depression
.
Refugees and internally displaced people
Refugees and internally displaced people suffer from
all the usual mental disorders such as depression, anxiety, somatic symptoms and psychosis,
which are all more common in refugees and IDPs because of the added stresses which they
encounter, and increased vulnerability from malnutrition etc,
increased rates of post traumatic stress disorder.
delirium
suicidal person
What is HMIS?
A system of collecting, recording, keeping and reporting including dissemination of health related
information (Mental Health).
It has a clear flow of communication from service point to decision/policy level and vice versa.
What information should be collated by Health Centres and Dispensaries and passed to the
District Health Management Team in the Quarterly Reports
Registering a case
Statistics are vital for planning including determining drug supply, service required, space for
patients accommodation, staff continuing education needs in order to improve the quality of mental
health care at different levels of service delivery. Statistics are also useful in evaluation of service s
provided.
There should be at least two register books, one for new patients (first attenders) and the other for
follow-up patients.
Identification information
Interviews conducted
Diagnosis
Management plan
All patients’ files should be kept at the Health Centre.
Proper filling system should be maintained to ensure patients’ records are not misplaced.
Patient’s progress report including treatment should be written in his/her file.
Clinical roles
identification, diagnosis, treatment, follow up, referral
address physical, psychological and social axes simultaneously
use good practice guidelines
use psychosocial skills
rational prescribing of psychotropics and antimalarials
reduce use of benzodiazepines
conduct outreach and home visits
liaise with community health workers
liaise with families
Skills
attend CPD programmes in house and elsewhere
develop psychosocial skills
receive on job support, supervision and training from district level
Administration
proper use of registration book and patient files
collect data on consultations using diagnostic categories
ensure availability of
antidepressants, antipsychotics, anti-epileptics by auditing and ordering on time
develop and maintain simple case registers of people with severe mental illness
for follow up, relapse prevention, outreach and planning for medicines
access transport for outreach
communicate and liaise with district
mental health coordinator, medical officer, clinical officer and nursing officer
Administration
be a member of the district health management team
be a member of the district PHC core team
liaise with district health management team on all issues which affect the delivery of mental
health services at PHC and District level
Epilepsy phenobarbitone
30mg start dose 60mg od drowsiness,
and 100 mg max dose 100 mg bd hyperactivity in
phenytoin children
50 and 100mg 50 to 200 mg
Carbamazepine 600 – 1200mg drowsiness
200mg hypertrophic
Na valprovate 800 – 1200mg gums
200mg liver function
abnormalities
Risperidone 2mg –
6mg
Acute haloperidol 1.5 mg to 10 mg in
psychotic 1.5 mg 2 divided doses a day see above
disorder
chlorpromazine 100 mg to 400 mg in 2
25 mg and 100 mg divided doses a day
see above
Risperidone 2mg-
6mg
Bipolar haloperidol
disorder 1.5 mg 1.5 mg to 10 mg in two see above
divided doses
LiCO3 500mg –
750mg
Depression Imipramine 25mg 50 to 100mg in 2 divided sedation, orthostatic
doses hypotension
Fluoxetine 20mg 20mg- 60mg Sedation
Guide to start Phenobarbital treatment in children of 2 years and above and in adults
Start doses 30 mg 60 mg 60 mg 60 mg
Management Guidelines get help, exercise caution, allow for escape, identify
yourself
try to calm the patient; speak gently (e.g. ‘I can see
that you are very upset’); avoid any sudden or
threatening action.
listen to the patient
do not loosen any bonds
do not contradict or argue with the patient
do not make false promises
attempt to negotiate treatment (medication to calm
you)
try to persuade the patient to surrender any weapon in
his/her possession
do not attempt any heroics
if the patient has to be restrained, ensure there is
enough help to control each limb without hurting the
patient
approach from behind
Presenting complaints the patient may present with one or more physical symptoms,
such as headache or ‘tiredness all the time’
irritability
anxiety, insomnia, worries about social problems such as
financial or marital difficulties, increased drug or alcohol use,
or (in a new mother) constant worries about her baby or fear
of harming the baby
Information for patient and depression is a common illness and effective treatments are
family available.
depression is not weakness or laziness.
Advice and support to assess risk of suicide: ask a series of questions about suicidal
patient and family ideas, plans and intent (e.g. does the patient think life is not
worth living? Has the patient thought they would rather be
dead? Has the patient often thought of death or dying? Does
the patient have a specific suicide plan? Has he/she made
serious suicide attempts in the past? Close supervision by
family or friends, or hospitalization may be needed. Ask about
risk of harm to others. )
identify current life problems or social stresses.
plan short-term activities, which give the patient enjoyment or
build confidence.
advise to stop alcohol use.
support the development of good sleep patterns and
encourage a balanced diet.
encourage the patient to resist pessimism and self-criticism
and not to act on pessimistic ideas (e.g. ending marriage,
leaving job.
if physical symptoms are present, discuss the link between
physical symptoms and mood (see ‘Unexplained somatic
symptoms — F45’).
Information for patient and stress, worry and panic have both physical and mental
family effects, are quite common and can be treated
learning skills to reduce the effects of stress are the most
effective relief
anxiety often produces frightening physical symptoms: chest
pain, dizziness or shortness of breath are not necessarily
signs of a physical illness; they will pass when anxiety is
controlled
mental and physical anxiety reinforce each other.
concentrating on physical symptoms will increase fear
Advice and support to encourage the patient to use relaxation methods daily and to
patient and family do exercises to reduce physical symptoms of tension
avoid using alcohol or cigarettes to cope with anxiety
Referral to district hospital refer to district if symptoms are severe for more then 6
months.
Information for patient and stress often produces or exacerbates physical symptoms
family cure may not always be possible; the goal should be to live
the best life possible even if symptoms continue
Referral to district hospital patients are best managed in dispensary or health centre
Information for patient and physical or neurological symptoms often have no clear
family physical cause; symptoms can be brought about by stress.
symptoms usually resolve rapidly (from hours to a few weeks)
leaving no permanent damage.
Medication no tranquilizers
10mg iv diazepam may rapidly terminate an acute
dissociative state.
do not continue the diazepam; if depressed, follow depression
guideline
Referral to district hospital if unsure of the diagnosis, consider referral to district hospital
Diagnostic features heavy alcohol use (e.g. 3 or more beers a day, and local
home-made brews, over 28 units per week)
physical problems (e.g. liver disease, gastrointestinal
bleeding)
psychological harm (e.g. depression or anxiety due to
alcohol), or has led to harmful social consequences (e.g. loss
of job).
strong desire or compulsion to use alcohol
difficulty controlling alcohol use
withdrawal (anxiety, tremors, sweating) when drinking is
ceased
tolerance (e.g. drinks large amounts of alcohol without
appearing intoxicated)
continued alcohol use despite harmful consequences.
Information for patient and alcohol dependence is an illness with serious consequences
family ceasing or reducing alcohol use will bring mental and physical
benefits
drinking during pregnancy may harm the baby
because abrupt abstinence can cause withdrawal symptoms,
medical supervision is necessary
Advice and support to discuss costs and benefits of drinking from the patient’s
patient and family perspective
give clear advice on changing drinking habits
Referral to district hospital if severe withdrawal symptoms (fits, severe trembling, very ill)
Presenting complaints family may request help before the patient (e.g. because the
patient is irritable at home or missing work.)
patients may have depressed mood, nervousness or
insomnia
patients may present with a direct request for prescriptions for
narcotics or other drugs, a request for help to withdraw or for
help with stabilizing their drug use
they may present in a state of intoxication or withdrawal or
with physical complications of drug use, e.g. abscesses or
thromboses
Differential diagnosis alcohol misuse - F10 often co-exists; polydrug use is common
symptoms of anxiety or depression may also occur with heavy
drug use; if these continue after a period of abstinence (e.g.
about four weeks) see ‘Depression - F32#’ and ‘Generalized
anxiety - F41.1
psychotic disorders -F23, F20
delirium - F05
Information for patient and drug misuse is a chronic, relapsing problem and controlling or
family stopping use often requires several attempts; relapse is
common
ceasing or reducing drug-use will bring psychological, social
and physical benefits
Advice and support to using some drugs during pregnancy risks harming the baby
patient and family for intravenous drug-users, there is a risk of transmitting HIV
infection, hepatitis or other infections carried by body fluids
discuss appropriate precautions (e.g. use condoms, and do
not share needles, syringes, spoons, water or any other
injecting equipment)
Medication don’t give medication; drug users try to mislead you and will
try to get a prescription.
Referral to district hospital if severe withdrawal symptoms (fits, severe trembling, very ill)
Information for patient and acute episodes often have a good prognosis, but long-term
family course of the illness is difficult to predict from an acute
episode
advise patient and family about the importance of medication,
how it works and possible side effects
continued treatment may be needed for several months after
symptoms resolve
Advice and support to ensure the safety of the patient and those caring for him/her:
patient and family - family or friends should be available for the patient if
possible
- try to ensure that the patient’s basic needs (e.g. food,
drink, shelter and safety) are met
minimize stress
do not argue with psychotic thinking (you may disagree with
the patient’s beliefs but do not try to argue that they are
wrong)
if there is a significant risk of suicide, violence or neglect,
admission to hospital or close observation in a secure place
may be required; if the patient refuses treatment, legal
measures may be needed
patient should start his normal activities (like work) after
Prescription guidelines:
Haloperidol: 5 to 10 mg per day in 2 divided doses
Risperidone 2mg-6mg a day in 2 divided doses
Referral to district hospital referral should be made under the following conditions:
- as an emergency, if the risk of suicide, violence or neglect
is considered significant
- if there is non-compliance with treatment, problematic
side effects, failure of community treatment, or concerns
about co-morbid drug and alcohol misuse.
Differential diagnosis Alcohol misuse — F10 and Drug use disorder — F11# can
cause similar symptoms and both conditions may be present
Schizophrenia
Information for patient and sudden changes in mood and behaviour can be symptoms of
family the illness
effective treatments are available; long-term treatment can
prevent future episodes
if left untreated, manic episodes may become disruptive or
dangerous; manic episodes often lead to loss of job, legal
problems, financial problems or high-risk sexual behaviour;
patient should be brought to clinic when first symptoms occur
Diagnostic features Chronic recurrent problems longer than 4 weeks with the
following features:
- social withdrawal
- low motivation, interest or self-neglect
- disordered thinking (exhibited by strange or disjointed
speech).
Periodic episodes of:
- agitation or restlessness
- bizarre behaviour
- hallucinations (false or imagined perceptions e.g. hearing
voices)
- delusions (firm beliefs that are often false e.g. patient
believes they are an important person; may believe they
are a special prophet, receiving messages from television
or radio, being followed or persecuted).
Differential diagnosis Depression - F32# (if low or sad mood, pessimism and/or
feelings of guilt)
Bipolar disorder - F31 (if symptoms of mania excitement,
elevated mood, exaggerated self-worth are prominent)
Alcohol misuse - F10 or Drug use disorders -F11#,
chronic intoxication or withdrawal from alcohol or other
substances (like banghi) can cause psychotic symptoms
patients with chronic psychosis may also abuse drugs and/or
alcohol
Information for patient and symptoms may come and go over time
family medication will reduce the current difficulties and prevent
relapse
stable living conditions (housing, support of relatives) are
important for effective recovery
support of the relative is essential for compliance with
treatment and effective rehabilitation
Prescription guidelines:
Chlorpromazine: 100 to 400 mg a day in 3 divided doses.
Maintenance dose: 100 to 200 mg daily
Haloperidol: 5 to 10 mg per day in 2 divided doses.
Maintenance dose 1.5 to 5 mg daily
Risperidone 2-6 mg per day. Maintenance dose: 2-4mg
daily
Referral to district hospital if the patient doesn’t respond on the medication and there is
a danger for the patient and the relatives if managed at home
(e.g. if patient is very aggressive)
Status epilepticus:
monitor pulse, respiration and blood pressure; prevent
aspiration, maintain clear airway
Diazepam iv (very slowly, 1mg/min) or rectally
- children under 5 years: up to 5 mg
- children 5 to 10 years: 10 mg
- older children: 15 mg
- adults: 20 mg
Referral to district hospital Children under 5 with fits should be referred to the district
hospital for further examination; in case of frequent fits start
treatment already; they will be referred back to the health
worker for the follow up.
Diagnostic features slow decline in memory, initially for recent events, names,
faces of relatives
decline in thinking, orientation and speech
patients may have become disinterested and don’t take
initiative
decline in everyday functioning (e.g. dressing, washing,
cooking)
patients may become easily upset, tearful or irritable
common with advancing age (5% over 65 years; 20% over
80 years), very rare in youth or middle age
ask history from relatives!
tests of memory and thinking include:
- ability to repeat the names of three common objects
immediately and recall them after three minutes
- ability to accurately identify the day of the week, the
month and the year
- ability to give their full name and names of their relatives
Information for patient and strange behaviour or speech and confusion can be
family symptoms of a physical illness.
Advice and support to take measures to prevent the patient from harming
patient and family him/herself or others
presence of relatives helps to reduce confusion
frequently reminding the patient the time and place will
reduce disturbed orientation
hospitalization may be required because of agitation or
because of the physical illness, which is causing delirium.
mortality rate of patients with delirium is high
Presenting complaints parents may complain that child doesn’t develop like other
children.
“milestones” delayed:
- laughing (6-8 weeks normally)
- sitting (6-8 months normally)
- crawling (9 month normally)
- walking (1 year to 1 ½ year)
- talking (first words 9 month to 1 years)
- simple sentences (2 to 3 years)
Information for patient and give parents the proper information (tell the truth, don’t
family promise anything what can not be done!)
the child will develop, but at a low pace, and will not develop
as a normal child
Advice and support to the child should live an “as normal as possible” life, should
patient and family not be locked in the house; proper feeding, healthy diet
teach child normal day to day things like washing, dressing,
sweeping, step by step
effects of depression
- poor school work
- poor relationship with family and friends
- increased risk of self harming
- drugs or alcohol misuse
Referral to district hospital if symptoms are not resolving, and are interfering with
education
if risk of harm to adolescent or others
Causes neurobiological
may be aggravated by
- large class sizes
- poorly trained teachers
- language not commonly used at home
mental retardation
depression
conduct disorder
difficulties with hearing or vision
drug misuse
Presenting complaints learning difficulty that affects ability to read or deal with
numbers, irrespective of intelligence
problems with concentration, perception and memory
verbal skills, abstract reasoning, hand-eye coordination
social adjustment (low self esteem), poor grades,
underachievement
child may have difficulties with
- copying, spelling and writing
- understanding instructions
- numbers and mathematics
- reading
- behaviour problems
voluntary admission
involuntary admission
emergency admission
admission through criminal justice system as special category patient or mentally disordered
offender.
CAGE questionnaire
Alcohol dependence is likely if the patient gives two or more positive answers
to the following questions
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or
get rid of a hangover (Eye-opener)?
The combination of CAGE questionnaire, MCV and GGT activity will detect about
75% of people with an alcohol problem.
2. How many standard drinks containing alcohol do you have on a typical day when
drinking?
1 or 2 3 or 4 5 or 6 7 to 9 10 or more
4. How often during the last year have you found that you were not able to stop
drinking once you had started?
Never less than Monthly Weekly Daily or almost
monthly daily
5. How often during the last year have you failed to do what was normally expected
from you because of drinking?
Never less than Monthly Weekly Daily or almost
monthly daily
6. How often during the last year have you needed a drink in the morning to get
yourself going after a heavy drinking session?
Never less than Monthly Weekly Daily or almost
monthly daily
8. How often during the last year have you been unable to remember what happened
the night before because you had been drinking?
No Yes, but not in the last year Yes, during the last year
10. Has a relative or friend or a doctor or other health worker been concerned about
your drinking or suggested you cut down?
No Yes, but not in the last year Yes, during the last year
Scores for each question range from 0 to 4, with the first response for each question (e.g. never)
scoring 0, the second (e.g. less than monthly) scoring 1, the third (e.g. monthly) scoring 2, the
fourth (e.g. weekly) scoring 3, and the last response (e.g. daily or almost daily) scoring 4. For
questions 9 and 10, which only have 3 responses, the scoring is 0, 2 and 4 (from left to right).
Each correct answer scores one mark. No half marks. A score of 6 or less suggests dementia.
1. Age
2. Time to nearest hour
3. An address, e.g. 42 West Street, to be repeated by the patient at the end of the test
4. Year
5. Name of hospital, residential institution or home address depending on where
patient is situated
6. Recognition of two persons, for example doctor, nurse, relative, home help etc
7. Date of birth
8. Year of Independence
9. Name of present President
10. Count backwards from 20 to 1.
This checklist is simply a list of areas that need to be considered in the care of someone
with a long-term, severe illness, in addition to more medical assessments such as the
individual's mental state, severity of symptoms and medication side effects.
Housing
1. Is the housing situation adequate? Yes No
2. Is supervision adequate for this individual? Yes No
3. a. Is individual happy with his or her current housing situation? Yes No
b. Is health professional happy? Yes No
c. Are carers happy? Yes No
4. If not happy with housing, what kind of housing is preferred? Yes No
Finances
1. Is individual receiving all benefits to which he or she is entitled? Yes No
2. Is the individual's income adequate? Yes No
3. Can the individual budget and handle money effectively? Yes No
4. Can individual handle financial commitments without assistance? Yes No
Employment
1. If employed, is the work situation satisfactory? Yes No
(e.g. punctuality, attendance, performance, social interactions, etc.)
2. If unemployed, is individual suitable for employment? Yes No
3. If unemployed, can the individual find work without assistance? Yes No
Legal
1. If subject to the Mental Health Act or legal proceedings, is the matter
being handled appropriately? Yes No
Education
1. If the individual is currently undertaking a course of study, is
he or she coping with the demands of this study? Yes No
2. If a current course of study has been interrupted, has the
3. university (or other) been notified and supplied with supportive
4. the documentation for deferral of the course, etc.? Yes No
5. Is the individual satisfied with his or her current educational
status or situation? (e.g. further education may be desired). Yes No
From: Andrews G & Jenkins R (Eds), 1999, `Management of Mental Disorders (UK Edition). Sydney.
World Health Organisation Collaborating Centre for Mental Health & Substance Abuse
The pages that follow contain summaries of information about the six disorders most
common in primary care.
These are designed to be used interactively within the consultation, to help the practitioner
explain key features of the disorder to the patient and enter into discussion about a
possible management plan.
Common symptoms
‘High-risk’
drinking: Psychological: Physical:
Men Poor concentration Hangovers/blackouts
More than three units Sleep problems Injuries
alcohol/day Less able to think Tiredness/lack
(21 units/week) clearly of energy
Depression Weight gain
Women Anxiety/stress Poor coordination
More than two units High blood pressure
alcohol/day Impotence
(14 units/week) Vomiting/nausea
Gastritis/diarrhoea
Liver disease
Brain damage
Many have no
symptoms but
are at risk
Men No more than three units Each day (only for five days/week)
Women No more than two units Each day (only for five days/week)
Pregnancy
Physical alcohol dependence
Physical problems made worse Recommendation is
by drinking not to drink
Driving, biking
Operating machinery
Exercising (swimming, jogging, etc.)
Common triggers
Psychological triggers: Physical triggers: Medication:
Depression Anaemia Thyroid Steroids
Stress Bronchitis disorder Antihistamines.
Worry Asthma Influenza
Anxiety. Diabetes Alcohol/
Doing too much Arthritis. drug use
Doing too little activity Bacterial, viral and
other infections.
Common causes
Psychological:
Physical: Lifestyle: Environmental:
Medical
problems:
Depression Overweight Too hot or too cold Noise
Anxiety Heart failure Tea, coffee and Pollution
Worries Nose, throat and alcohol Lack of
Stress. lung disease Heavy meal before privacy
Sleep apnoea sleep Over-
Narcolepsy Daytime naps crowding.
Pains. Irregular sleep
Medications: schedule.
Steroids
Decongestants
Others.
THPs are a major health care resource. At least 50% population consult Traditional Health
Practitioners or Religious Healers at some time
People often simultaneously consult both traditional health practitioners and western medicine.
THPs are accessible, operate in the social context, and their interventions are sometimes
effective, so there are reasons for public health services to be in dialogue with traditional healers.